Experiences of New Mothers During the Coronavirus Disease 2019 (COVID-19) Pandemic : Obstetrics & Gynecology

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Contents: Original Research

Experiences of New Mothers During the Coronavirus Disease 2019 (COVID-19) Pandemic

Critchlow, Elizabeth BS; Birkenstock, Lyena BA; Hotz, Melanie MD; Sablone, Lauren; Riley, Amy Henderson DrPH; Mercier, Rebecca MD, MPH; Frasso, Rosemary PhD, MSc

Author Information
Obstetrics & Gynecology 139(2):p 244-253, February 2022. | DOI: 10.1097/AOG.0000000000004660

In January 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) a public health emergency.1 Social distancing and lockdowns helped reduce viral spread, but they were not without social, mental health, and economic effects.2–5 Globally, studies of postpartum women have identified worsened depression and mother–infant bonding during the pandemic compared with before.6–8 Postpartum depression has important negative effects on both parent, including increased risk of suicide, and child, including impaired cognitive development and infant health concerns.9 Additionally, the stress of delivering during the COVID-19 pandemic has been linked to posttraumatic stress and impaired bonding and breastfeeding.10

Qualitative studies of pregnant and postpartum individuals during the pandemic in the United States and India identified challenges related to fear and uncertainty, isolation, and social support, while also noting times of resiliency and positive experiences.11,12 Other recent studies in the United States and Canada highlighted difficulties with child care, infant feeding, and lack of support.13,14 However, much is still unknown about how the COVID-19 pandemic affects postpartum individuals, particularly across socioeconomic strata.

This study aimed to describe the experiences of postpartum women during the COVID-19 pandemic through the use of photo-elicitation, which provides participants an opportunity to share a window into their lives.15 We not only aim to identify the challenges postpartum individuals faced during this public health emergency, but also define ways to better support postpartum individuals in the future.

METHODS

This study was approved by the Institutional Review Board at Thomas Jefferson University and followed COREQ (Consolidated Criteria for Reporting Qualitative Research).16 In addition to consent for participation in the study, participants provided explicit permission for their photographs and quotations to be used in this manuscript. Consent was confirmed at the end of each interview. Photo-elicitation is a qualitative research method using participant-generated photos on a topic to guide subsequent interviews, offering depth and structure by allowing participants to reflect on the research question before the interview and facilitating conversation during the interview.15,17 This qualitative design was intended to elicit open-ended responses rather than quantifiable data.15,18

Participants were eligible for inclusion if they were comfortable conversing in English, self-identified as ciswomen, were older than 18 years of age, and delivered within 10 weeks of recruitment. Not all pregnant or birthing people are cisgendered women; however, gender nonbinary and transgender patients were expected to have unique perspectives and needs related to delivery and postpartum care and were therefore not included in this study. Other exclusion criteria included delivery before 34 weeks of gestation and neonatal admission to the intensive care nursery. To ensure the inclusion of women of lower socioeconomic status, participants were recruited in two groups based on use of public or private insurance, using public or no insurance as a proxy for lower socioeconomic status.19 The sample size of this study was guided by thematic saturation; participants were recruited until no new information emerged during the interview process.20

Participants were recruited in-person by the primary author on the inpatient postpartum unit of a large academic hospital in Philadelphia, or via snowball sampling (participants were asked whether they had eligible peers who might be interested in participating), often used in studies when participants may be difficult to reach or engage. At the time of recruitment, study procedures were fully reviewed and informed consent was obtained.

A member of the research team then called participants at 3–10 weeks postpartum. Up to three unanswered attempts by phone and one by text message were made to reach participants. Research team members provided training on ethical photo-taking17 and asked participants to take photographs during their daily routine to illustrate their postpartum experience during the COVID-19 pandemic.

Interviews were conducted 1–2 weeks after the training call. Data collection and analysis was supervised by a qualitative research scientist (R.F). Interviews were conducted by trained MD–MPH students via phone call or video conferencing platform that allowed sharing of photographs in real time.

Interviews began with a broad question about a photograph (“tell me what is going on in this picture”), followed by a question about how the photograph helped to explain what postpartum life was like for participants during the COVID-19 pandemic.18 Interviewers asked follow-up questions based on participants' responses, ending with a general summary question allowing participants to share final thoughts.17 Interviews lasted roughly 60 minutes, and participants were compensated with a $50 debit card. Interviews were audio recorded, transcribed verbatim, and checked for accuracy by the investigators.

We used a directed content analysis approach wherein a priori codes were conceived during literature review, and deductive codes were borne from line-by-line review and open coding of transcripts.21 A constant comparison approach was deployed throughout data collection to compare themes between the two groups. Although there was an adequate number of participants in each group based on insurance type, the shared challenges between them predominated, and the sample was analyzed as one unit. Codebook development began with four authors (E.C., L.B., M.H., and L.S.) open-coding the first transcripts. The coding team then met and created a preliminary codebook with explicit definitions for each code to improve coding validity.22 All coauthors, including two obstetrician-gynecologists (M.H. and R.M.) and two qualitative methodologists (R.F. and A.H.R.) provided feedback on the codebook. Three researchers (E.C., L.B., L.S.) independently coded two transcripts using this preliminary codebook, and final revisions were incorporated.

To ensure coding reliability, 50% of the transcripts (15) were collaboratively coded. Coding discrepancies were resolved in real-time through consensus with entire coding team (E.C., L.B., L.S., R.F).23 After coding was completed, the study team organized codes into thematic categories to form an explanatory model (Fig. 1). Coding and analysis were facilitated by NVivo 12 software.

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Fig. 1.:
Explanatory model of postpartum wellness in a pandemic. Based on the Swiss cheese model of accident causation.24 Illustration by Aaron Miller, MD. Used with permission.Critchlow. Postpartum Experiences During COVID-19. Obstet Gynecol 2022.

Given the personal nature of interviews, a contingency plan was created to address potential ethical and safety concerns. Participants' locations were requested at the beginning of interviews in case concerns necessitated emergency assistance. This information was destroyed at the conclusion of the interview. Local resources were offered to all participants, including information on resources for mental health, breastfeeding, and parenting support.

RESULTS

Between December 10, 2020, and April 1, 2021, 30 women completed interviews at 5.4 weeks postpartum on average (Table 1). Twenty-five participants (83.3%) were recruited in-person on the postpartum unit, and five (18.7%) were referred by participants (no two participants were referred by the same individual). Participants were of diverse racial and ethnic backgrounds reflecting the host institution's hospital demographics. Twenty-three (77%) participants were cohabiting with a partner, while four (13%) did not live with another adult.

T1
Table 1.:
Demographic Characteristics of the Study Participants (N=30)

Analysis of transcripts resulted in data being organized into four thematic categories (stressors, self-care, interpersonal support, and organizational support), which informed the development of an explanatory model of postpartum wellness during the COVID-19 pandemic (Fig. 1). This model was inspired by the “Swiss cheese” model of accident causation24 to demonstrate how new mothers' stressors during a pandemic interact with supports at individual, interpersonal, and organizational levels. In this model, stressors encounter each layer of support and can either be softened by support, alleviating some stress, or fall through “holes” in that support, continuing or enhancing stress. Each category is described below, supported by participant-generated photographs and quotations. Additional photographs and quotations can be found in Appendix 1, available online at https://links.lww.com/AOG/C557.

Participants described multiple stressors that characterized their postpartum experiences during the COVID-19 pandemic. Worry and fear were common emotions both first-time and experienced mothers expressed, most often in relation to safety during the pandemic.

“I wasn't this worried with my other three children. With [my newborn], it's just like so many things are out there and this-this disease is out there, and we don't know what can happen, we don't know who can get it, we don't know who has it…I'm so paranoid.” (024)

“I caught COVID already while I was, uh, 37 weeks pregnant. So um, I'm pretty, uh, scared…As long as I feel like, um, the kids go outside and come back, I feel like they have to have a mask on when they interact with [my newborn].” (033, Fig. 2)

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Fig. 2.:
Photograph taken by a participant of her older child in a mask holding her newborn.Critchlow. Postpartum Experiences During COVID-19. Obstet Gynecol 2022.

In taking precautions to keep their newborns safe, some participants worried that their baby was missing valuable social interaction important for their normal development.

“Normally [my newborn] would be exposed to more people and, you know, he would get a chance to kind of build…his like social skills and stuff like that.” (012)

Uncertainty and feeling out of control, such as in the case of rapidly changing guidance and information, were common sources of stress for participants.

“…everything you've been reading is like, ‘Kids can't get it’ …‘Well actually kids…get this terrible other disease that goes along with it instead, and now they're super-spreaders’ and it's like, there's just been so much conflicting information… there's so much unknown…” (028)

Due to the COVID-19 pandemic, participants' plans for newborn child care were often fraught with roadblocks. Many participants discussed how initial plans for support from extended family no longer felt safe or feasible during the pandemic. Alternate child care plans, such as hiring caregivers or enrolling in daycare, posed similar challenges and safety considerations.

“The plan before…was having [my partner's] mom come and stay with us as I transitioned back to work. Um, she works in a nursing home…so that kind of scrapped our-our idea. Um, so we're looking into nanny-share…we don't have a car, either, so it would have to be walkable- or even a daycare, which kind of scares the living crap out of me.” (003)

Many participants relied on those living with them, or few trusted family members living nearby, to assist with child care for their newborns and older children. For some families, this required multitasking child care with work or household duties.

“I had to feed him at a certain time, change him at a certain time, so he'll sleep for a certain amount of time so when I go [to my doctor's appointment], [my partner could] watch him, but [my partner] had a two-hour meeting at that same block of time…” (003)

Although some participants found various resources to make child care work for them, many participants still expressed that they did not get adequate help.

“I was expecting to get more help…There was some periods in which I was just so overwhelmed that I used to cry…” (093)

Participants with multiple children reported stressors caring for older children along with a newborn. Pandemic precautions meant that many participants spent almost all of their waking time with their children without reprieve. In addition, most participants reported that their older children were receiving virtual schooling from home due to the pandemic, placing a greater burden on these parents who were concurrently caring for a newborn.

“When you're at home with your second grader, you're a teacher now too…” (071, Fig. 3)

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Fig. 3.:
Photograph of a participant holding her newborn while simultaneously helping her older child with schoolwork.Critchlow. Postpartum Experiences During COVID-19. Obstet Gynecol 2022.

The experience of grief and loss in the postpartum period was pervasive in many interviews. Some participants were navigating loss of loved ones to COVID-19. Others highlighted the loss of rituals like baby showers, loved ones meeting the newborn, and newborn photography.

“…this my first baby, so I wish I could have had a baby shower. Um, I'm not sure if I'll have another baby, so I feel like that's something that I would have wanted to-would have wanted to experience...” (047)

“…it takes some of the joy away from it because you want to be able to share your child and share the joy of this new birth with everybody.” (064)

As a result of limiting contacts as a safety precaution during the COVID-19 pandemic, participants shared feelings of isolation and the toll these precautions had taken on their mental health.

“…it kind of could get like real depressing…like your mindset is stuck because there's not really a lot of stuff you can do…you ever see in those movies where they throw the person in the room with a straight-jacket on…? That's basically like it is for me but I'm not in a straight-jacket, my mind is the straight-jacket it's just stuck.” (017)

Discussions about participants' jobs and returning to work during the pandemic included safety and financial concerns, from working a demanding job from home with a newborn to safety of their newborn once returning to work outside the home. Three participants disclosed they worked in health care and expressed worries about managing exposures. The pandemic necessitated unpredictable changes to participants' employment, and those seeking a new job met challenges in the pandemic economy as well.

“Financially things are just tough. Very, very tough right now…before, um, COVID came into play, I was doin’ Uber…I stopped drivin’ in March…I'm just broke until everything blows over I guess.” (005)

“You can't get a job, everything's closed down, or if it's not closed down, it's not hiring…And then like, if you do have a job…it was just a hundred times harder because you couldn't find nobody to watch your kid.” (017)

Almost all participants were juggling several stressors that compounded on one another. For example, one participant discussed the financial stress she faced in coordinating her work schedule with her partner's to adapt without reliable child care for their four children in a pandemic.

“[If] my job would've told me they didn't have an overnight position, I would've lost my job. And I would've had to, because I can't put [my newborn] in daycare with all this going on….oh God, it was so scary, ‘cause like at this point, what are we gonna do, how're we gonna live, how're we gonna pay rent, how're we even gonna get groceries… We have no back up plan, we don't have anything...” (024)

During the interviews, participants reflected on strategies they used to cope with the stressors of the early postpartum period and the COVID-19 pandemic. Although participants expressed feelings of isolation, they developed new ways of thinking to help them feel less alone, such as reflecting on shared struggles or staying optimistic.

“….Don't compare to like what your friends had or even for me, exactly how it was the first time… you have to just focus on all of the really good things. You know, I'm just so happy that [my newborn is] healthy…” (044)

Self-care was a common and important form of coping for participants, ranging from walks outdoors to watching television to showering. Although certain coping strategies were unimpaired, some participants faced challenges maintaining self-care during this time, such as closed businesses or lack of child care. Some participants reflected on turning to their faith and spirituality as a way to cope.

“So whenever I have time I—which is, I have a lot of time now, I read the Bible…it gives you strength and hope and helps you, like, not be all depressed about the pandemic and all of the bad things that were happening in 2020.” (057)

In coping with the stressors of the pandemic, participants described several groups of support persons. From rotating child care and feeding responsibilities to providing a listening ear, participants expressed how their partners provided physical and emotional support during this time.

“Dad is a great help, he's doing bottles, he's going to doctor's appointments by himself. Um, he's changing diapers, he's washing her up…he's a great support system.” (024)

“I also feel like the emotional help is pretty powerful that like [my partner] is like pretty aware of how-how I need to process things and…I feel very very lucky that um, he's kind of been there every step of the way for me and for [our baby].” (035)

Social distancing restrictions during the pandemic limited the number of people who could attend perinatal and pediatric visits. Our participants explained challenges they faced attending visits alone.

“Normally my husband and I would go [to the pediatrician] together…the things that we're struggling with with baby, it's very much like a collaborative…at home, so I had to repeat back to him what [the doctors] said.” (010)

Although partners were a strong support during a stressful time for some participants, for others, disagreements about COVID-19 safety at home and outside exposures complicated or strained relationships.

“…while I was pregnant…[my partner] decided he wanna be around his friends and stuff like that, he's still shakin’ hands…and he knowin’ I don't want my kids, you know, close up on people with everything goin’ on...” (005)

“…That picture means something to me because [my newborn is] with his father. But again, you see the dry wall on his shirt. He, he hasn't stopped working….He comes to the house to see him. He spends time with him and it's a risk…Do I say, no, you can't come in here or no, you can't go to work for 2 weeks. You have to quarantine. Like, how does that work?” (064)

Family members including participants' parents, siblings, and older children, and friends were frequently mentioned as important physical and emotional supports. Some friends and family provided support to participants through delivering gifts and food, which manifested as opportunities for connection. Participants expressed both gratitude for this support as well as stress in communicating that gratitude during times of social distancing and quarantining.

“…My friends are awesome and they set up a meal train…we felt so guilty because they were doing something so kind and so thoughtful for us and then like we were kinda like okay but you have to stay outside…” (046, Fig. 4)

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Fig. 4.:
Photograph of participant with her newborn at their window waving to friends who have dropped off food.Critchlow. Postpartum Experiences During COVID-19. Obstet Gynecol 2022.

Social distancing and quarantining during the pandemic made it difficult for participants to feel supported by family or friends they did not live with. Participants also expressed stress over communicating these socially distant boundaries, sometimes complicated by loved ones disagreeing with the participants' decisions.

“Uh, sometimes [my family members do] get it but sometimes...they tell me that it's very strict…And it's just like I'm not being mean it's just, you know, your job is very risky, and I don't want you to, you know, be here with the children.” (093)

Many participants turned to virtual means as a compromise, helping family and friends support participants and meet the baby without risk of transmission. Participants relied on friends and family, particularly other new mothers, for information or advice and described some ways in which the shift to virtual communication during the pandemic had actually made seeking support from peers easier.

“…I have my one friend we were just talking FaceTiming and she was saying, ‘Oh no you need to lift him up and burp him now’…just through a FaceTime conversation she was like, ‘Okay, now do this.’ (laughter) Um so we're learning…literally virtually how to be a parent.” (003)

Despite the benefits of virtual connections, participants emphasized that messaging or videoconferencing could not replace in-person support from friends and family.

Participants identified several organizational and structural supports that helped them through their postpartum period and shared how COVID-19 affected access and navigation of these resources. Several participants discussed using government resources such as SNAP (Supplemental Nutrition Assistance Program), WIC (Special Supplemental Nutrition Program for Women, Infants, and Children), and unemployment assistance. Many expressed a greater need for these resources during the pandemic due to the economic climate and difficulty finding employment. Participants with experience utilizing these resources described the ways in which the COVID-19 pandemic had altered the process, in some cases creating additional barriers to obtaining essential resources.

“…Before [the pandemic]…you get everything that you need [at WIC appointments], all the resources in one day, whereas now it's just like, drop the card in there, there's no contact with us, and if I didn't have a car it would've been awful ‘cause I would've had to wait outside [in the cold].” (024)

Participants explained that, in an effort to decrease face-to-face interactions and potential exposures, these programs incorporated more virtual components during the pandemic. Although some participants found that this made the process more difficult, others found it easier.

“So with my food stamps, I wasn't able to go to actually set everything up, it was all done email or via, like, the computer or, like, internet, so it's harder and it was a longer wait...” (088)

“At the hospital they give you information, um, to reach out to them, to your local WIC office and…everything was on the phone obviously because of the pandemic, um, which was a lot easier than having to go there in person taking the baby and everything. It was very, very easy…less overwhelming.” (057)

Participants also discussed their experience with support from employers. Many participants expressed gratitude for receiving paid parental leave and reflected on what their postpartum experience would be like without this support.

“…I think a lot about mothers in my same situation who, like, can't work from home or…don't have the kind of maternity leave that I have…I just think it's so-so critical like I can't imagine going back to work right now [at 5 weeks].” (041)

Participants had regular in-person and virtual interactions with health care systems throughout their pregnancy and postpartum. Some participants found these interactions supportive, highlighting the benefits of new virtual programs and consolidation of care in the context of the pandemic.

“… people are starting to come together because of the pandemic, it's like more forums for women to talk about the situations that they're going through, to ask questions possibly about parenting, um, the lactation app that they just like formed in Philadelphia…I'm sure that they were around before, but the information is being circulated better… I was able to talk to a lactation specialist by just clicking a link…” (064)

“…if [the] lactation doctor wasn't [at the pediatrician's office], it was like, it was gonna be hard for me to find a lactation doctor that was actually, like, [good] help. I don't know where to look for a lactation doctor because I- my family didn't breastfeed…So it was like actually good that it was already there because COVID would've been, it would've been hard because you not allowed to go to a lot of places...” (088)

Other participants, however, felt that changes made during the pandemic negatively affected their health care experience. Some participants felt less cared for due to limited in-person interactions.

“…My experience with the actual doctors or hospital, it just was bad…Like they didn't want to be near the patients that much because they were like, ‘we don't know if y'all have [COVID] or not,’…” (047)

“Cause I was, like I said, used to going [into the office] and making sure everything was okay, but I- they even lessened your appointments throughout, I was only in the office maybe a handful of times.” (058)

DISCUSSION

Postpartum women are a vulnerable population profoundly affected by the COVID-19 pandemic. This qualitative study of postpartum women of diverse obstetric, socioeconomic, and racial backgrounds identified important stressors and different levels of support in the early postpartum period (Fig. 1). Similar to findings from the literature, participants described stressors exacerbated by the pandemic, including fewer options for newborn child care14 and feelings of isolation25 compounding poor mental health,14 which can predispose to serious conditions like postpartum depression. Although most participants relied on partners living with them for child care, four participants had no other adults in the home to help. Inquiring about patients' living situations can help to understand their child care needs and supports postpartum. Feelings of fear, uncertainty, and loss were unique to the pandemic, adding layers of psychological stress to an already emotional time, and pandemic-related employment concerns contributed to economic stress.

For some participants, self-care, interpersonal, and structural support helped alleviate those stressors. Effective self-care strategies and interpersonal supports included taking walks and receiving virtual support and advice from loved ones. Participants also expressed gratitude for paid maternity leave and virtual access to governmental supports. Lactation support from pandemic adaptations like care consolidation and a new phone application in Philadelphia increased some participants' ability to continue breastfeeding, which has important physical, mental, and financial benefits. However, participants' experiences demonstrated the many ways in which the pandemic exposed deficiencies in these supports. For example, participants identified barriers to self-care, unsupportive partners and partners whose jobs posed a greater risk to the newborn, and governmental supports ill-adapted to serve the elevated needs of a pandemic economy. Challenges within the health care system during the pandemic included feeling unsupported via telehealth and restrictions on visitors such as partners and doulas for delivery and doctor’s appointments. Visitors provide emotional support and advocacy, and restrictions disproportionately disadvantage women of color, particularly Black women, contributing to existing disparities in maternal morbidity and mortality.26 Barriers to care must also be considered in the context of other social constructs; for example, women of color were particularly vulnerable to changes in access to mental health care during the pandemic.27

Our findings can be used to improve care for postpartum women during a global disaster and in its aftermath (Table 2). These findings may also inform avenues of future research, including interviews or surveys that inquire explicitly about the stressors and supports that emerged from this study and their relationship to clinical outcomes.

T2
Table 2.:
Themes and Proposed Action Items for Supporting Postpartum Women

This study has several strengths. Purposeful sampling of participants of varying socioeconomic backgrounds ensured that the study included women across socioeconomic strata. Additionally, the participants of this study were diverse by self-reported racial and ethnic background, age, and gravidity, which is particularly important as COVID-19 disproportionately affects women of color.28 Photo-elicitation methodology was also a major strength of this study, as it prepared participants for the interview and facilitated development of rapport, allowing for conversations with greater depth.

Our study has limitations. Our findings should be understood in context of the timing of the interviews (December 10, 2020, to April 1, 2021) and their location given that fluctuating case numbers and local social distancing and mask regulations likely influenced participants' experiences. The use of self-reported data results in an inherent risk of social desirability bias. To mitigate this, researchers maintained a safe and validating interview environment and assured participants of their anonymity. Our sample was limited to English-speaking, cisgendered women with term or late preterm deliveries primarily in the Philadelphia metropolitan area, and thus the experiences of those outside of this group are not reflected by our results. Finally, it is possible that individuals who were struggling more during the pandemic may not have had the time or energy to participate in this type of study.

Overall, the pandemic has exacerbated key fault lines in the support systems that postpartum individuals need to manage stressors. Our findings highlight a need to proactively discuss potential postpartum stressors and supports during perinatal visits to establish these support systems in advance. Better understanding the needs and available supports for postpartum individuals during the COVID-19 pandemic will be crucial in providing effective care in its aftermath and in future public health emergencies.

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