Pregnancy and birth are transforming experiences for both parents and the newborn, typically requiring adjustments and challenges at both an individual and family level (Epifanio, Genna, Luca, Roccella, & Grutta, 2015; Stern, Bruschweiler-Stern, & Freeland, 1998). During pregnancy and birth, the mother experiences physical, biological, psychological, and relational changes (Carmona et al., 2019; Olza et al., 2020), that favor the baby’s development while requiring specific care and support from a third party, frequently the partner or father. Both parents must guarantee the baby’s survival, development, and mental health while undergoing this normative crisis and balancing their life roles (Epifano et al., 2015; Stern et al., 1998). Considering how sensitive these processes are to the environment and the parents’ role in preparing the baby’s arrival (Olza et al., 2020), there is a potential risk that life demands may exceed the individual, interpersonal,l and contextual resources available in the triad. This could generate negative consequences for the parents and the baby (Baldwin & Kelly, 2015; Paulson & Basemore, 2010).
Currently, the coronavirus pandemic and its related health measures have triggered high levels of fear in pregnant and puerperal women and their partners, due to the perceived vulnerability, and the risk of contracting the virus and its consequences (Rashidi, Fakari, & Simbar, 2020). Although fear is an emotion that leads to protective and caring behaviours in dangerous situations, when it is activated for a significant amount of time during pregnancy, labor, and peripartum, it can lead to negative consequences (Olza, 2017). In the mother, it has been linked with anxiety and depression (Fontein-Kuipers et al., 2014), as well as attachment issues (Monk, Spicer & Champagne, 2012). In the baby, a neurotoxic effect from long-term stress has been described, which interferes with the later emotional management skills, learning, and posterior executive functions (Nelson, 2020).
Studies conducted during the pandemic on parents going through the peripartum period, describe concerns, fears, stress, and symptoms at different levels. Concerning infection and childbirth, anxiety related to the risk of death has been reported. Also, the following concerns have been identified:
- Protocols during delivery and newborn care.
- Mothers fear being unaccompanied during check-ups and labor.
- Increased frequency on requests for c-sections.
- Induced labor.
- A higher number of deliveries at home without the necessary assistance.
- Fear of exposition to toxic effects of disinfection products.
- Early mother-baby separation after birth and
- Difficulties to start breastfeeding (Rashidi et. al. 2020).
There are also medical risks described linked to lock down and the lack of sun, physical activity, and vitamin D, such as a higher risk of thromboembolism and a rise in the mothers’ and family stress (WHO, 2020). At a psychological level, recent studies describe an increase in anxious and depressive symptoms on pregnant women in isolation and/or with decreased social contact, even considering symptomatology before the pandemic, as well as an increase in gender violence during pregnancy and birth (Davenport, Meyer, Meah, Strynadka, & Khurana, 2020; WHO, 2020).
Fortunately, preliminary findings from scientific research on the effects of coronavirus during pregnancy and peripartum show a minimal probability of vertical transmission, low risk for virus-related complications in pregnant women and fast remission, as well as low impact on the development of the unborn baby (Chen et al., 2020; Khalil et al., 2020). However, due to the lack of knowledge about the virus and its consequences to date, and to the physical and inmunitary changes that take place during pregnancy, expecting mothers have been considered, with their babies, a risk group (Allotey et al., 2020; OMS, 2020a).
Suggestions from the WHO for the care of pregnant and puerperal women are the same as for the general population and emphasize that both breastfeeding and skin-to-skin contact should be prioritized due to the lack of evidence of transmission through breastfeeding (OMS, 2020b). The fostering of these practices bolsters the role that nursing and skin-to-skin contact have in nurturing: physiological regulation, sleep quality, health, development, and mortality risk reduction in babies. In turn, these elements, trigger the creation of new neural circuits in the mother for the care and protection of the baby (Bergman, 2014).
Despite all of the above, the protocols and guidelines suggested by different governments in some European and Latin American countries can vary greatly between each other. Moreover, the enforcement of these protocols depends on each particular establishment and location, generating important differences between the recommendation and what is being practiced.
Unfortunately, with the intention of controlling infection, professionals have made their own decisions based on limitations within their healthcare centers and fear. These measures include interruption of partner support during pregnancy check-ups and delivery, over-operated labors and restrictions in parents visiting hospitalized premature babies (GCABA, 2020; Martínez-Pérez et al., 2020; Minsal, 2020; Minsalud Colombia, 2020; Ministerio Sanidad España; Sadler, Leiva & Olza, 2020).
Before COVID-19, evidence had shown a considerable reduction of mortality at birth due to the medical advances and the assistance of professionals during pregnancy and labor (OMS, 2019). Nevertheless, the fear and uncertainty associated with COVID-19, increased speculation of death and disease, which in some cases impacted decisions and procedures during pregnancy and delivery. Furthermore, the concerns and uncertainties linked to COVID-19 that intimidate the parents and their babies also affect the healthcare professionals that assist the deliveries, who may change their professional behaviour. This could lead to increased medicalisation, and imposed interventions of greater control that are not necessarily in line with the available information (O´Connell, Crowther, Ravaldi & Homer, 2020; Wilson et al., 2020). All of that could have negative effects during the birthing process, in the mothers’ and babies’ mental health, and in the creation of a secure attachment, which may reduce the mother’s participation in her own experience of labor (Horsch, Lalor & Downe, 2020; Olza et al., 2020).
Evidence shows that overvaluing medical procedures at the expense of natural and instinctive processes of birthing can result in negative experiences in childbirth for the mother and the baby (Olza et al., 2020). Studies indicate that, depending on the characteristics of the mother, these experiences could lead to post-traumatic stress disorder (Dekel, Stuebe & Dishy, 2017). Common risk factors to developing PTSD have been described to include factors such as first-time mothers, preterm labors, c-section, and early separation of the mother from her newborn (Olza et al., 2014). Such factors could even impact the future reproductive life plan of the mother (Gottvall & Waldenström, 2002), the breastfeeding process, and the initial interaction of the mother and the baby as it reduces the enjoyment and increases the unpleasant emotions within this relationship (Beck & Casavant, 2019).
As mentioned above, pregnancy, delivery, and puerperium are processes of large physical, biological, and psychological vulnerability for both parents and the baby. These subjective experiences cause deep and lasting changes at a neurobiological, psychological, and relational level, that could leave a long-lasting and permanent mark, and that could impact on the infant’s brain structure with the risk of later psychopathology (Carmona et al., 2019). In the current context of the pandemic where the real risks of death and disease have increased, the levels of individual and family stress, and especially, the feeling of uncertainty are growing; particularly in the risk groups that include pregnant and puerperal women and newborns.
Guidelines must have clear information based on current scientific research so that they safeguard the processes of pregnancy and childbirth. In this scenario pregnancy and after birth care and protocols must promote and guarantee mother and child contact, allowing that the mother deploys her competencies in relation to the health and wellbeing of the baby (Olza et al., 2020).
A study carried out in Chile about COVID-19 and its impact on early parenthood had almost 300 pregnant women participating (Olhaberry et al., 2020). They reported fear and worries about the idea of getting infected, of isolation, not having company during checkups and delivery, and the possibility of being separated from their newborn should they have a positive PCR test. For example:
I fear that whilst going for a checkup I could get infected…
Isolation… you already know you are going to be alone during the first months after your baby is born, but now, also 3 months before! It makes it so much harder to prepare for postpartum.
Going alone to the routine checkups and exams, not being able to share your pregnancy with your loved ones…
Knowing the baby is going to be born whilst in the peak of the pandemic and that if either you or your husband have a positive PCR they won’t let you see your newborn for 14 days…
Not knowing who will assist you during labor, if I will have company, what protocols will be enforced at the moment, and especially the fear of me or my husband getting infected before or after my daughter is born.
In the same study, these women also reported worries concerning their motherhood in isolation and to the future relationship with their children:
I will be avoiding physical contact of my baby with the outside world until all of this is completely over …
More fear and apprehension during upbringing my child…
I think this might trigger an overprotectiveness in me…
Practice guidelines from local governments, should be based on scientific evidence and be promoted and enforced correctly so that in addition to avoiding new infections they protect parents and newborns. It cannot be forgotten that pregnancy, childbirth, and puerperium are periods highly vulnerable and sensitive for both parents and the baby. Decisions made should facilitate and promote contact with other significant caregivers in the presence of a positive COVID-19 test in the mother. The support of the father, or other significant figures, to the mother-baby dyad, should always be allowed, acknowledging the importance of early bonding for future development and mental health.
Healthcare providers should also be guaranteed safe working conditions, that allow them to assist adequately pregnancies and birthing. Currently, the challenge is to protect ourselves from coronavirus at the time proper conditions of peripartum are safeguarded, this means, not to forget the need for contact, closeness, and emotional availability of the parent towards their newborn and their own emotional needs.
Key ideas for the clinical practice
- Pregnant women are a special group that requires specific considerations in clinical practice. During a highly-sensitive environment period, they need attention in mental health that takes into account their particular needs and characteristics.
- Fear can have a strong influence on the development of mother and child mental health and in the child’s’ later development that needs to be acknowledged.
- There is a need to create guidelines based on evidence, that are respectful of the needs and the mother-child bond during pregnancy.
Allotey, J., Stallings, E., Bonet, M., Yap, M., Chatterjee, S, Kew, T.,… Thangaratinam, S. (2020). Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ, 370(m3320). https://doi.org/10.1136/bmj.m3320.
Baldwin, S., & Kelly, P. (2015). Postnatal Depression: Don’t reinvent the wheel. Community Practitioner, 88(9), 37-40. Recuperado de https://pubmed.ncbi.nlm.nih.gov/26489251/
Beck, C. T., & Casavant, S. (2019). Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth. Journal of obstetric, gynecologic, and neonatal nursing: JOGNN, 48(4), 385–397. https://doi.org/10.1016/j.jogn.2019.02.004
Bergman, Nils J. (2014). The neuroscience of birth and the case for Zero Separation. Curationis , 37(2), 1-4. https://dx.doi.org/10.4102/curationis.v37i2.1440
Carmona, S., Martinez-Garcia, M., Paternina-Die, M., Barba-Muller, E., Wierenga, L., Alemán-Gómez, Y.,…Hoekzema, E. (2019). Pregnancy and adolescence entail similar neuroanatomical adaptations: A comparative analysis of cerebral morphometric changes. Human brain mapping, 40, 2143-2152. https://doi.org/10.1002/hbm.24513
Chen, H., Guo, J., Wang, C., Luo, F., Yu, X., Zhang, W.,…Zhang, Y. (2020). Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet, 395(10226), 809-815. https://doi.org/10.1016/S0140-6736(20)30360-3
Davenport, M. H., Meyer, S., Meah, V. L., Strynadka, M. C., & Khurana, R. (2020). Moms Are Not OK: COVID-19 and Maternal Mental Health. Frontiers in Global Women’s Health, (1). https://doi.org/10.3389/fgwh.2020.00001
Dekel, S., Stuebe, C. & Dishy, G. (2017). Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors. Frontiers in Psychology, 8(560). https://doi.org/10.3389/fpsyg.2017.00560
Epifanio, M., Genna, V., Luca, C. D., Roccella, M., & Grutta, S. L. (2015). Paternal and Maternal Transition to Parenthood: The Risk of Postpartum Depression and Parenting Stress. Pediatr Rep, 7(2). https://doi.org/10.4081/pr.2015.5872
Fontein-Kuipers, Y. J., Nieuwenhuijze, M. J., Ausems, M., Budé, L., & de Vries, R. (2014). Antenatal interventions to reduce maternal distress: a systematic review and meta-analysis of randomised trials. BJOG: An International Journal of Obstetrics and Gynaecology, 121(4), 389–397. https://doi.org/10.1111/1471-0528.12500
Gobierno de la Ciudad Autónoma de Buenos Aires (GCABA). (2020). Protocolo de manejo de mujeres embarazadas y recién nacidos en el contexto de la pandemia COVID-19. Recuperado de https://www.buenosaires.gob.ar/coronavirus/equipos-salud/protocolos-coronavirus-covid-19/protocolo-de-manejos-de-mujeres-embarazadas-y-recien#
Gottvall, K., & Waldenström, U. (2002). Does a traumatic birth experience have an impact on future reproduction?. BJOG: An International Journal of Obstetrics and Gynaecology, 109(3), 254–260. https://doi.org/10.1111/j.1471-0528.2002.01200.x
Horsch, A., Lalor, J., & Downe, S. (2020). Moral and mental health challenges faced by maternity staff during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S141-S142. http://dx.doi.org/10.1037/tra0000629.
Khalil, A., Kalafat, E., Benlioglu, C., O´Brien, P., Morris, E., Draycott, T.,… Magee, L. (2020). SARS-CoV-2 infection in pregnancy: A systematic review and meta-analysis of clinical features and pregnancy outcomes. The Lancet, 25(100446). https://doi.org/10.1016/j.eclinm.2020.100446.
Martínez-Perez, O., Vouga, M., Cruz Melguizo, S., Forcen Acebal, L., Panchaud, A., Muñoz-Chápuli, M. & Baud, D. (2020). Association Between Mode of Delivery Among Pregnant Women With COVID-19 and Maternal and Neonatal Outcomes in Spain. JAMA. Published online June 08, 2020. https://doi.org/10.1001/jama.2020.10125
Ministerio de Salud de Chile. (2020). Recomendaciones para prevención de transmisión de la infección por COVID-19 en unidades de pediatría y UPC pediátricas. Recuperado de https://www.minsal.cl/wp-content/uploads/2020/07/Recomendaciones_Medidas_prevencion_Servicios_Pediatrias_UPCP080720.pdf
Ministerio de Salud de Colombia. (2020). Lineamientos provisionales para la atención en salud de las gestantes, recién nacidos y para la lactancia materna, en el contexto de la pandemia de COVID-19 en Colombia. Recuperado de https://www.minsalud.gov.co/Ministerio/Institucional/Procesos%20y%20procedimientos/GIPS14.pdf
Ministerio de Sanidad de España. (2020). Documento técnico. Manejo de la mujer embarazada y el recién nacido con COVID-19. Recuperado de: https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/Documento_manejo_embarazo_recien_nacido.pdf
Monk, C., Spicer, J., & Champagne, F. A. (2012). Linking prenatal maternal adversity to developmental outcomes in infants: the role of epigenetic pathways. Development and Psychopathology, 24(4), 1361–1376. https://doi.org/10.1017/S0954579412000764
Nelson, C. A. (2020). The Implications of Early Adversity Even Before Birth. JAMA Netw Open, 3(1), e1920030. https://dx.doi.org/10.1001/jamanetworkopen.2019.20030
O´Connell, M., Crowther, S., Ravaldi, C., & Homer, C. (2020). Midwives in pandemic: A call for solidarity and compassion. Women and Birth, 33(3), 205-206. http://dx.doi.org/10.1016/j.wombi.2020.03.0081871-5192
Olhaberry, M., Sieverson, C., Romero, M., Franco, P., Morán, J., Tagle, T., Muzard, A., Iribarren, D., Díaz, F. & Honorato, C. (Octubre, 2020). Parentalidad temprana y COVID-19: Cambios, desafíos y aprendizajes. Ponencia presentada en el Congreso Virtual de la SIP Aportes de la Psicología ante el COVID-19.
Olza, I., Marin Gabriel, M., Gil-Sanchez, A., Garcia-Segura, LM. & Arevalo, MA. (2014). Neuroendocrinology of childbirth and mother-child attachment: the basis of an etiopathogenic model of perinatal neurobiological disorders. Frontiers in Neuroendocrinology, 35(4), 459-472. https://doi.org/10.1016/j.yfrne.2014.03.007
Olza, I. (2017). Parir. El poder del parto. Barcelona: De Books.
Olza, I., Uvnas-Moberg, K., Ekström-Bergström, A., Leahy-Warren, P., Karlsdottir, SI., Nieuwenhuijze, M.,… Buckley, S. (2020). Birth as a neuro-psycho-social event: An integrative model of maternal experiences and their relation to neurohormonal events during childbirth. PLOS ONE 15(7): e0230992. https://doi.org/10.1371/journal.pone.0230992
Organización Mundial de la Salud. (2020a). Preguntas frecuentes sobre la COVID-19, el embarazo, el parto y la lactancia materna, 2 septiembre 2020. Recuperado de https://www.who.int/es/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-covid-19-pregnancy-and-childbirth
Organización Mundial de la Salud. (2020b). Preguntas frecuentes: Lactancia materna y COVID-19 para trabajadores de la salud, 12 mayo 2020. Recuperado de https://www.who.int/docs/default-source/coronaviruse/breastfeeding-covid-who-faqs-es-12may2020.pdf?sfvrsn=f1fdf92c_8
Organización Mundial de la Salud. (2019). Mortalidad materna, 19 septiembre 2019. Recuperado de https://www.who.int/es/news-room/fact-sheets/detail/maternal-mortality
Paulson, J., & Bazemore, S. (2010). Prenatal and Postpartum Depression in Fathers and Its Association With Maternal Depression A Meta-analysis. JAMA, 303(19), 1961–1969. https://doi.org/10.1001/jama.2010.60
Rashidi Fakari, F., & Simbar, M. (2020). Coronavirus Pandemic and Worries during Pregnancy; a Letter to Editor. Archives of Academic Emergency Medicine, 8(1), e21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075675/
Sadler, M., Leiva, G. & Olza, I. (2020). COVID-19 as a risk factor for obstetric violence. Sexual and Reproductive Health Matters, 28, 1. https://doi.org/10.1080/26410397.2020.1785379
Stern, D., Bruschweiler-Stern, N., & Freeland, A. (1998). The birth of a mother. New York, EUA: Basic Books.
Wilson, A. N., Ravaldi, C., Scoullar, M. J. L., Vogel, J. P., Szabo, R. A., Fisher, J. R. W., & Homer, C. S. E. (Accepted/In press). Caring for the carers: Ensuring the provision of quality maternity care during a global pandemic. Women and Birth. https://doi.org/10.1016/j.wombi.2020.03.011
World Health Organization. (2020). COVID-19 and violence against women: what the health sector/system can do, 7 April 2020. World Health Organization. Recuperado de: https://apps.who.int/iris/handle/10665/331699.
By Macarena Romero (Programa de Salud Mental Perinatal. Centro de Salud UC Christus Pontificia Universidad Católica de Chile), Catalina Sieverson (Programa de Salud Mental Perinatal. Centro de Salud UC Christus, Pontificia Universidad Católica de Chile), Marcia Olhaberry (Programa de Salud Mental Perinatal. Centro de Salud UC Christus Escuela de Psicología, Pontificia Universidad Católica de Chile), Carolina Honorato (Programa de Salud Mental Perinatal. Centro de Salud UC Christus, Pontificia Universidad Católica de Chile) and Trinidad Tagle (Programa de Salud Mental Perinatal. Centro de Salud UC Christus Pontificia Universidad Católica de Chile).
Acknowledgments to: This study was supported by the Fund for Innovation and Competitiveness (FIC) of the Chilean Ministry of Economy, Development and Tourism, through the Millennium Science Initiative, Grant N° IS130005 (Millennium Institute for Research in Depression and Personality MIDAP, Chile).
The anonymous participant research data presented in this article, is part of a major study: "Learning about parenting experiences with children and unborn babies during the Coronavirus (COVID-19) pandemic in Chile", led by Dr. Marcia Olhaberry.
Corresponding author: Marcia Olhaberry, Escuela de Psicología, Pontificia Universidad Católica de Chile. Vicuña Mackenna 4860, Macul, Santiago, Chile. E-mail: email@example.com