For many, having a baby during the pandemic era may have been a more isolating experience than usual. Masks during delivery. Birthing without a partner in the room. Skipping traditional baby showers. Fewer visits from family and friends.

And now, two new studies suggest that living in the times of COVID has taken a toll on new moms' mental health.

One in three new people who had babies in the beginning of the pandemic experienced postpartum depression – potentially triple pre-pandemic levels – while one in five had major depressive symptoms, according to research led by the University of Michigan School of Nursing and Michigan Medicine.

A separate study from the same U-M team also found that those who gave birth during the first six months of COVID-19 reported more distress and anxiety.

"Even before COVID, we were seeing an increasing number of women with mood and anxiety disorders around the time of pregnancy, including postpartum depression," said Vanessa Dalton, M.D., M.P.H., an obstetrician gynecologist at University of Michigan Health Von Voigtlander Women's Hospital and a senior author on both studies.

"Then we layer in COVID, a time when many of us who were taking care of pregnant women had to prioritize reducing transmission of the virus," she added. "We are starting to understand the potential consequences these measures had on moms in terms of isolation and moms' mental health."

Before COVID, the Centers for Disease Control and Prevention estimated that one in eight women experienced postpartum depression, and about five to seven percent experienced major depressive symptoms, said lead author of both studies Clayton Shuman, U-M assistant professor of nursing.

The two studies are part of a larger COVID M.A.M.A.S. (Maternal Attachment, Mood, Ability and Support) study, which collected survey data on maternal mental health and breastfeeding during the COVID-19 pandemic.

Postpartum depression prevalence during the pandemic

U-M teams analyzed survey results from 670 postpartum patients who delivered babies between February and July 2020 for one of the studies that appears in BMC Research Notes.  

Among factors associated with higher risks of depression were formula feeding, neonatal intensive care unit admission and worry around COVID-19 infection.  

Shuman says he was surprised by the numbers – a third of women screened positive for depression and a fifth for major depression. One in five who screened positive for postpartum depression reported thoughts of harming themselves.

He said the findings were especially concerning following a Michigan Medicine led study that found increased prevalence of suicidal thoughts and self-harm among childbearing women.  

"Treatment is pivotal to recovery," he said. "Resources and education about postpartum depression must be better disseminated and implemented. These resources should be shared with the general public to reduce stigma, and shared with those who provide social and emotional support to postpartum patients, such as partners and family members."

Participants who fed their infants formula had 92% greater odds of screening positive for depression and 73% greater odds to screen positive for major depressive symptoms compared to those who breastfed or bottle-fed with their own human milk.

This could be attributed to several factors, authors note. Previous research has found that breastfeeding support resources such as lactation consults were limited during early COVID and may have increased distress or caused people to switch to formula. Stress from supply chain problems that resulted in formula shortages could have also contributed to depression.

Studies also suggest that breastfeeding may help to protect postpartum patients from postpartum depression, authors say, helping to minimize the severity of depressive symptoms and improving recovery time.

Each one week increase in weeks postpartum also increased the odds of screening positive for depression by 4%, the new study suggests.

"COVID was really anxiety provoking for some people. It upended their lives, and many didn't experience some of the joyful festivities that usually occur around a birth like gatherings and family help," Dalton said. "This meant an already at-risk group of people were made more vulnerable by the pandemic."

Pandemic pregnancy: Increased anxiety, distress, but also a few surprise benefits

The U-M team analyzed the same data for separate research in Maternal and Child Health Journal, resulting in the first known study to describe the lived experiences of postpartum women in the United States who delivered an infant during the early days of the COVID-19 pandemic.

Five themes emerged: heightened emotional distress; adverse breastfeeding experiences; unanticipated hospital policy changes shifting birthing plans; expectation versus reality – or mourning the experience of what should have been; and unexpected benefits of the pandemic.

Social distancing and infection control measures contributed to increased guilt, isolation and depression in postpartum parents, and many were denied pre-pandemic coping mechanisms and experienced a lack of support, Shuman said.

While researchers expected some increase in emotional distress and guilt, the extent surprised Shuman.

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"Moms said they felt like no matter what they did, it was wrong," he said.

Some women shifted birthing plans, for instance switching from in-hospital to out-of-hospital births, or elective inductions, to avoid a trip to the hospital. Restricted visitation was described by one mom whose doula was prohibited from attending her birth as "heartbreaking."

Dalton, whose previous research has explored the relationship between depression and anxiety and cesarean deliveries among pregnant women, said when expectations around labor and delivery don't match the day itself, it can lead to intense disappointment.

"People have very deep feelings and excitement around having a baby," she said. "They often have a vision about what that day should look like. When things go differently, there may be feelings of loss because the event wasn't what they always dreamed of.

"Add on the biologic reasons women experience depression after pregnancy and all of the disruptions to the labor and delivery experience over the last two years and you can understand how COVID could exacerbate mental health issues in this population."

But there was a surprising finding too: the pandemic also brought the benefits of unexpected quiet time. Fewer visitors immediately after the birth, both at the hospital and at home, was viewed as a positive by many parents, the research suggests.

Shuman said the pandemic highlighted existing shortcomings in the United States' cookie-cutter approach to maternal care.

"Providing a one-size-fits-all approach to maternal care isn't working," he said. "Because of mental health issues, we need tailored care—some do well with telehealth but not all. Prenatal and postpartum visit schedules should also be tailored to individuals, especially for new moms."

"We have an urgent need to address mental health around the time of pregnancy," Dalton added. "We have to do a better job of screening and recognizing depression in pregnancy and do whatever we can to remove barriers to mitigate risk factors and make resources and treatment available.

"This is a fire alarm for us to recognize and address a long-existing problem," she said. "We hope the heightened awareness around this topic will lead to making changes in the way we support women and reduce stigma around talking about depression and anxiety during pregnancy."

Additional authors include Mikayla Morgan, Jolyna Chiangong, Neha Pareddy, Philip Veliz and Alex Peahl, all of U-M.

Studies cited:

"'Mourning the Experience of What Should Have Been': Experiences of Peripartum Women During the COVID-19 Pandemic," DOI: 10.1007/s10995-021-03344-8

"Postpartum depression and associated risk factors during the COVID-19 pandemic," DOI: 10.1186/s13104-022-05991-8.    

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