Postpartum post-traumatic stress symptoms during the COVID-19 period: exposure and fear as mediating factors

ABSTRACT

Background: Post-traumatic stress symptoms (PTSS) following childbirth are common within a stressful environment and are mitigated by social support. During the COVID-19 pandemic, an increase in such symptoms has been reported. The current study aims to longitudinally model the influence of general and pandemic-specific risk and protective factors on the temporal unfolding of symptoms among postpartum women.

Methods: Participants were 226 women following a liveborn, term birth during the first lockdown in Israel. Participants completed questionnaires 10 weeks (T1) and 6 months (T2) after delivery. PATH analyses included predictors of symptoms in T1: demographics, exposure to traumatic events, medical complications during delivery or pregnancy, exposure to COVID-19-related events and their subjective impact, fear of COVID-19, and social support. Predictors of symptoms in T2 were: T1 predictors, both as direct effects and mediated by T1 PTSS, as well as predictors measured again in T2.

Results: Results showed the suggested model fit the data. The effect of COVID-19-related fear and subjective impact at T1 on symptoms at T2 were fully mediated by PTSS in T1, as were the effects of marriage and high social support at T1. COVID-19-related fear at T2 positively predicted symptoms at T2, while social support at T2 had the opposite effect. Medical complications during pregnancy negatively predicted symptoms in T2 only.

Discussion: Persistent fear appears to be a risk factor and supports a consistent buffer in postpartum PTSS during the COVID-19 pandemic. Medical complications during pregnancy served as a protective factor, possibly due to habituation to medical settings.

HIGHLIGHTS

• Post-traumatic stress symptoms (PTSS) following childbirth during the COVID-19 pandemic may unfold in a unique manner, relating to pandemic-related stressors and fears.

• Women who experience stressful pandemic-related events are not at heightened risk of developing PTSS within the six months following birth, but those reporting COVID-19 related fears are.

• Women who had medical complications during pregnancy, but not delivery, are at lower risk of developing subsequent PTSS, perhaps due to their ongoing contact with medical facilities despite the pandemic.

GRAPHICAL ABSTRACT

Antecedentes: Los síntomas de estrés postraumático (SEPT) luego de dar a luz son comunes dentro de un ambiente estresante y son mitigados por el apoyo social. Durante la pandemia del COVID-19, se ha reportado un aumento en tales síntomas. El presente estudio busca modelar longitudinalmente la influencia de los factores protectores y de riesgo generales y específicos de la pandemia en el desarrollo temporal de los síntomas entre las mujeres después del parto.

Método: Las participantes fueron 226 mujeres después de un parto de término nacido vivo durante el primer confinamiento en Israel. Las participantes completaron cuestionarios a las 10 semanas (T1) y 6 meses (T2) luego de dar a luz. Los análisis PATH incluyeron predictores de síntomas en T1: las variables demográficas, la exposición a eventos traumáticos, las complicaciones médicas durante el parto o embarazo, la exposición a eventos relacionados al COVID-19 y su impacto subjetivo, el temor de COVID-19 y el apoyo social. Los predictores de los síntomas en T2 fueron: predictores de T1, tanto los efectos directos y mediados por los SEPT en T1, como también los predictores evaluados de nuevo en T2.

Resultados: Los resultados mostraron que el modelo sugerido se ajustó a los datos. El efecto del temor asociado al COVID-19 y el impacto subjetivo en T1 en los síntomas en T2 fueron completamente mediados por los SEPT en T1, como también los efectos del matrimonio y alto apoyo social en T1. El temor asociado con el COVID-19 en T2 predijo positivamente los síntomas en T2, mientras que el apoyo social en T2 tuvo el efecto opuesto. Las complicaciones médicas durante el embarazo predijeron negativamente los síntomas solo en T2.

Discusión: El temor persistente parece ser un factor de riesgo y amortigua consistentemente los SEPT después del parto durante la pandemia del COVID-19. Las complicaciones médicas durante el embarazo sirvieron como factores protectores, probablemente debido a la habituación a los contextos médicos.

背景：分娩后的创伤后应激症状 (PTSS) 在应激环境中很常见，可以通过社会支持得到缓解。在 COVID-19 疫情期间，报告的此类症状有所增加。本研究旨在对一般和疫情特定风险和保护因素对产后妇女症状随时间演变的影响进行纵向建模。

方法：参与者是 226 名在以色列第一次封锁期间活产、足月分娩的妇女。参与者在分娩后 10 周 (T1) 和 6个月 (T2) 完成问卷调查。路径分析纳入了 T1 症状的预测因素：人口统计学、创伤事件暴露、分娩或怀孕期间的医疗并发症、暴露于 COVID-19 相关事件及其主观影响、对 COVID-19 的恐惧和社会支持。T2 症状的预测因素是：T1 预测因素，既作为直接效应，也由 T1 PTSS 中介，以及在 T2 中再次测量的预测因素。

结果：结果显示提出的模型拟合了数据。 T1 时与 COVID-19 相关的恐惧和主观影响对 T2 症状的影响完全由T1 PTSS 中介，T1 中婚姻和高社会支持的影响也是如此。 T2 时与 COVID-19 相关的恐惧可以正向预测 T2 时的症状，而 T2 时的社会支持则产生相反的效果。怀孕期间的医疗并发症仅对 T2 中的症状产生负向影响。

讨论：持续的恐惧似乎是一个风险因素，并支持在 COVID-19 疫情期间持续缓冲产后 PTSS。怀孕期间的医疗并发症是一个保护因素，可能是由于对医疗环境的习惯。

KEYWORDS:

• Birth
• trauma
• PTSD
• COVID-19
• structural equation modelling
• PTSS

PALABRAS CLAVE:

• Nacimiento
• trauma
• TEPT
• COVID-19
• Modelamiento de Ecuaciones Estructurales
• SEPT

关键词:

• 出生
• 创伤
• PTSD
• COVID-19
• 结构方程模型
• PTSS

Acknowledgements

Authors wish to thank Michal Tevet and Tal Malka for their assistance in data preparation and manuscript formatting and submission.

Author contributions

Noga Shiffman – Data collection, writing the first draft, editing the final manuscript. Hadar Gluska – Data collection, editing the final manuscript. Yael Mayer – Study conceptualization and final draft review. Shiri Margalit – Data collection, Data analyses and write-up. Rawan Daher – Data collection, translation to Arabic of relevant materials. Lior Elyasyan – Data collection. Nofar Elia – Data collection. Maya Sharon Weiner – Data collection, collaboration between centres. Hadas Miremberg – Data collection, collaboration between centres. Michal Kovo – Data collection, collaboration between centres. Tal Biron-Shental – Data collection, collaboration between centres. Rinat Gabbay-Benziv – Study conceptualization, draft conceptualization, supervision of data collection. Liat Helpman – Supervision of and participation in manuscript conceptualization and writing, design of analyses, editing.

All authors provided critical feedback and helped shape the research, analysis, and manuscript. All authors gave their final approval to the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All data may be available upon request contingent on the approval of institutional Helsinki committee.