Identifying pregnant women at risk of developing COVID-19 related mental health problems – a call for enhanced psychoeducation and social support

As the global infection and death rate of COVID-19 soars in the second wave of infections, and with a vaccine still at least a year away, we need to ensure we manage pregnant women appropriately in this difficult period [1]. We have to help women adjust to this “new normal”. This means we need to support each other and join forces to fight the virus, whilst maintaining social distancing. We want the best for our patients, whilst taking care of our family, friends and ourselves. Every day we have to make decisions about whom we can help, and those we cannot. In a time of high demand, we have to maximize efforts to identify groups at particular risk to direct help to those who will benefit the most at the individual, family and population level. This requires research that not only focusses on the direct medical impact of the virus, but also on the indirect psychosocial and mental health effects which will persist beyond the advent of any vaccination program.

In the last six months there have been many publications on COVID-19. As pregnant women and their unborn children were considered to be a risk group for COVID-19, more than 1000 studies have evaluated concerns [2]. In this edition, the letter by Ifdil et al. stresses the importance of paying attention to treating depression and psychological distress in pregnant and postpartum women during COVID-19. Based on Indonesian case reports, they highlighted how pregnant women who experienced psychological distress during the Covid-19 outbreak because they were precluded from health services had an increased risk of maternal death [3]. Although the availability of health services and pregnancy outcomes between countries varies, data suggests that pregnant women experience high levels of psychological stress due to COVID-19. The authors argue that a synergy between medical and psychological experts is needed to manage physical and psychological effects of COVID-19.

Effects of negative pregnancy and child outcomes

As a result of the growing number of publications about the effects of COVID-19 on pregnant and postpartum women, it is possible to perform reviews and meta-analyses to obtain more robust outcomes. These outcomes show that pregnant and postpartum women do not seem to have an increased risk of infection compared to the general population and that there is minimal risk for vertical transmission [4]. However, pregnant women, when they are infected, are more likely to need intensive care treatment and invasive ventilation [5]. In addition, the odds of preterm birth is approximately three times higher in pregnant women with COVID-19 and neonates have a two times higher risk of admission compared with those without disease [5]. The long-term effects of the virus on both maternal and fetal outcomes are still unclear. Altogether, the emerging information may cause stress in pregnant women and lead to altered help-seeking behavior.

Psychological and psychosocial effects

Although far less research is available on the mental and psychosocial effects of COVID-19, some studies show increased levels of anxiety and depression among pregnant women compared to others with infection [4]. The new reality of social distancing and social withdrawal from friends and family, may aggravate concerns in vulnerable pregnant and postpartum women.

In this edition a study of Değirmenci et al., reports that the psychosocial health status and perceived social support of pregnant women with working spouses is significantly higher [6]. This conclusion has significant importance in the context of COVID-19, since the prolonged pandemic will certainly have economic and financial consequences, including unexpected unemployment. COVID-19 related stressors can predispose to negative coping strategies that threaten physical and mental health, such as substance abuse, reduction of help seeking because of fear of infection, and relational stress, including intimate partner and domestic violence [4].

In this edition Salameh et al. used data from the National Survey on Drug Use and Health (NSDUH) to study longitudinal trends in mental health, substance use disorders and treatment receipt of pregnant and nonpregnant women [7]. Notably, pregnant women had lower odds of mental illness, but those who had mental illness were less likely to receive mental health treatment than their nonpregnant counterparts. This conclusion should also be taken into account when addressing pregnant women during COVID-19, as they are less likely to receive mental health care.

We must remain vigilant in identifying, preventing and treating intimate partner violence (IPV) during COVID-19. A qualitative study of Jackson et al. recognized the importance of giving adequate treatment to pregnant women who experienced IPV [8]. In this group of women, they investigated the impact of Trauma and Violence-Informed Cognitive Behavioral Therapy (TVICBT) during pregnancy. Their results showed that therapy positively impacted on IPV-related mood and anxiety disorders. Women valued the assistance received and reported ‘life changing’ insights that enabled them to understand their health care challenges and identify potential triggers. Women reported that TVICBT was an opportunity to disclose their experiences and struggles without judgment – leading to the fostering of positive therapeutic relationships and more positive parenting outcomes. The study highlights the importance of psychoeducation and support for vulnerable pregnant women. This message is further reinforced in the meta-analyses by Akgün et al., which found that psychoeducation is effective in reducing pregnant women's fear of childbirth and rate of cesarean sections [9].

Support for women at risk

So far only a few studies have been published on the detection, prevention and treatment of COVID-19 related psychological and psychosocial functioning and mental health of pregnant and postpartum women. Therefore, we have to rely on studies performed in high-risk women outside COVID-19. These studies suggest that pregnant women with life stress, poor social support, and domestic violence are at-risk for mental health problems [10]. Since COVID-19 is an important life stressor in itself, it is important to develop and enhance social contact and support for pregnant women who otherwise lack support or who avoid help-seeking because of fear of infection. One suggestion on how we might proceed is articulated in a perspective paper by Orru et al. [11] who argue a triple approach involving psychoeducation and use of questionnaires to detect psychological distress for healthcare professionals, online channels of psychological support for the population, and specific targeted strategies for high-risk groups.

It is a joint responsibility for all clinicians to work together to develop and enhance support for pregnant women as we manage the second wave of infections.

Disclosure statement

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