Maternal mental health in the time of the COVID‐19 pandemic

With the pandemic of Coronavirus disease-19 (COVID-19) spiraling out of control, the world is desperately frazzled at the moment. A few empirical studies related to this pandemic have reported higher prevalence of mental health problems among women compared to men.1 In this context, pregnant women and new mothers could certainly be more vulnerable. Are there psychological repercussions of this outbreak on maternal health? Are perinatal maternal mental health disorders an inevitable burden of this pandemic? Could this be averted with a proactive, multidisciplinary, integrated health services approach targeting the vulnerable population of pregnant women? Although pregnancy is commonly believed to be a joyous time for most women, some women experience a range of negative emotions during pregnancy leading to anxiety and depression. Maternal mental health problems are associated with short-term and long-term risks for the affected mothers' overall health and functioning, as well as their children's physical, cognitive and psychological development. Conditions such as extreme stress, emergency and conflict situations, and natural disasters can inflate the risks of perinatal mental health morbidity. Therefore, it is plausible that pregnant women are vulnerable to mental ill-health during the COVID-19 pandemic. Several studies on COVID-19 and pregnancy have been published recently, but the impact of this pandemic on maternal mental health has not yet been properly evaluated. However, the importance of considering the possibility of increased risk to avoid adverse effects has been highlighted.2 The risk may be related to concerns regarding the wellbeing of the unborn child, but aggravated by unintended consequences of preventive measures, such as quarantine, physical distancing, home isolation, remote consultations with healthcare professionals, and inability to obtain expected level of support and care prenatally as well as during the intrapartum and postnatal periods. The World Health Organization and several professional societies of obstetricians and gynecologists have come up with guidelines in managing COVID-19 during pregnancy and delivery, but the recommendations vary due to lack of solid evidence.2 Although initial data from China suggested no increased risk of infection and morbidity among pregnant women compared to the general population,3 a different picture is emerging as the outbreak has escalated into a global pandemic. Pregnant women may be at risk of having more severe disease, preterm deliveries are more common, and maternal and neonatal mortalities have been reported.4, 5 Furthermore, risk of miscarriage associated with COVID-19 remains unclear although the presence of severe acute respiratory syndrome corona virus-2 (SARS-COV-2) in a second trimester placenta has been demonstrated.6 These uncertainties are likely to add to psychological stress and may even lead to increased rates of pregnancy terminations. As many hospitals have put restrictions on visits by partners and relatives to pregnant women admitted to hospitals for delivery, some women may choose to deliver at home. This could create a problem as availability of qualified birth attendants and midwives to support home deliveries is limited, even in affluent countries, and may lead to increased maternal and neonatal complications. Although transmission of SARS-COV-2 through breast milk is unlikely,7 some infected women may choose not to breast-feed temporarily to avoid direct contact with the newborn and reduce the risk of neonatal infection. However, such practices and early cessation of breastfeeding may contribute to poor health among mothers and infants.8 Strict public health measures directed towards mitigating the spread of disease are necessary, but known to have negative psychological effects leading to stress, anger and confusion.9 The prolonged pandemic chaos will inevitably have economic consequences, and financial uncertainties are likely to further escalate psychological burden and worsen the mental wellbeing of pregnant women and new mothers. Some individuals may resort to harmful methods of coping with the crisis, such as alcohol consumption and substance abuse, thus adding to existing mental health problems. This may also lead to an increase in gender-based intimate partner violence, reduction in preventive help seeking behavior, and increase in suicide rates with devastating results, especially among low-income families and immigrant communities. In this unprecedented time, every country in the world is struggling and trying its best to join forces to combat an unfamiliar disease. The importance of surveillance for emerging threats to pregnant women and infants during times of crisis cannot be overemphasized.10 However, mental health needs are currently overshadowed by other, more pressing issues in healthcare. It may take time to generate sufficient and sound evidence, but we can safely speculate that pregnant women are at increased risk of developing mental health problems such as depression, anxiety, and post-traumatic stress symptoms. There appears to be a substantial knowledge gap, but also a reluctance to accept that the psychological wellbeing of pregnant women is important to care for during such a crisis. Hence, it is important to proactively develop appropriate strategies to alleviate stress by screening, identifying and managing perinatal mental health disorders during the pandemic, without delay. Internet-based screening tools, virtual online consultations/counseling and web-based psychological support and therapeutic interventions may have an important role in this regard. None.