Study design and recruitment
Pregnant women were recruited for the “Implications of and Experiences Surrounding being Pregnant during the COVID-19 Pandemic” at Woman’s Hospital in Baton Rouge, Louisiana. Participants were recruited via advertisements communicated through participating institutions’ outreach resources (hospital newsletter, the Woman’s Hospital Pregnancy app, social media, and the Woman’s Hospital obstetrical nursing hotline) and via targeted, secure notifications (MyChart messages, text messages) when permissible by institutional policies. If participants began the survey or indicated interest to their prenatal care provider but did not complete the survey, a research assistant contacted them and encouraged them to complete the survey. Because recruitment was virtual, receiving care at a participating hospital was not a requirement, but a large majority of the participants received care on site.
This analysis covers up to 3 surveys. Participants enrolled in the study at any point during their pregnancy and completed the baseline survey at this point. The first follow-up survey was sent one week after baseline; if not completed then, reminders continued to be sent until they completed it or delivered their baby; median time of completion was 1.6 weeks after baseline. An additional survey was sent 4 weeks postpartum. Woman’s Hospital limited visitors starting on March 13, 2020, and Louisiana issued a stay-at-home order on March 22, 2020. Recruitment began in April 2020 at Woman’s Hospital. Louisiana entered phase 1 of lifting of requirements (stay at home order removed, occupancy restrictions, masks and social distancing required) in May 2020, phase 2 (more businesses open) in June 2020, phase 3 in September 2020, and returned to phase 2 in November 2020. In March of 2021, the state returned to phase 3 [17]. This analysis includes participation through March 2021: 1037 participants with baseline surveys; 596 with follow-up surveys; and 302 with postpartum surveys (Table 1). Participants were sent the postpartum survey regardless of whether they had completed follow-up surveys previously.
Social distancing behaviors
Questions on social distancing behaviors were asked at baseline about behavior over the last 7 days. We created scales of social distancing behaviors based on whether they involved social distancing from work, friends and family, or public places. Because we had no a priori reason to think any particular social distancing behavior would be more strongly associated with mental health than another, all indicators were scored equally (one point on the scale).
Work social distancing score was the summed number of positive responses to the following: stayed home from work, was working from home and hadn’t before, or was working or studying from home (all of which were considered to represent the same experience); “left your home and went to work” (reverse-coded), and “cancelled or postponed work or school activities”. Analysis of this variable was limited to those who were employed before the pandemic.
Social distancing from friends/family was the summed number of positive responses to the following: stopped social visits with friends; stopped social visits with family; stopped playdates/visits with children’s friends; gone to friend, neighbor, or relative’s home (reverse-coded); had visitors at your home (reverse-coded); and cancelled or postponed personal or social activities.
Social distancing from public places was the summed number of positive responses to the following: stopped travelling/travel plans; stopped attending worship or religious services; gone out to a bar, club, or place people gather (reverse-coded); attended a gathering with more than 10 people, such as reunion, wedding, funeral, birthday party, concert, or religious service (reverse-coded); avoided public spaces; remained in residence at all times.
A summary measure summed all the above indicators as well as positive responses to “have you been placed in isolation?” and reporting that they lived alone.
On the postpartum questionnaire, participants were also asked whether they had been avoiding: public spaces, gatherings, and crowds; and eating at restaurants.
Mental health
Timing and sample size for each measure is outlined in Table 1.
Anxiety was measured at baseline and follow-up with the Generalized Anxiety Disorder-7 (GAD-7) scale [18]. In both cases, women were asked about their emotional state during the last two weeks. The GAD-7 has been validated in pregnant populations [19].
Perceived stress was measured at baseline with the Cohen Perceived Stress scale (PSS) using the10-item version. Questions were asked about the previous month. The PSS has been shown to correlate with depression, social support, and self-esteem in pregnant populations [20].
Pregnancy-related anxiety was measured at follow-up with the Perinatal Anxiety Specific Scale (PASS). Questions were asked about the time since the COVID pandemic started. The PASS scale correlates with depression and identifies pregnant persons with significant anxiety [21].
Pregnancy stress was measured at baseline using items that asked both about overall feelings of stress and anxiety since the pandemic (3 questions) and feelings of stress and anxiety about the pregnancy specifically (3 questions). This instrument was created to be a snapshot of mental health during the pandemic and has not been validated.
Depression was assessed at follow-up and postpartum with the 2-item Patient Health Questionnaire (PHQ-2). This instrument has been validated in pregnant populations and performs reasonably well with a small tendency towards false positives [22].
Analysis
Each type of social distancing (variable construction provided above) was categorized into quartiles; due to the relatively limited number of responses, the work social distancing variable was categorized into 3 levels. The association between social distancing and mental health factors was examined using ANOVA, and with other covariates using chi-square tests. Covariates were chosen on the basis of being known predictors of mental health during pregnancy (race, marital status, parity, education, and income [categorized as listed in Table 2]) and thought to be potentially associated with social distancing. Participants also reported whether they had a positive COVID-19 test, had been told by a doctor that they had COVID-19, or thought they had been infected with COVID-19. We also examined predictors of social distancing, incorporating all covariates simultaneously into a cumulative logistic model and conducting backward selection until only factors significant at p < 0.05 remained. These factors were incorporated as covariates into subsequent models.
Linear models using mental health factors as continuous outcomes were examined, with social distancing as a categorical major predictor with adjustment for race, marital status, parity, education, and income. Interaction with race and parity was examined in these models using a product term; no interactions were found. For outcomes with both a baseline and measure taken prospectively, a model was also constructed incorporating both the covariates listed above and the baseline mental health levels.
This study was approved by the Institutional Review Board of Woman’s Hospital, and participants provided informed consent during the online survey.
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