Experiences of early parenthood in and beyond the Coronavirus pandemic/outbreak

doi:10.21203/rs.3.rs-4986698/v1

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Research Article

Experiences of early parenthood in and beyond the Coronavirus pandemic/outbreak

https://doi.org/10.21203/rs.3.rs-4986698/v1

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The term ‘Perinatal’ incorporates pregnancy, birth and the postnatal period. The perinatal period is a milestone event in both the individual and familial life cycle, an experience shared by the wider social network and community. Yet, it can be a period where the impact of pre-existing and emerging mental health problems during this time could necessitate specialist Perinatal Mental Health Services (PMHS) support via the NHS. COVID-19 pandemic is considered to have exacerbated the adversity for Perinatal Mental Health (PMH), yet questions on the lived experience remain unanswered.

Interviews with expectant and new mothers were analysed using Reflexive Thematic Analysis (RTA) establishing themes of 1- Perinatal Medical Care during COVID-19 Pandemic, 2- Becoming a Parent within social isolation, iii- Managing the Perinatal Period with the Support of Perintal Mental Health Services (PMHS) and iv- Parenthood beyond the COVID-19 Pandemic.

Findings indicated that the COVID-19 Pandemic caused concerns and worries amongst pregnant, birthing, and post-partum women and that diminished opportunities for social support during the perinatal period created an adverse mental health impact upon them. Overall, COVID-19 appears to have a ripple effect on women and their families experiencing the perinatal period during COVID-19. Although participants largely did not link their poor mental well-being during the perinatal period to the COVID-19 Pandemic, they attributed the causes of their poorer experiences to the COVID-19 Pandemic, identifying the pandemic as contributor to their heightened perinatal mental distress and at times as sole cause for their referral to Perinatal Mental Health Services.

Perinatal distress is an umbrella term referring to parental experiences of anxiety and depressive symptoms, as well as other stresses from the time of conception up until the infant reaches 12 months of age. Distress during this period is associated with increased risk of parental mortality (Lewis, 2004) decreased quality of life, and poorer physical and mental health outcomes for the mother, as well as long-term negative health outcomes for the child, ranging from premature delivery to increased risk of behavioural and emotional problems in later years (Glover & O’Connor, 2002; Letourneau et al. 2012). Maternal mental health outcomes may result from hormonal changes as well as the strain of childcare and other related stressors within the individuals’ lives. These may be exacerbated by more general factors impacting on the wider population. Such a threat was posed by the COVID-19 pandemic, and there is now an established literature addressing the mental health impact of the COVID-19 on the perinatal population (e.g., Iyengar, Jaiprakash, Haitsuka, 2021 & Kim, 2021; Osborne, Kimmel, & Surkan, 2021; Olivier et al., 2021) although aspects of lived experiences remain unexplored within this population group.

COVID-19 placed a particular stress on pregnant and post-partum women as, coinciding with the normal biopsychosocial stresses and strains associated with childbirth, they may have experienced more severe ‘lockdown’ due to increased risk of acquiring covid, pneumonia (Goodnight and Soper 2005), experiencing miscarriage and foetal growth restrictions (Wong et al., 2016). Pregnant and post-partum women needed to shield themselves and their babies, limiting their access to resources including antenatal classes and, perhaps more critically, immediate social and family support; the latter being primary markers of resilience and protective against a range of mental health problems, including postpartum depression (Mundorf et al., 2018). This limited access to social support due to social distancing, as well as concerns about the potential impact of transmission of the virus to unborn or newborn children were found to contribute to relatively high levels of anxiety among new mothers by Almeida et al. (2020). The present study adds to these data, providing a deeper knowledge of lived experience, by focusing on a group of women in the peri-natal period who were already experiencing mental health problems prior to the time of lockdown. It aimed to explore their and their families’ experiences during this time and to determine how best to provide support in the case of future pandemics or similar catastrophes.

Ethical considerations

Ethical approval was granted through an IRAS (ID: 286205) application to Wales NHS Research Ethics Committee (REC 20/WA/0243); received on the 24^th of November 2020.

Welsh Context

This research was located in the geographical area served by two Welsh health care providers (Hywel Dda University Health Board - HDUHB and Swansea Bay University Health Board-SBUHB) during 2020-2021, during which the Welsh Government implemented lockdown measures, including limiting non-essential travel, preventing and limiting meeting of people from outside of one’s own household and changes to the service delivery of the NHS. On the 17^th of March 2020 the NHS announced cancellation of non-urgent operations and on the 23^rd of March 2020 wide-ranging restrictions were imposed to protect the public and enable the NHS to respond to the needs of individuals effected by the virus. The restrictions imposed impacted the delivery of health and care provision and had an impact on the levels and quality of the care received by women experiencing pregnancy, labour, and birth (Tadesse, 2020).

Participants

Participants were service users, and their partners referred to HDUHB and SBUHB. All participants were over the age of 18 years. A total of 23 participants were interviewed, including two male partners of service users. Due to the low number of interviews with male respondents, insufficient data was collected to permit analysis, and these interviews were excluded from analysis. The remaining interviews were transcribed and analysed. All participants identified as females in heterosexual relationships. Twenty were new mothers: one was currently pregnant and due to give birth in the coming days. (See Appendix 1: Table 1: Participant Demographics).

Procedure

Semi-structured interview was conducted, using videoconferencing software Zoom, between April and August 2021. Participants were asked about their perinatal experiences during the COVID-19. The semi-structured interview addressed their experiences during pregnancy and the peri-natal period and their views on how these differed from their expectations as a consequence of covid and how their mental health was affected by them. Interviews were audio recorded with live close captions and lasted between 28 and 65 minutes. Transcripts were corrected by listening to audio recordings and manually correcting errors.

Data Analysis

Data was analysed using Reflexive Thematic Analysis (RTA: Braun & Clarke 2019). After the transcripts were corrected and anonymised, the data was read and re-read with some text units marked and broad sets of themes noted by the lead researcher. Data was coded and codes were clustered together as they formed into distinct categories based on the topic/theme they generated which then generated sub-themes and themes using a saliency analysis approach (Bestow, 2010). The lead researcher (female, cisgender, nulliparous, BAME, a systemic psychotherapist and researcher) completed the process of coding and generating themes, at intervals sharing the process and discussing with a key colleague (male, cisgender, white British, clinical psychologist, and researcher) to ensure the data supported each category of the themes, and coded and clustered consistently. A reflexive approach was maintained towards data and the researchers had ongoing dialogue about their own assumptions and reactions to the data: the findings are treated as co-construction of meaning (Bell, 2013; Charmaz, 2015).

Data Analysis from the accounts of pregnant and post-partum women accessing Perinatal Mental Health Services via the NHS in Southwest and West Wales produced four main themes, and eleven subthemes as illustrated in Figure 1 Themes and Sub-themes in the Findings sub-section.

1- Perinatal Medical Care during COVID-19 Pandemic

Participants going through all phases of the perinatal period reported they had experienced significant adverse impacts as a result of the measures to prevent the spread of COVID-19. Sub-themes described the impact of: (i) the exclusion of partners from scans and hospitals; (ii) negative hospital experiences; and (iii) home births to avoid hospitalisation (Please see Table 1: Themes and Sub-themes)

i- The exclusion of partners from scans and hospitals.

To contain the spread of the virus there were limitations on who could enter health care centres, inadvertently created a situation whereby pregnant women had to attend their antenatal appointments alone and under uncomfortable circumstances:

PSB01: … you have to you have to wear a mask and then, when you did so the nurses all wear like visors and masks and everything on but you were still like sat there with like really advice to wear a mask…the waiting room was hot, it was horrible, all the chairs taped up and you're all just there on your own kind of like compared to the normal scans I had like in January [referring to pre lockdown scan in January 2020] it like it was it was really different, it was, trying to explain it like really lonely, you know.

The lack of a partner in the room meant that participants could not share the milestone experience of looking at the ultrasound image of their babies and hearing heartbeats with their partners. This loss became magnified when there was the potential for problems with the pregnancy:

PHD03: I was about nine weeks pregnant and I’m there to find out whether or not there's a viable pregnancy. And that's the sort of news you don't want to be alone, for you know if you do find out its bad news, you really want to have your husband with you…or even just a friend. And you had to go in alone for that, completely alone, which was extremely stressful you know. I was so anxious, I was so... Just upset anyway at the at the the thought that that could be the outcome and yeah you have to be dropped off at the hospital entrance and that's it - there’s nobody can come any further than that.

Those with healthy pregnancies talked about their concerns for future distress, as they could not foresee what the regulations would be and how this would impact their future ante-natal appointments and birth plans. Participants referred to restrictions on who can be at the wards inadvertently resulting in their partner’s and family not being there to support them and added to this often less than optimal care from the staff whose availability was also reduced owing to the impact of the COVID-19 Pandemic.

ii- Negative hospital experiences

All participants described the adversity of their experiences of going to hospitals from outpatient departments to admissions for birth and post-partum care. Unfortunately, reduced quality of medical care could lead to emotional experiences of high levels of distress and even psychological trauma.

PHD03: And he[her husband] had to leave, and that was it, you were you just had surgery you lost a lot of blood and you're there with a new born baby take care of, you know, I mean this is the situation, and you are responsible for yourself, I mean, I know, technically, the midwives, are there and the staff are there, but they are so busy, and so rushed off their feet that it's you can't really get hold of them every time you need something I mean you do need a lot at this point, you I was there, I was in I was lying in the bed completely naked with nothing but a sheet covering me with a new born baby right next to me, who was constantly crying, I’d lost an awful lot of blood my blood pressure, had dropped to I don't know what but you know very, very low, that they were very concerned and have to keep me in recovery for a long time and baby is crying you need to reach over to try and get him because you buzz for a nurse, and it takes about five minutes for someone to come because they're so busy, in the meantime, your baby is absolutely screaming their heads off this tiny little new-born and they're right next to you and you can't really even twist your body to get them it's a horrible situation to be in really, really, you know horrible and you feel very, very helpless.

iii- Home births to prevent hospitalisation

One of the challenges faced by the participants was giving birth under lockdown rules. Owing to fear of giving birth in the absence of family support, some of the participants changed their birth plans from hospital to home births so their partners could be with them throughout the process. Community births are considered riskier than hospital births, yet COVID-19 sparked an interest in home births (Cheng, Fisher and Nicholson, 2022). Anticipation of how the birth experience would be is not uncommon amongst pregnant women and it could affect the emotional wellbeing of women in the post-partum period (Sieber et al., 2006). However, uncertainty about how the COVID-19 Pandemic related restrictions would affect their birth experience is identified to heighten the feelings of anxiety and other emotional distress for the participants.

PHD10: I wanted to have a home birth, because I hadn't had a positive experience last time, but but my decision was influenced by worries about whether my husband, will be able to be in hospital with me and worries about what we would do with our other child while I was in hospital.

PSB03: But anyway, definitely that was that was the one non-negotiable was, I wanted him to be with me the whole time when we knew that., he was going to be separated from me, straight after we change to having home birth so we booked and set it up with a great time doing that we figured out what was going to happen we figured out the timings from our house hospital, checking the statistics and everything.

2- Becoming a Parent in Social Isolation

Participants talked about difficulties of becoming a parent in social isolation during various lockdowns. Two sub-themes emerged in this context: i- Regular activities becoming non-existent and ii- Restricted access to social support.

i- Regular activities becoming non-existent.

Pregnancy, birth, and post-partum periods are phases of life that are celebrated rituals, from being photographed to having baby showers and introducing the new baby to the world. The COVID-19 Pandemic changed the context, these well-established rituals could not be practiced. Pregnant and post-partum women represent a more vulnerable group and identified to be at risk of being negatively impacted by the related restrictions put in place to prevent the spread of the disease (Brooks, et al, 2020; Capobianco, et al., 2020).

PSB15: Especially because everyone's anxiety was through the roof anyway, while being pregnant, because you couldn't you couldn't go outdoors I see we're locked down because the point where we need to go for five minute walk every day, and that was that.

PSB07: …I never got the pregnancy massage I thought I go to yoga and meet other mums feeling, and I think I did one session of that before they shut it down the entities route that we joined again to make friends or the parent that was a new zoom nothing was in passing and I remember feeling at the time, like I just started showing when we went into lockdown and it kind of felt like those stories you hear about the Victorian teenagers, you know that you get pregnant out of wedlock and they get like I should away into a house somewhere where they do all in secret and nobody knows it's kind of like that I’d be on work meetings, and of course you're owning that up and I had this great big belly and it was it was all nobody saw nobody knew it was very weird.

PHD01: there was times I was really looking forward to my antenatal appointment because it was literally, the only socialization and the only trip out of the House, and then the midwife would call and say oh we're gonna have to do it over the phone…. There was no hypno birthing classes, which I was hoping to attend, there was no antenatal classes, which I would have attended… There was no pregnancy yoga which I plan to attend basically everything was cancelled, and it was it was quite a solitary experience, to be honest and the midwife was always on the end of the phone, but you know it's not the same…

ii- Restricted access to social support

Existing literature on post-partum experiences of women indicates that those who has access to social support from family and friends fare better with depression in the post-partum period (O'Neill, Cycon & Friedman, 2019; O’Neil, 2019; Razurel & Keiser, 2015; Reid & Taylor, 2015). Primiparous women expressed that they often struggled to make sense of their experiences from judging if they were progressing well with their pregnancy to managing their expectations of birth and post-partum periods.

PSB15: I didn't know as being like it my first my first pregnancy, I wasn't sure what was normal and what what wasn't obviously I understand because of covid 19, nothing was normal you know everything had been adjusted anyway, and I understand that, but. I also I wasn't sure when exactly I was supposed to be having check-ups and seeing the midwife and having scams and it was actually my family like or facetime over message and that were like have you seen your midwife, and I was like no not seen her. I think it was 10 weeks, I went without seeing her and they were like no, you need you need to report, you need to ask what what's going on and to be fair, without them saying I probably wouldn't have done anything.

Multiparous women had the advantage of knowing about the process owing to their previous experiences, the comments such as “because this is my second child, I already knew how to…” were amongst repeated comments. However multiparous women commented on the negative impact of a lack of social interactions and the challenges of managing a newborn whilst taking care of an older child who could not be sent to nursery or managing the home schooling of older children. Although people used online platforms to connect, linking in digitally whilst not substituting physical contact was slightly remedying the complete social isolation.

PSB10: Obviously, having one child, you know I know I know where it's like I know the baby blues say know, everybody gets it and that's normal, but I knew this time it wasn't normal and I think a lot of it was triggered by obviously lockdown and you know, we had covid and we were struggling…

PHD03: I think mentally long term mental health conditions are definitely going to arise as a result of it, you know unless you're super woman who is you know the most mentally stable person who would never be affected by anything frankly you've got to be a little bit on the psychopathic scale so something like that, not to affect you mentally I’ve got to be in that position and given us like that and to have absolutely no support : and have to hold it together and walk out of that hospital and find your car or find your partner who's waiting outside.

3- Managing the perinatal period with the support of PMHS

Participants reported the challenges posed by the COVID-19 to their mental health and to their receiving support from PMHS. Three sub-themes informed this theme: i- Exacerbated anxiety due to COVID-19, ii- The Mental health impact of COVID-19, iii- Accessing PMHS remotely.

i- Exacerbated anxiety due to COVID-19

The prevalence of anxiety disorders is higher for the maternal perinatal population (Leach, Poyser & Fairweather-Schmidt, 2017). Accounts of the participants reflected on how their anxieties emerged / exacerbated by the COVID 19 Pandemic. Women referred to their need to shield from COVID-19 but in doing so paradoxically their mental health worsening, lacking everyday interactions and social support.

PHD01: And I didn't even go to the shops, because I was worried about being pregnant and it was so early that there wasn't a lot of research, and pregnant women were being told to be more cautious.

PSB08: So, I was working still aren't I think the day Boris Johnson announce that pregnant women shouldn't work beyond a certain week I got sent home. So I was, like all right okay sent home and I stayed in my house only went for a walk but felt oh my God couldn't go for a walk it was quite scary because I will you know what we're seeing on TV and stuff.

PSB04: Well, I I feel like I can't take her anywhere, you know we don't take her into shops. You know just the everyday stuff. So that's really you are really restricted and I I’m really, I get quite anxious about it, I mean its just family, but I get anxious about family members come into the House because.

ii- The mental health impact of COVID-19

The COVID-19 pandemic was found to have varying levels of adverse impact on the mental wellbeing of the general population (Benke et al., 2020). Pregnant and post-partum women were identified to be at heightened risk of being negatively impacted by the related restrictions put in place to prevent the spread of the disease (Brooks, et al, 2020; Capobianco, et al., 2020). Accounts of the research participants highlighted the inescapability of their mental health suffering.

PHD03: I think mentally long term mental health conditions are definitely going to arise as a result of it, you know unless you're super woman who is you know the most mentally stable person who would never be affected by anything frankly you've got to be a little bit on the psychopathic scale so something like that, not to affect you mentally. I’ve got to be in that position and given us like that and to have absolutely no support and have to hold it together and walk out of that hospital and find your car or find your partner who's waiting outside.

PSB02:… then I started like suffering a little bit because I was seeing my partner less and less because of the outbreak in his workplace, he was having to cover like loads of shifts so I was on my own even more… and I will say that the maternity care during covid has been pretty awful and… you know I worry about what what's that done to their mental health, mothers who didn't have their partners with them for the scans…

iii- Accessing PMHS remotely

Participants’ accounts overwhelmingly demonstrated that they found the support of PMHS beneficial. Some participants commented on PMHS being an underused service because of women finding it difficult to ask for support. PMHS as a sub-speciality psychological service is still has a very young service in the UK (Thompson, Clarke & Moore, 2016) and was only appointed a national clinical PMHS Lead in Wales in 2019.

PSB12: Just that I think it's the perinatal mental health services, a very undervalued, I suppose, really, especially in times like COVID and I think that they've done a wonderful job of being there for expectant mothers throughout and they've given a lot of support and I think that more women shouldn’t, they shouldn't be frightened to ask for how they shouldn't be frightened to, you know, admit that there's something wrong with feeling low and share so anything because services are there to not to judge and, yes, I just like to add that in that's okay.

PMHS adapted their services in line with the COVID-19 regulations and began routinely offering remote provision of services via telephone and online platforms. Accounts of the participants reflect that transformation of the services to online was well received by some of the participants as it helped with their anxiety about going out to meet someone as well as new anxieties about exposure to COVID.

PHD07: Fantastic absolutely fantastic and, obviously, it was initially it over the phone when I spoke to, I think my first lady I spoke to was [name omitted] and I spoke to her. Initially it was just a telephone interview, how I was feeling and where I was, but I found that that was easier because I hadn't had to go anywhere and meet a stranger and talk to a stranger face to face and so yeah that was brilliant and then we had a program run by a lovely lady called [name omitted] and that would give us just basically emotional coping skills and different strategies that we could we could do is at all I’m not just myself, but you know as a family to to help manage….and they've been great as well with regards my medication, the communication between perinatal and my GP and you know I didn't have to go through the whole ringing the GP waiting for a call back…

PSB01: in my local surgery and I just sat there bawling my eyes out the whole time because I didn't want to go to work like like for safety reasons…so, she referred me from there and I didn’t, so I had a phone call, then, and which was really helpful…

Those who felt that they were disadvantaged by the remote service delivery made comments that they would find it easier to engage if the services were offered face-to-face. A participant’s account summarised this as:

PHD02: It was a big thing, because I think if I’d have been able to go in, it would have been easier to see that there was problems and those things I needed to talk about so I didn't take the advantage of that service that I should have because it was remote, that was the trouble.

4- Parenthood beyond COVID – 19 Pandemic

An attachment theory informed approach suggests that heightened distress due to the COVID-19 Pandemic might have long-term impact on parent-child relationships. The attachment relationship between parent and offspring starts developing from pregnancy (Condon, 1985; Condon & Corkindale, 1997) and can be impacted by major disasters due the frightening and life-threatening nature of them (Perkonigg et al., 2000). Research already suggests an adverse impact of COVID-19 on family systems through the added distress of COVID-19 and social isolation on mothers during the perinatal period (Venta, Bick & Bechello, 2021; Ollivier et al., 2021). Participants talked about their concerns around parenting during the COVID-19 Pandemic and raising their babies in isolation. Three subthemes formed this theme; i- babies overly attached to their mums, ii- new babies and older children and iii- Dads – the other parents.

i- Babies overly attached to their mums.

20 out of 21 participants were women who had already given birth to their babies during the COVID-19 Pandemic. Participants expressed concern that they were bringing their babies up in an isolated environment, not going to mother and baby events, celebrating the arrival of the babies, having the involvement of the extended family or friends and therefor they reported concerns that their babies were or would be overly attached to them.

PHD01: it's hard to say, and I think I don't think we're going to know for a few years what the impacts of this will have been on the babies themselves, and I think like for me and my baby, we've got a very strong bond and I think, maybe there's an element he's at an age now where he recognizes strangers he's got a strong attachment to me, so I think a lot of it is normal, but I think there's also an element of when there's a lot of people or people he doesn't recognize he does get a bit sensitive about it, and I think part of that is because he hasn't ever kind of had his you know he's never been to a park he's never been to a baby group he's never done…. Say Oh, can you take a minute for me to go to toilet, so you know so from a practical point of view, it had an impact because I felt like I was doing absolutely everything by myself and from a mental and emotional point of view, it was it it's been really hard because I’ve really wanted to share him. And I wanted to spend time with friends and family, and it's just not been possible.

ii- New babies and older children

Accounts of the participants indicated different challenges of the COVID-19 Pandemic period for primiparous and multiparous women. Whilst primiparous parents reported their struggle with lack of support during their novel experiences of pregnancy, birth and managing a new-born, multiparous parents talked about challenges of utilising home as a space for living and working, with partners often also working from home. They also discussed the challenges of managing older children who could not go to nurseries or child minders or supervising those requiring home-schooling, all alongside caring for a new-born with reduced social support.

PHD02: We found ourselves in this position, your childcare problems or your child care problems and I said, well, I can't I can't leave him unattended, you know, have to have to be there…incredibly difficult and there was lots of arguments within the home, we were in with each other's way all of the time, and I was really, really tired with the pregnancy, because I’m a little bit older and and it was just really difficult I couldn't give the children, what they needed I couldn't do the home schooling that they needed me to do on the level that they they needed it because the system weren't as good as they need it initially they didn't do the zoom lessons, either here for the children, it was all just the primary school anyway, it was all just sort of that send through tasks each day for the children to do, and you would have to do it with them, so it was even more difficult because it was less independent that it was on the second lockdown for the children. They would attend, like the zoom lessons a second lockdown but, as I said, it was just work, it would come through whether it's experiments or to research, something and and it was doubly difficult because there's some of it is in Welsh and I don't speak Welsh…. and like when I first when I was pregnant a few other mums I said Oh, you know the kids can come around after school a couple of days a week, and have dinner, you know so you've got longer and things like that, on the weekend, they can come around, but obviously none of that could happen.

iii- Dads – the other parents

Participants expressed loss and grief that their partners could not share the milestone experiences of the antenatal period such as going to scans, accompanying their partners during labour or spending time with their partners and newborn in the hospital.

PSB08: We suffered as a family because things that that got taken away from us, so my partner is only properly started bonding with my daughter now. You know the dad, you know when she was born okay go now you're allowed two hours two hours, he could have been there for, but he was there for about an hour and he had to go home and and then like we've always said, like we both made her, I did not just make that baby, this is his daughter as well you know and he's always said, you know how it's and it has affected him, you know we asked, and he you know he hasn't been that that that he you know he is a brilliant now, but you know, he was too scared to do anything, you know if it was the same you know whether it's just our first daughter I don't know you know.

PSB06: Because he's already struggling with mental health, he felt like it was more difficult to connect with the baby, it was very,very protective over us but compared to my first pregnancy, with my eldest he was able to go to every appointment, he was very involved and now with this one, because of the pandemic. He couldn’t go to any of the appointments and all he could really get what's the updates, I will bring him when I come home and share it with pictures.

A common advantage was repeatedly referred to was the appreciation of the dads’ presence of which happened through furlough or work from home schemes. Compared to two weeks paternity leave, dads could spend more time with the newborn, bond better and support mums.

PSB03: I think it's been good, and because he's been able to be home and he said how grateful, he is that he's could be around to experience now um but I know he felt utterly useless when I was in hospital, I mean there was he couldn't even do the being there for me, because he had to be at home.

Participants of this research – who were all patients of PMHS of NHS during the COVID-19 Pandemic - talked at length about their experiences of being pregnant, giving birth and new parenthood during COVID-19 Pandemic. Participants talked about the COVID-19 Pandemic heightening their distress during the perinatal period due to the fear that they were unable to protect themselves and their babies from contracting the virus, and adjusting to life with such fear whilst their sources of resilience, i.e. practical and social support from their families, friends and communities were reduced significantly to prevent the spread of the COVID-19 Pandemic. In this study, deprivation of such support owing to COVID-19 measures is identified to contribute feelings of loneliness and anxiety during perinatal period.

Although COVID-19 is no longer a pandemic and the alert levels are suspended as of 29th of March 2023 (Government Digital Service, 2023), the process of understanding the impact of the COVID-19 is underway. Learning from this will help us understand the future experiences of current population and even experiences of future generations. This is imperative as the lessons learned from smaller scale illness outbreaks, - e.g. Severe Acute Respiratory Syndrome Coronavirus Epidemic SAR-COV-1 in 2002 and 2003 (Giannis, Ziogas and Gianni, 2020) and regionally contained Middle East Respiratory Syndrome Coronovirus (MERS-CoV) since 2012 (Rabaan, et al., 2020), and the Ebola Virus Disease (EVD) 2014–2016 (Dudas et al., 2017) – seemingly did not effectively inform practices of pandemic preparedness for COVID-19.

One of the significant learning points was that the participants did not link all their emotional distress and mental health problems leading to referral to PMHS directly to the COVID-19 Pandemic, however they linked their heightened distress to the circumstances and environment in which they experienced their perinatal period. The increased demand for PMHS is noted in the emerging literature (Capobianco et al., 2020) however paradoxically, - similar to other health care service delivery – PMHS needed to limit their interventions due to the pressures of COVID-19 (Basu et al., 2021). Inaccessibility of social support, leading to adverse mental health outcomes emerged as an overarching theme within this research. The changes of medical care created an environment that restricted quantity and quality of social support for women. In medical settings, meetings with medical staff were moved to the telephone or videoconferencing meetings and the quality of care in hospital settings -both outpatient and inpatient- were negatively impacted due to virus-related staff shortages impacting both medical care and psychological support through social interactions.

Accounts of the participants indicated different levels of need for social support for primiparous and multiparous women. Primiparous women referred to their expectations of low self-efficacy about the process of pregnancy and impending parenting. Expectations of low-self efficacy in perinatal women can correlate with perinatal experiences of depressive symptoms and anxiety (Wernand et al., 2014) hence receiving support emerged as notable particularly -but not exclusively - for primiparous women. The benefits of such support can range from contributing to a healthy pregnancy to birth and post-partum experience (Razurel et al., 2011; Razurel & Kaiser, 2015; Tani & Castagna, 2017).

Pregnancy and birth and having a new baby are milestone experiences and are experienced with certain rituals from announcement of the pregnancy to baby showers, to introducing the babies. Confinement created by the COVID-19 pandemic prevented such rituals, it was poignant that the participants would talk about how no-one saw them pregnant, one of them likening their experiences to the pregnancy of women from the Victorian era, hiding their pregnant bellies. Furthermore, women commented on video meeting platforms falling short of duplicating in-person experiences and furthermore the lack of social support adding to their distress. The adverse impact of the lack of support from the social support network adds to the finding of existing studies, suggesting an association between parental support and maternal self-efficacy and lower depressive symptomology (Haslam et al., 2006), perceived social support from friends and significant others contributing to reduction of depression in post-partum women (O’Neil, 2019; Razurel & Keiser, 2015; Reid & Taylor, 2015).

Multiparous women reported other causes for anxiety and perinatal mental distress as they had to look after and home school older children whilst adjusting to the parenting of their new-born. Under non-pandemic circumstances older children would be in school, or looked after by family and friends which would provide respite for the parents. Participants talked about changing their birth plans to home births so their partners could be with them, but multiparous women also referred to challenges of arranging childcare during COVID-19 as a factor in considering or deciding on a home birth.

A strong narrative was presented by the women about the practical and emotional difficulties created by the exclusion of their partners from scans and other hospital appointments and admissions. It was noted by Davis-Floyd et al., (2020) that in the USA home births were favoured over hospital births during the COVID-19 Pandemic and restrictions around having a person for support during births impacted adversely on maternal well-being. A study by Liu et al., (2021) concluded that unexpected changes to birth plans during COVID-19 may contribute to depressive symptoms and even PTSD among birthing mothers.

Further challenges emerged for the parents who experienced complicated births or had neonates who needed immediate medical attention and were admitted to NICU (Neonatal Intensive Care Unit). A NICU admission and limited parental contact during the COVID-19 Pandemic added to adversities of the period and could contribute to a detrimental effect on the attachment relationships between parents and neonates (Tscherning, Sizun, & Kuhn, 2020) and this detrimental impact can continue to adversely influence the later mental and physical well-being of the infants (Feldman; 2017). There is a relationship between heightened perinatal distress and poorer bonding between mothers and infants, which is largely studied through a Maternal - Fetal Attachment (MFA) perspective and existing research indicates the significance of social support in preventing poorer MFA (Cranley, 1981) and a correlation between prenatal anxiety and perceived lack of social support contributing to poorer MFA (Alhusen et al., 2012; Glover & O'Connor, 2002; Hopkins et al., 2018). Poor MFA would directly impact on the infants’ wellbeing (Alhusen, 2008; McMahon et al., 2016). Poorer attachment relationships with infants could affect the future mental being of the infants negatively and adding to child, adolescent and adult mental health difficulties (Flowers et al., 2018; Rossen et al., 2016).

Further attachment related concerns were raised by the participants about how their infants were denied essential interactions with the wider world due to COVID-19 related restrictions. Participants referred to their babies being overly attached to them and expressed concern that the babies were deprived of meeting grandparents, uncles, aunts and friends or other babies and interacting with them. Multiparous women compared their earlier perinatal experiences to highlight the differences between pre and during COVID-19 experiences and talked about their inability to attend events and activities such as baby yoga, mother and baby groups, swimming classes and their COVID-19 babies having much narrower experiences of the wider world as a result. The ability of children to develop Cognitive Executive Functions (CEF) is directly linked to the stimulating activities that they engage in with their caregivers (Rosen et al., 2020), and a reduction of the sources of support from the social environment reduced the capacity of parents during COVID-19 (Hendry et al., 2022).

Limitations and Recommendations

This research presents a snapshot of the challenges and experiences of mothers during the COVID-19 Pandemic through analysis of the narratives of women (expectant and new mothers) who were referred to and in receipt of support from Perinatal Mental Health Services through the NHS in West and Southwest Wales. The views and opinions expressed in this research are specific to the women who took part in the research. Hence, this research is limited in purporting generalisations of those views and opinions, yet they are very strong voices of women who came forward to make their experiences known so that improvements can be made in perinatal mental health care delivery.

Research emerging about the impact of the COVID-19 Pandemic is indicating the highly detrimental effect of this period on maternal mental health from heightened symptoms of anxiety Mirzaki et al., 2022; Olivier et al., 2021) to post-partum depression and Post-traumatic Stress Syndrome (PSSS) (Ostacoli et al., 2020) and is likely to contribute to poorer outcomes for the infant and for familial mental health. Perceived social support is linked to better maternal mental health through decreased parental stress, increased parental responsiveness and stimulus, reduced maternal depression, anxiety and harsh behaviour (Venta, Bick & Bechello, 2021). Furthermore, perceived poor maternal support is linked to negative impacts on the infant into childhood and adolescence with outcomes such as poorer cognitive abilities and increased child mental health problems (Loureiro & Silva, 2014). The impact of COVID-19 on the development of the babies born during the pandemic is likely to be researched widely, since as Davies-Floyd, Gutschow and Schwartz (2020) suggested, the COVID-19 Pandemic provided a testing ground for working on disaster preparedness for perinatal care both for future pandemics and other disasters. Research conducted during the COVID-19 Pandemic is needed to be consulted to understand the impact of this pandemic and possible future endemics, epidemics and pandemics as unfortunately, the risk of the variants of the COVID-19 virus, or a novel virus overwhelming populations remains possible. Further, there is now cohort of families who experienced new parenting during COVID-19 and a generation of children growing up with the legacy of being born during the pandemic and the consequences this may bring.

Ethics approval and consent to participate : Ethical approval was granted through an IRAS (ID: 286205) application to Wales NHS Research Ethics Committee (REC 20/WA/0243); received on the 24^th of November 2020.

Consent was sought from the participants via providing them with Participant Information Form which they needed to read and then sign the Consent Forms to participate in the research. Copies are attached in Appendices 3 & 4.

Consent for publication: Included in the Consent Form

Availability of data and materials: Anonymized data is stored by Swansea University for a period of 10 years.

Competing interests: ‘Not Applicable’

Funding: Pathway to Portfolio funding of NHS was provided by Hywell Dda University Health Board to the Lead Researcher Dr Filiz Celik, please see Appendix 5 for

Authors' contributions: Researchers Filiz Celik, Rachel Harrad, Rob Keasley, Paul Bennett worked collaboratively.

FC is the lead researcher.

FC, RH, RK and PB collectively generated the research design.

FC and RH prepared ethics submission.

FC conducted interviews.

FC & PB analyzed the interviews.

FC and PB written the methods, results and conclusion sections.

FC, RH, RK & PB contributed to all other sections of the manuscript jointly.

Acknowledgement:

Dr Warren Lloyd, Research Manager contributed to launching of this research project.

Mrs Angela Lodwick, gatekeeper for Hywel Dda University Health Board.

Mrs Jane Whalley, Service Manager for Perinatal Mental Health Services for

Dr Joanne Noblett, co-investigator for the Swansea Bay University Health Board.

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Table 1 and 2 are available in the Supplementary Files section.

No competing interests reported.

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Experiences of early parenthood in and beyond the Coronavirus pandemic/outbreak

Status:

Version 1

Abstract

Figures

Introduction

Methods

Ethical considerations

Welsh Context

Participants

Procedure

Data Analysis

Findings

1- Perinatal Medical Care during COVID-19 Pandemic

i- The exclusion of partners from scans and hospitals.

ii- Negative hospital experiences

2- Becoming a Parent in Social Isolation

i- Regular activities becoming non-existent.

3- Managing the perinatal period with the support of PMHS

i- Exacerbated anxiety due to COVID-19

ii- The mental health impact of COVID-19

iii- Accessing PMHS remotely

4- Parenthood beyond COVID – 19 Pandemic

i- Babies overly attached to their mums.

ii- New babies and older children

Discussion

Limitations and Recommendations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1