In this study we explored the relationship between the mental health status of perinatal women, and their experiences of food insecurity and domestic violence during the COVID-19 lockdown. We found that 12% of women had probable CMDs and 43% were severely food insecure. Levels of psychological distress increased significantly during the lockdown period, compared to before the COVID-19 outbreak in South Africa. While we did not find an increase in women who felt suicidal, significantly more women reported feeling anxious and depressed. Using multivariate Poisson regression modelling, we showed that the risk of CMD was almost three times greater in women who were severely food insecure, or who experienced psychological or sexual abuse. Importantly, the strength of the association between key risk factors (having more than four pregnancies or a previous miscarriage or stillbirth, experiencing increased crime in the community, decreased income or less food in the household, severe food insecurity, or any form of abuse) and psychological distress increased during the COVID-19 lockdown.
Compared to other studies in South Africa, 3 4 7 12 our study found a relatively low prevalence of CMDs (12.5%) in pregnant women during the COVID-19 lockdown, given that more than 80% of those interviewed reported feeling anxious about getting infected, more than 60% were unemployed and fewer than 20% of households were food secure. This is contrary to a recent review assessing the psychological impact of the lockdown, which found that being quarantined resulted in a higher prevalence of psychological problems such as depression and anxiety. 39
We found that the proportion of women experiencing psychological distress during the lockdown was significantly more than those who were distressed at their first clinic visit. Yet, we did not observe a change in the number or proportion of women who felt suicidal. This is not out of keeping with other research; when examining studies reporting on suicidal thoughts and behaviour during pregnancy and the postpartum period, several studies have reported a decreased risk. 40-42
In LMIC, poverty is a well-documented risk factor for CMDs, especially during the perinatal period. 43 44 The relationship is considered to be complex and bidirectional with several social issues interacting.45 46 Similar strong associations between food insecurity and CMDs have been consistently reported. 4 47 48 In a particularly low-resource setting in Cape Town, the odds of depression was five times greater in perinatal women who were food insecure compared to those who were food secure, while the odds of experiencing food insecurity was four times greater in women who were depressed compared to those who were not.4 Our study found that being severely food insecure doubled the odds of CMDs during the COVID-19 lockdown, and that 80% of participants reported experiencing various levels of food insecurity. The high prevalence of food insecurity can be attributed to the COVID-19 lockdown. During April and May 2020, when South Africa was at Alert Level-4 and Level-5 of the lockdown, all non-essential services were halted. This resulted in high levels of unemployment, affecting the most vulnerable workers, who were low-skilled and less educated, the most.49 Six weeks into the lockdown, Statistics South Africa, using an online survey, found that 4.3% of respondents reported experiencing hunger during the month prior to the lockdown, while 7% experienced hunger during the lockdown.50 This is likely being underreported as those living in poverty and experiencing hunger would be unlikely to have access to a web-based survey. In our already vulnerable group of perinatal women living in low-resource settings in Cape Town, we found that more than 40% were severely food insecure. This translates to 40% of perinatal women living in households where they were eating fewer meals than needed, lacked the resources to acquire more food, went to sleep hungry or went a whole day and night without eating.36
We found that the risk of CMDs was almost three times greater in women experiencing psychological or sexual abuse. However, we found quite a low prevalence of domestic abuse in our study compared to findings in a similar population.51 While we found that 15% of participants reported experiencing psychological abuse and less than 2% reported experiencing sexual abuse, Malan et al. 51 reported that more than 40% of perinatal women experienced psychological abuse and 25% experienced sexual abuse. The low prevalence in our study is possibly due to the alcohol ban, implemented during Alert Level-4 and Level-5,18 which resulted in a 69% drop in the number of domestic violence cases being reported during that period.52 Several studies have demonstrated that alcohol abuse increases the risk of intimate partner violence (IPV),53-55 and that IPV increases the risk of CMDs.56 57
Our study has a number of limitations. More than half the women were not contactable. While levels of psychological distress before the lockdown were similar in those who were and were not contactable, it is possible that those who were not contactable could not afford a cellular phone. This study could therefore have underreported the level of unemployment and food insecurity. We used only quantitative questionnaires which did not allow us to fully explore the perceived causes of CMDs, food insecurity and experiences of violence. We were only able to compare psychological distress as measured by a brief screening tool across the two time points, instead of using a validated tool such as the EPDS. In addition, the first screening was done at healthcare facilities by healthcare workers, while the second screening was telephonically administered by fieldworkers. We started data collection on the same day that the alcohol ban was lifted, which did not give us enough time to measure the impact of alcohol sales on domestic violence.
Further research is needed (1) to understand the coping mechanisms used by perinatal women to mitigate the stress of living in households with high levels of unemployment, food insecurity and domestic violence; (2) to investigate the effect that lifting the alcohol ban has had on domestic violence; and (3) to examine longer term trends in mental health, domestic abuse and food insecurity among perinatal women during the COVID-19 lockdown.