In December 2019, news media reported a viral outbreak in Wuhan, China. In early 2020 the World Health Organisation (WHO) declared COVID-19 a global pandemic with 110,000 confirmed cases of virus infection in 110 countries. Subsequently governments all over world responded with lockdowns and other preventive measures.
In Denmark the epidemic got little publicity before March 2020. The government announced a first lockdown on the 11th of March. Schools and day-care centres were closed, and employees in the public sector and most of the private sector were sent home from work. Danish authorities encouraged social distancing from the start and set up rules for numbers meeting and travelling. Pregnant women were advised to follow the general recommendations, which in the spring 2020 and winter 2020-2021 involved social distancing. Pregnant women were also advised to follow recommendations for high risk patients which included talking to their employer about avoiding risk of infections at work. The National Board of Health recommended that pregnant women employed in the health and social sector were sent home in their third trimester (6). From July 2021 vaccination was recommended for all pregnant women in their second and third trimester (7). Pregnancy health consultations were considered as high priority health care and women were encouraged to take part in normal preventive care. Partners were still allowed to be present during the birth and while the mother and baby were in the hospital. As testing and PPE was introduced in summer 2020 women and their partners were also subject to these restrictions at the hospitals. A gradual re-opening began April 15th 2020, starting with day-care, schools and the private labour market. Infection rates declined during summer, but from the start of August 2020 hospital admissions for Covid-19 patients started to increase. Due to high admission rates a second lock-down was ordered on December 22nd. On March 1st 2021 a gradual reopening was started because of falling infection rates and increasing vaccination of the population. Based on these events, the time between October 2019 to June 2021 may be divided into 6 periods (Before first lockdown, First lockdown, First reopening, Rising incidence, Second lockdown, Second reopening). Each period represents specific risks and difficulties for pregnant women and young mothers (figure 1).
Our study population was embedded in an inception cohort (women recruited in the beginning of pregnancy). Data about mental health of the woman was obtained in relation to pregnancy and child development (first trimester, 8 weeks postpartum and 5 months postpartum), and data were analysed cross-sectionally according to calendar time (periods defined by infection rate and lock-down during the COVID-19 epidemic). This design made it possible to observe changes in symptoms of anxiety and depression in pregnancy and the early motherhood as a function of events in the COVID-19 pandemic.
Pregnant women were recruited consecutively from October 2019 until June 2021 by their general practitioner (GP) at the first antenatal consultation (between 6 and 10 weeks gestation) Participants gave informed consent to take part in a cluster randomized trial designed to evaluate an online psycho-educational program designed for use by all pregnant women (clinicaltrials.gov registration number NCT04129359). No exclusion criteria were used, but knowledge of Danish language was necessary.
After informed consent, electronic questionnaires were sent to the women in the first trimester, 8 weeks postpartum and 3 months postpartum. A secure electronic mail system (e-Boks) was used to approach participants about the survey, and questionnaires were completed and returned into the study database (REDCap) (8). Two reminders were sent in relation to each of the three questionnaires if they had not been received within two weeks. Answers received before June 1st. 2021 were included in the study. We also received a copy of the pregnancy health record from the GP by means of REDCap.
The level of depression and anxiety was assessed by the Hospital Anxiety and Depression Scale (HADS). HADS was developed for patients with somatic conditions (9), but it is often used as a self-rating scale to screen for anxiety and depression symptoms in the general population and across a range of patient groups. The instrument prioritises mental symptoms, rather than physical symptoms that can be confused with pregnancy-related symptoms or physical illness. The self-completed HADS contains 14 items in two subscales: anxiety (HADS-A) and depression (HADS-D), each with seven items. Each item is rated on a four-point scale from 0-3 (3 indicating maximum symptom severity), and the scores are summed (9). The scale has been translated into Danish and has proved to have high internal consistency in a large sample of Danish patients with cardiac disease (10). A 1.5 point change in HADS score has been considered clinically important (11). HADS was administered with the baseline questionnaire in the first trimester, again at eight weeks postpartum and a third time at five months postpartum.
We obtained information about the age of the women (≤25, 26-30, 31-35, >35 years) and cohabitation status (single/ living with partner) from the pregnancy health record provided by the GP. The electronic patient questionnaire obtained in the first trimester contained information about occupational status (employed/ student/ unemployed/ sick leave/other) and whether other children were living at home (no/yes).
For each of the three assessments, the mean of the two HADS scales (anxiety and depression) were calculated in each of the six defined periods and plotted with corresponding 95% confidence intervals on a time line. In each of the graphs a moving average based on penalized B-splines was superimposed; the transparency proportional to the uncertainty. The means of the different periods were compared to the mean in period 5 in linear regression analyses adjusting for age, number of children in the household and employment status. Period 5 five was chosen because at that time responses from women in all three phases of motherhood were available and because it a priori could be expected to be the period of maximum stress (second lockdown).