Worldwide research is currently focused on SARS-CoV-2, possible therapeutic targets and preventive measures, as well as the COVID-19 pandemic and its various potential impacts on health care, mental health and economic effects. The majority of studies center on physical effects and immunologic pathways of infection. Pregnant women were particularly observed regarding vertical transmission, fetal infection and pregnancy outcome during the first wave of the pandemic, while their mental health was not investigated . As previous results show a general increase of mental health problems, women, especially in perinatal situations, seem to have a higher risk for impairment of mental health [37–39] or loneliness and isolation [40–42]. For this reason, the present study aimed to fill this gap in current knowledge.
In our study, the scores of the COVID-19 pandemic questionnaire showed overall a low to moderate overall level of concern, whereas the level of concern increased over the course of the pandemic, i.e., between delivery stay (T1) and three to six months postpartum (T2). This corresponds to findings in other studies , although most of studies show results from one date and no comparison of stress level to a later date during the ongoing pandemic [43–47].
The SCI results showed low stress levels, while a significant increase in active coping mechanisms could be detected between delivery stay to postpartum assessment (from T1 to T2), especially in the following subgroups: women under 35 years, academics, body mass index (BMI) < 25 kg/m2, caesarian section, first birth and high-risk pregnancies. Coping strategies are known to be an important factor for maternal mental health [48–50]. Our results support the hypothesis of an Italian longitudinal study where women are likely to develop better resilience in the course of the pandemic .
At the delivery stay (T1), higher total load of stress related to more overall COVID-19-related concern, especially stress by insecurity and stress by being overwhelmed. This effect dissolves over time and cannot be detected anymore at the postpartum assessment (T2), which might be interpreted as an effect of habituation and of the improvement of coping strategies during the pandemic as described above [52–54].
No significant correlations between psychosocial stress or stress symptoms of SCI and FCV-19S could be shown, considering the fact, that the FCV-19S focusses on general fear concerning COVID-19 and not specific worries of pregnant women during the pandemic as the CPQ . A possible reason to explain the lack of relationships could be that the stressors for our group are the specific concerns relating to pregnancy and the obstetrical situation and not a generally raised level of fear. In contrast to our observed low score of the FCV-19S, another study reported high levels . This difference could be due to differences in ethnic and socio-demographic aspects in the tested population. It is also possible that the time period studied during the COVID-19 pandemic, the week of pregnancy and the care capacity of the health care system are important confounding factors.
Many studies reported increased depression and anxiety symptoms in pregnant women during the COVID-19 pandemic [42, 56–58]. In our study, we have found relatively low scores of the EPDS and the ASI-3. The rate of about 10% estimated depression detected by the EPDS was in the normal prevalence range (about 7-13%) in pregnancy and postpartum [6, 59]. At first this may seem to contradict the previously mentioned studies [42, 57, 58, 60]. However, due to our study design (Figure 1) we were unable to compare to pre-pandemic values. Instead, we investigated relationships of depression and COVID-19 specific factors. More COVID-19 related concerns related to higher depression, but not anxiety scores. In contrast, COVID-19 related fear correlated positively to anxiety, but not depression. There seems to be a difference between obstetric concerns in the face of COVID-19 pandemic and general fear of COVID-19, although they correlated to some degree.
In the face of the SARS-CoV-1 outbreak, Lee and coworkers have shown that anxiety and depression did not increase compared to pre-outbreak levels. The authors attribute this to increased social support . This might also be the underlying reason for this study sample´s low scores in anxiety and depression. Social support during pregnancy does not only have an influence on mental health symptoms such as depression but also on pregnancy outcome . Although some studies report low social support and the consequent negative impact on women in late pregnancy and postpartum during the COVID-19 pandemic [63, 64], pregnant women may also have benefited from increased flexibility of work schedules and jobs due to COVID-19 pandemic restrictions, such as themselves or their husbands' ability to work from home. Strengthening this line of evidence, our results show low to low-medium loneliness and social isolation and high social support on both the state and the trait level. Being lonely and socially isolated (state and trait) was associated with higher impairment scores both during the delivery stay and several months postpartum, while being socially connected and supported (state) related to lower impairment. Note that interpretation of the indicators of social support are limited by a low reliability. This may have been caused by extremely skewed score distributions and high scores for being connected and supported (state) and for social support and connectedness (trait 3). Nonetheless, these findings emphasize the effect of social support and particularly isolation and loneliness on the level of mental health impairment.
Although many factors influence the mother-infant-bonding with stress levels caused by the COVID-19 pandemic potentially being among them [65, 66], we detected a good maternal-infant bonding in our study, independent of concerns and fears regarding SARS-CoV-2 and the COVID-19 pandemic. This also corresponds well with the observed low stress levels. However, the impairment by the COVID-19 pandemic correlated negatively with maternal self-confidence. This was also the finding of Vazquez-Vazquez and co-authors. They suggest that maternal lack of contact with other mothers through the restrictions caused by the COVID-19 pandemic had an impact on the assessment of maternal self-efficacy .
Here, we found a significant inverse relationship of peripheral dopamine level with level of stress and level of concern in the COVID-19 pandemic questionnaire. There were also similar results for the correlation between peripheral dopamine levels and depression scores. These findings support the hypothesis that dopamine plays an important role in modulating stress-coping mechanisms although most of studies focus on dopamine levels in the central nervous system and not peripheral levels [68–72].
Our study showed a correlation of IL-6 and elevated stress levels, which emphasize the findings of other authors, that higher levels of IL-6 are associated with mental health problems such as depression and anxiety [73–75].
For serum levels of cortisol, adrenaline and noradrenaline we did not find any significant correlation. The results of other studies are heterogeneous, levels of these hormones are shown to be strongly dependent on individual baselines and circadian rhythm as well as the time interval to stressors and intensity of stressors, which our study did not take into account [76, 77].
A limitation of our study was that there were no clearly defined survey time or conditions for the survey as well as the maternal blood sample, which owed to the course of labour and the workflow in delivery rooms. This may have lead to a blur in the obtained data, however we rate this to be of minor influence on our overall finding.