The coronavirus (COVID-19) pandemic’s immense scope and duration has made clear the urgent need to better understand the virus’ physical and psychological impacts on vulnerable populations. From a generational health perspective, perhaps no population’s experience is more critical to understand and safeguard than that of delivering mothers. In the midst of a global public health crisis characterized by a potentially lethal and highly infectious virus, many non-emergency hospital-based health procedures were postponed. Nevertheless, delivering mothers all over the globe were among the very few populations that continued to be treated in hospital settings.
A significant portion of them underwent childbirth when they were suspected or confirmed of the novel coronavirus disease. Some may have experienced mild but also severe physical symptoms [1] such as fever, lymphocytopenia, and elevated C-reactive protein [2, 3] in accords with reports that pregnancy may result in acute immune changes and cause a viral illness to be more severe [4]. Many mothers, even if asymptomatic, may have experienced heightened emotional distress surrounding the concern that they might be contracting the virus in the hospital or transmitting it to their infant [5]. Labor and delivery present physical and psychological challenges during normalcy, therefore it is critical to understand the effect of COVID-19 on delivering mothers. At present, the impact of being COVID-19 positive, confirmed or suspected, on the childbirth experience and maternal and neonatal outcomes remains not fully clear.
Emerging studies have focused largely on obstetrical and neonatal correlates of COVID-19 infection status. A body of research suggests that there is increased risk for adverse outcomes in pregnant women with COVID-19. In a recent systematic review of nine studies in China, the incidence of preterm births, low birth weight, C-section, and NICU admission were found to be higher in COVID-19 positive cases than in the general population [6]. Likewise, in a second review of 41 cases, higher rates of preterm birth and NICU admission were found in positive pregnancies in comparison with non-positive [7], although other studies did not find differences between affected and non-affected women in maternal and neonatal outcomes [8, 9]. The inclusion of studies with small samples and inappropriate control groups in the reviews above may limit findings and interpretations.
An important issue to consider is the subjective experience of childbirth and potential heightened psychological adversity in birth for COVID-19-positive laboring women. Although childbirth is typically considered a happy event, a significant proportion of new mothers report their delivery as highly stressful in samples assessed before the pandemic [10, 11] and childbirth pain as the most agonizing of painful experiences [12]. To the best of our knowledge, no study has examined how giving birth while potentially being ill with the virus may amplify acute traumatic stress responses to childbirth.
A salient factor that may influence the childbirth of COVID-19-affected mothers concerns the unique stressor of the pandemic: social isolation. With the goal of reducing infectious exposures to visitors, other patients, the community, and healthcare teams, and in the wake of uncertain and rapidly evolving situations, policies restricting visitors have been implemented to lower the number of people in hospitals. Accordingly, mothers who contracted COVID-19 have faced drastic restrictions on maternal visitors and supportive companions in the delivery room and during the postpartum stay. A significant number of COVID-19-affected mothers may have even experienced childbirth without the emotional support provided by having close friends or family in the room with them [13]. They may also have gone without visitors while being separated from their newborn to reduce additional transmission risks [8]. Continuous support in labor and delivery can improve obstetrical and neonatal outcomes and reduce negative birth perceptions, which has been documented before the pandemic [14, 15]. It may further buffer against traumatic stress in response to birth [10].
As the obstetric health risks and benefits in the face of a still poorly understood virus remain unclear [16] and hospitals across the United States continue to evaluate and adjust their visitor policies in light of recommendations from the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG), a better understanding of the psychological childbirth experiences in COVID-19 vulnerable mothers, such as those being suspected or confirmed of infection, is warranted. In the writing of this work, visitor prohibitions have been largely lifted in maternity wards. However, those delivering who test positive for COVID-19 may still face social isolation and not be allowed any visitors during their entire hospital stay, underlining the importance of relevant research.
To this end, we studied a large sample of women who recently gave birth when COVID-19 was prevalent in the United States, among them 68 women reported suspected or confirmed COVID-19 positive. We matched this group on a wide range of background factors to 68 women who gave birth in the outbreak of the pandemic but were negative for COVID-19. There have been no studies to date that use a comprehensive matched-group analysis that could allow for better understanding of the contribution of COVID-19 positivity to childbirth outcomes while controlling for background factors that increase perinatal adversity. We examined whether being COVID-19 positive is associated with stressful psychological experiences of birth as well as obstetrical and neonatal outcomes and whether having no visitors during delivery hospitalization stay was associated with these outcomes.