According to recent studies, women have been more affected by psychological distress than men, and gender plays a significant role in the psychological consequences of COVID-19 (34). Women exhibit higher symptoms of coronavirus-related anxiety than men do (35). It is well understood that anxiety and stress tend to increase during pregnancy. A study conducted in Pakistan revealed that 70% of pregnant women experienced anxiety and depression (36), with most of these anxieties persisting into the postpartum period.
Research on prenatal and postnatal distress among American and Canadian pregnant women found that out of 288 participants, 21.2% experienced prenatal mental distress, while 70.5% faced postnatal distress. The study concluded that prenatal distress is a predictor of postpartum stress, anxiety, and depression (27).
Post-birth, mothers undergo various types of stress. An Australian study segmented postpartum distress into four phases: behavioral (encompassing the mother's sleep-relief), cognitive (highlighting uncertainty and shared human experience), child-related (focusing on sleep, nutrition-growth, and development), and social (including support) (37). Mothers with preterm neonates tend to experience greater postnatal distress, particularly concerning neonate care (38).
The advent of the COVID-19 pandemic has exacerbated this distress, particularly for mothers with hospitalized preterm neonates. As a result, pregnancy has been linked with increased anxiety and stress during the COVID-19 pandemic (24), occasionally leading to adverse outcomes (39). A Pakistani study reported that most pregnant women suffered heightened stress over the risk of contracting COVID-19 and transmitting it to their neonates (25).
In the study presented here, a moderate correlation was observed between postnatal distress and coronavirus anxiety. However, the reported levels of anxiety varied among different ethnic groups, with lower rates typically reported among Asians, likely due to their unique ethnic and cultural beliefs (35). Research involving 900 Canadian postpartum women revealed that 29% had moderate to high anxiety (anxiety score > 40 in positional and dispositional anxiety) prior to the pandemic, a figure that rose to 72% following the pandemic's onset (40). Another Canadian study also confirmed an uptick in the level and intensity of postpartum anxiety during the COVID-19 pandemic (41).
A cross-sectional study conducted in Belgium involving 3445 postpartum women found that approximately 42% exhibited symptoms of anxiety during the COVID-19 quarantine (42). Contrastingly, a Danish study reported no correlation between anxiety and postpartum stress before and after the COVID-19 pandemic among nulliparous women (43).
Prenatal anxiety and stress are known to increase complications such as preterm birth (44). There is a direct correlation between the anxiety levels of mothers and their children (45), and an inverse correlation between anxiety and mental health (46). Consequently, there is a pressing need for effective interventions to reduce anxiety and stress during the pandemic, to prevent their subsequent repercussions (47).
In addition, it was observed that maternal anxiety and distress declined as gestational age increased, suggesting that effective training and care aimed at preventing preterm birth could significantly enhance the mental health of postpartum women. Cultivating trust between healthcare personnel and mothers (37) and the perception of support delivered by healthcare workers (48) are critical strategies in this respect. It is recommended that families undergo training to bolster social support and to maintain the accompanying midwife support program (doula) at least until two months post-birth.
Moreover, the number of living children had the greatest influence on coronavirus anxiety. Women with more than three children exhibited lower coronavirus anxiety due to the fear of child loss prevalent among nulliparous mothers (49). This suggests that childbearing can have a positive impact on women who deliver preterm infants.
The current study's findings also indicate that postnatal distress was more pronounced among highly-educated and employed mothers. A study on postnatal distress in mothers with preterm infants showed increased levels of anxiety and depression. However, this anxiety was less evident in women with lower educational attainment (50). Mothers who are highly educated and employed likely absorb more information from their surroundings, which may contribute to heightened anxiety. Additionally, the limited time a working mother spends with her child can trigger anxiety in the child (45). Therefore, it may be feasible to reduce postnatal distress by developing supportive policies for working mothers and implementing information programs at workplaces.
This study also found that coronavirus anxiety was lower in women with higher education, possibly due to the distinct characteristics of the research population as an ethnic group. Brotto et al. examined the correlation between coronavirus anxiety and ethnic and cultural factors in Canada, revealing that Chinese and Taiwanese ethnic groups had fewer symptoms of coronavirus anxiety, while Canadian natives exhibited more symptoms during the COVID-19 pandemic (35). A study in Japan reported similar rates of postpartum depression before and after the pandemic (51). A comparison of the anxiety levels between Arab and Jewish women revealed that although coronavirus anxiety was prevalent among pregnant women, Arab women were more anxious than Jewish women (52). It appears that Asians reported less anxiety, likely due to their ethnic and cultural beliefs. However, during the pandemic, coronavirus anxiety fluctuated based on factors such as education level, income level, rural residency, and age (35). Nevertheless, the current study found that ethnicity did not significantly influence postnatal anxiety and distress levels.