Giving birth during a pandemic: From elation to psychopathology

Abstract Objective To compare the postpartum psychopathological symptoms of women who gave birth before the pandemic with those who gave birth during the pandemic. Methods A total of 212 women participated in the study, of which 96 gave birth before the pandemic and 116 during the pandemic. Psychopathological symptoms, postpartum depression, perceived stress, and resilience were evaluated. Results Women who gave birth during the pandemic had higher scores on somatization, obsessions and compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, and psychoticism. In addition, perceived stress was the common predictor of an increase in these symptoms. Conclusion Postpartum is a complicated period in a woman's life. Many psychological adaptations take place and women may be subject to psychological alterations during this period. In addition, women who gave birth during the COVID‐19 crisis may show greater psychological vulnerability, due to the specific situation experienced during the pandemic. The COVID‐19 pandemic may have played a role in the increase in psychopathological symptoms after childbirth. Detecting possible symptoms postpartum plays a crucial role, because it allows intervening and preventing the development of psychopathologies.


PUERTAS-GONZALEZ ET AL.
In addition, it has also been found that before delivery, pregnant women show more symptoms of somatization, phobic anxiety, or paranoid ideation than non-pregnant women. 4 These results suggest that mothers possibly undergo some form of "psychological vulnerability" both during pregnancy and postpartum. 1 In a similar line, other studies have shown that events experienced during pregnancy and postpartum may be the precursors of more serious diseases. 5 Traumatic or unusual experiences, such as the current global COVID-19 pandemic, may encourage the development of psychological disorders. In the light of this historical event, the psychological impact of the crisis on the population has been an object of study.
It has been observed that, due to fear of contagion, the symptoms of anxiety and levels of stress have considerably risen among the population. 6 In the case of pregnant women, higher levels of stress, anxiety, and depression have been found as a result of being exposed to the stressful ordeal of living through a pandemic. 7 In the same way, various studies have explored symptoms of postpartum depression in women who gave birth during the pandemic and higher levels of postpartum depression were found. 8 However, these studies did not perform an in-depth examination of the wide range of psychopathological symptoms that women may present after childbirth.
Given the psychological repercussions of both giving birth and experiencing the pandemic, it has become more essential to study the psychological health of women. Therefore, the aim of the present study was to verify the psychological and emotional state of women who gave birth during the pandemic compared with that of women who gave birth before it. The psychopathological symptoms of women who gave birth before the pandemic were compared with those who gave birth during quarantine. Possible variables related to these symptoms were also verified.

| Participants
A total of 240 women (mean age 33.46 ± 4.35 years) were recruited and consented to take part in the study. Of them, 212 women finally participated in the present study (13 women did not fill in the questionnaire, 10 filled in the questionnaire more than 1 month after delivery, and five women had been diagnosed with one physical or psychological disease in the previous year). The inclusion criteria were as follows: to be of legal age; to have given birth at some point before or after the State of Emergency was decreed in Spain; to complete the questionnaire within the first month after delivery; to read and write in Spanish; and to have an Internet connection. The exclusion criterion was experiencing physical or mental illness at the time of being diagnosed with any of them in the previous year.
All participants gave prior consent before being included in the study. Participation was voluntary and the study was conducted

| Instruments
First, sociodemographic and related variables for birth and newborns were collected from participants. In addition, a psychological assessment was performed using the assessment tools listed below.
• Edinburgh Postnatal Depression Scale (EPDS). 12 The EPDS is used to assess the risk of postpartum depression. Its reliability, in terms of internal consistency, is acceptable (α = 0.79).
In addition, in the group of women who gave birth during pandemic, the following assessment tool was used: Birth Satisfaction Scale-Revised (S-BSS-R). 13 Three subscales measured overall satisfaction with childbirth: stress during childbirth; personal attributes; and quality of care. The instrument presented adequate internal reliability (α = 0.77).

| Procedure
First, before the pandemic, and coinciding with the Gestastress research protocol, women who had just given birth in Spanish hospitals were recruited. These women, who gave birth between March 2019 and February 2020, constituted the group of women who gave birth before the pandemic. The procedure for recruiting these women was as follows: they were informed of the study after giving birth, and those who agreed to participate filled in the informed consent form. At this point, the questionnaires were sent to them online, using Google forms (sociodemographic variables, SCL-90-R, PSS, EDPS, and CD-RISC) and they were given a maximum of 1 month to fill them in, according to the inclusion criteria.
Second, after the sudden onset of the pandemic, and following the declaration of a State of Emergency by the Spanish Government, participants continued to be recruited. However, those women who agreed to participate (through the procedure explained above) were included in the group of women who gave birth during the pandemic (from April 1, 2020, to July 1, 2020).
This left two groups (women who gave birth before the pandemic vs those who gave birth during the pandemic). The data obtained and the differences between the two groups were analyzed.

| Data analysis
A descriptive analysis (mean ±standard deviation [SD]) was performed of the sample's main continuous variables, of a sociodemographic and obstetric nature. A frequency analysis was carried out for the remaining categorical variables.
In order to verify whether there were any significant differences in psychopathological symptoms between women who gave birth before and during the pandemic, a Student t-test was performed.
The dependent variables were the scores of the nine main dimensions of the SCL-90-R and postpartum depression score, and the independent variable was the moment of delivery (before or during the pandemic). Whether the woman was primiparous or not was included as a covariate.
Finally, to verify which psychological variables could predict psychopathological symptoms in women who gave birth during the pandemic, various hierarchical linear regression analyses were conducted, the dependent variables being the scores on the SCL-90-R subscales. The variables related to delivery were included in step 1 (gestational age at birth, whether primiparous or not, vaginal or instrumental delivery, and satisfaction with delivery), and in step 2, the predictive variables were the perceived stress and resilience (PSS, CD-RISC) scores. A collinearity diagnosis was performed to examine variable associations. Tolerance greater than 0.3 and a variance inflation factor below 10 indicate the absence of multicollinearity.
The analyses were carried out using the SPSS version 26.0 (IBM Corp., Armonk, NY, USA).

| Sample description
The total sample of participants was divided into two groups: the first group consisted of 96 women (mean age 32.96 ± 3.97 years) who gave birth in the pre-pandemic period; and the second group consisted of 116 women (mean age 33.86 ± 4.60 years) who gave birth during the pandemic.
Both groups were found to be even in relation to the main sociodemographic and obstetric history variables. Statistically significant differences were found between both groups, however, regarding whether they were primiparous or multiparous (ꭓ 2 = 5.62; P = 0.018) ( Table 1).  Table 2.

|
No differences were found for postpartum depression, with 25 women (26%) displaying depressive symptomatology (score >10 in EPDS) in the pre-pandemic group, compared to 33 women (28.4%) in the group who gave birth during the pandemic.

| Predictive psychological variables of psychopathological symptoms in women who gave birth during the pandemic
Psychological variables were analyzed as predictors of psychopathological symptoms, using hierarchical linear regression analysis.
All models were significant after controlling for variables related to delivery (gestational age at birth, type of delivery, primiparous or not, and satisfaction with delivery). Furthermore, perceived stress was the only predictor variable for the following psychopathological symptoms: somatization; obsession and compulsion; interpersonal sensitivity; anxiety; phobic anxiety; and psychoticism. In the case of depression, resilience was found as a predictor, along with perceived stress. Regarding hostility, the two predictors were perceived stress and being primiparous. These data are shown in Table 3.

| DISCUSS ION
The aim of the present study was to verify the psychological and emotional status of women who have given birth during a pandemic. To do this, it was first verified whether any differences could be found in a range of psychopathological symptoms between women who had given birth before and during the pandemic. A check was subsequently made as to whether birth and psychological variables were related to, or acted as, predictors of such psychopathological symptoms.
The results of the present study indicate that women who had given birth during the pandemic presented more psychopathological symptoms than those who had given birth during the pre-pandemic period, specifically somatization, obsessions and compulsions, interpersonal sensitivity, anxiety, depression, hostility, phobic anxiety, and psychoticism.
Some authors have shown that, during this pandemic, women consider postpartum as a period that involves even more challenges than before; this perception can lead to psychological stress and make women more vulnerable to emotional disturbances. It can also reduce their psychological well-being. 14  Other psychopathological symptoms such as obsessions, compulsions, and phobic anxiety are equally more widespread in the current situation, characterized by excessive hygiene and fear of contagion. 16 The latter, coupled with the fact that during postpartum, the likelihood of experiencing obsessions and compulsions increases twofold, could explain the differences found and the growth in symptomatology. 17 However, it should be noted that the scores found in the present study exceeded, on average, the 70th percentile. This latter psychopathological dimension thus presented clinical scores, with all its therapeutic implications.
As far as somatization is concerned, this increased during pregnancy, due to the complex emotional and physiological processes proper to gestation. 4 Although the role of postpartum somatization is currently unknown, it has been found to increase in different samples of the population. Therefore, it would be unsurprising if it was found to increase after childbirth as a result of the pandemic. 18 TA B L E 1 Description and comparison in sociodemographic variables and obstetric history, in women who gave birth before and during the pandemic. a Finally, symptoms such as interpersonal sensitivity, hostility, and psychoticism can be explained by the social restrictions imposed on the population. 9 The pandemic's side effects include a rise in individualism and loneliness derived from a halt to social relations. These latter side effects may lead to the accentuation of this type of symptomatology. 19 In addition, the pregnancy's own evolutionary perspective means that the mother is capable of detecting threats in the environment to protect her infant and will reject anyone outside her "group," which may exacerbate the symptoms described at the same time. 4,20 As far as postpartum depression is concerned, no difference was found between the two groups in the present study. One possible explanation is that this problem presents a high incidence during postpartum anyway, making it unlikely to detect differences in symptomatology. 21 Some authors have reported a rise in these symptoms of depression. 22 However, the failure to find any differences demonstrates that women are vulnerable to postpartum depression no matter the moment during which it is experienced, and the first signs of the disease must be addressed.
Most of these psychopathological symptoms, which were more widespread in women who gave birth during the pandemic, shared a common predictor variable: that of perceived stress. Stress is one of the psychological problems that has increased the most during this pandemic. This is unsurprising, because the unpredictability of the situation added to a sense of low personal control over it, leading to increased levels of stress. 23 In addition, other authors have found that during pregnancy, perceived stress is also a predictor of psychopathology. 4 Resilience, an important pregnancy variable, equally seems to be a possible predictor and could dampen the severity of psychopathological symptoms. 24  In conclusion, the results of the present study highlight the delicate period women endure around childbirth, and such conditions have been aggravated by a pandemic. The COVID-19 pandemic has affected the whole world, and these women, who must go through the important life process of childbirth, have increased psychopathological symptoms. As a result, it has become essential to work on psychopathological symptoms during pregnancy, to alleviate the effects and their exacerbation after childbirth. Especially now, when they live in a world that generates uncertainty and fear.
In addition, assessing the perceived stress that women experience constitutes an essential step. Indeed, early detection leads to timely intervention and provides women the support and tools they need to help them cope.

ACK N OWLED G EM ENTS
The authors thank every woman who participated in the study.
They would also like to thank those who fight against COVID-19,