By MGH Center for Women's Mental Health | June 10th, 2021
"When we meet with women for perinatal psychiatry consultations, we now ask about vaccinations. It’s not something we typically do, but after the last year, we are now getting involved in their decisions regarding vaccination against COVID-19. Just as we counsel women to avoid alcohol and to consistently take their prenatal vitamins, providing information on the COVID-19 vaccine is an important aspect of promoting the health of pregnant and postpartum women.
Considering a growing body of evidence indicating that pregnant women are more likely to have certain manifestations of severe COVID-19 illness, including admission to the ICU and mechanical ventilation, the American College of Obstetricians and Gynecologists (ACOG) has urged the CDC’s Advisory Committee on Immunization Practices to include pregnant and lactating women in the high-priority populations for COVID-19 vaccine allocation. ACOG clearly states that all pregnant and lactating people should be allowed to receive the vaccine, and that their decision to do so should be based on a careful discussion of risks and benefits with their healthcare provider.
From our vantage point, there are other benefits to the COVID-19 vaccine. During the past year, before the vaccination was available, we watched as pregnant and postpartum patients undertook the most extreme forms of lockdown. Many of these women were literally housebound: never leaving the house and cutting off contact with friends and family, while at the same time taking on more childcare responsibilities as outside care providers and day care centers were no longer available. And all the while wondering what would happen if they or a member of their family felt ill?
We are yet to fully appreciate the impact of the COVID-19 pandemic on perinatal women, but preliminary studies indicate that during the lockdown, pregnant and postpartum women reported higher levels of stress, loneliness, depression, and anxiety. And this is not really a surprise. So many of the things we typically recommend to reduce stress and social isolation, such as exercising regularly or spending time with friends and family, vanished.
While it might seem like the pandemic is fading into the distance, the resurgence of the pandemic in places like India and Brazil where immunization rates are low, we cannot be so sure about this. So far the most successful way to avoid becoming seriously ill with COVID-19 is to get vaccinated.
A recent article in Medscape, however, suggests that mothers appear to be less likely to get vaccinated than others in the general population. According to a recent poll from Morning Consult, about two-thirds of adults in the US have either already been vaccinated against COVID-19 or plan to do so. In contrast, mothers are the most likely to be hesitant about the vaccine. In this study, 51% of the mothers reported that they are unwilling to get vaccinated or are uncertain about getting vaccinated, at 51% (compared to 32% of other women and 29% of fathers)."
"Seaneen Molloy was excited to discover she was expecting her second baby during lockdown. With a history of mental illness, she carefully planned the pregnancy, but when her baby arrived she experienced the "terrifyingly rapid" onset of a crisis which left her unable to hold baby Jack."
"Having a baby is supposed to be a joyful experience, and for lots of women it is. However, up to 20% experience mental ill health during pregnancy and the year after birth. Tragically, suicide is the leading cause of death in new mothers.
Women who already have a mental illness are at a high risk of relapse during pregnancy - that's women like me.
I have a diagnosis of bipolar disorder and an anxiety disorder. This meant that pretty much from the moment I became pregnant, the perinatal mental health team were involved.
This includes specialist midwives, psychiatrists, nurses and social workers whose goal is to support women to stay well, and intervene quickly if they don't.
Normally, I manage my mental health by being careful with my sleep and leading a pretty boring life away from overwork and alcohol, but pregnancy chucks in a host of factors you have no control over.
Hormones rage through your body, wreaking havoc upon your mood, your energy levels and your ability to keep your lunch down. You either can't stay awake or are awake for hours - peeing a thousand times and being hoofed by tiny feet.
I had managed to stay well, and off medication, for years, but in the run-up to birth antipsychotic medication was introduced to prevent postpartum psychosis. This can cause women to develop delusions and lose touch with reality.
It's the one I was most at risk of developing due to my history of bipolar disorder, but in the end, I experienced postnatal anxiety.
My mental health had been largely OK during my pregnancy and my labour and after-care were carefully planned.
I had a calm elective Caesarean section due to a traumatic first birth, a room of my own and the baby was whisked away on his inaugural night so that I could get some all-important sleep (this bit was hard - it went against every natural instinct). A procession of midwives, doctors and social workers visited to see how I was doing.
Although I found it intrusive, it helped me feel safe. When I was discharged from hospital with my baby, Jack, I felt swaddled in care and confident everything would be OK.
It was a complete shock that I did get ill.
In the chaos of newborn-life I forgot a dose of my anti-clotting medication which is given to mothers after C-sections.
And this one tiny event broke my brain.
I went from mildly chiding the home treatment team for their postnatal visits, because I was fine, to a full-blown mental health crisis within about 12 hours. It was terrifyingly rapid - which is why perinatal mental illness can be so deadly.
My mild anxiety exploded into an all-consuming panic that I was going to die imminently from a blood clot in my lung. I couldn't think of anything else but the black terror of certain death that was coming for me - how I was going to leave my children, how I'd brought a new child into the world never to know me.
I called out-of-hours GPs describing symptoms I was convinced I had, sobbed, screamed and couldn't breathe. I terrified my husband and myself.
Then we hit the emergency button.
The psychiatrist came over with the home treatment team. They took my fears seriously, which I appreciated, and gave me a physical examination and the missed dose of medication. My antipsychotic medication was increased to the maximum dose and benzodiazepines - a type of sedative - prescribed, to try and calm me down.
I wasn't allowed to be left alone and the mental health team were to visit me every day where I tried to articulate my terror to their masked faces.
At first I resented their visits, but they became a 30-minute space where I could let down the exhausting facade and share how I was really feeling.
My anxiety then transformed into an obsession that Jack was going to die. I was afraid to leave the room and rested my hand on his chest all night.
If my husband took him out to the shops with his brother, I cried and paced about, imagining they had all been hit by a car. I texted him incessantly.
Everyone was saying I needed "rest", so he tried to give me space. But after the second or third breakdown, he agreed to keep his phone on loud and to answer quickly. The home treatment team also advised he give me clear timescales so I knew when to expect them home.
But the medication also caused intense restlessness. I couldn't sit still. I couldn't get comfortable enough to hold my baby for more than a minute."
"Women who had Covid while expecting experienced guilt, shame and unhealthy levels of stress."
By Katharine Gammon | December 14, 2020
"Kate Glaser had chalked up her exhaustion to being 39 weeks pregnant and having twin toddlers in the house. She also wondered whether her flulike symptoms were a sign that she was about to go into labor. But when she woke up one morning with a 100.4-degree fever, she called her doctor and got a rapid Covid-19 test.
Two nurses came to deliver her results to her in the waiting room. They were dressed in full gowns, masks, face shields and gloves.
“I knew by the eerie silence and the way they were dressed that I was Covid positive,” she said. “It was an emotional moment; I felt really disappointed and shocked and, as a mom, I felt a lot of guilt. What did I do wrong?”
Glaser, who lives in the Buffalo, N.Y., area, returned home and isolated from her husband and the twins in her bedroom, where she spent hours mentally replaying all her activities leading up to the positive test result. She also made a public post on her Facebook page about her positive status, and what she was feeling — guilt, embarrassment and panic. The post went viral, and Glaser started hearing from women around the world who were pregnant and worried about Covid-19. The majority of the of the 2,300 comments she received were supportive; a few were harshly critical.
“I was going down a rabbit hole of guilt and stress,” Glaser said, adding that for her, as much as the physical symptoms were bad, the mental stress of Covid was much worse.
Prolonged stress can have real consequences on pregnant people even outside of a pandemic and has been tied to low birthweight, changes in neurological development and other health impacts in children. And the pressure associated with a positive Covid-19 test increases these mental health risks.
The anxiety is not without reason. As of November 30, there have been more than 42,000 cases of coronavirus reported in pregnant women in the U.S., resulting in 57 maternal deaths. U.S. health officials have said pregnancy increases the risk of severe disease for mother and child, and being coronavirus-positive in late pregnancy may increase the rate of preterm birth.
Prenatal care and birth plans are also disrupted by a positive test result. “Women are expressing so much fear about being infected, but also about going to the hospital, delivering and being separated from their child,” said Laura Jelliffe-Pawlowski, an epidemiologist who is the primary investigator of HOPE COVID-19, a new study that focuses on the well-being of women who are pregnant during the pandemic.
The study launched in July and will follow more than 200 women around the world, from pregnancy to 18 months postpartum, to understand how Covid-19 and the pandemic response impacts pregnancy and infant health outcomes.
Dr. Jelliffe-Pawlowski and her team have analyzed the data from the first group of women, and they are finding “absolutely incredible” levels of stress and anxiety. “Sixty percent of women are experiencing nervousness and anxiety at levels that impede their everyday functioning,” she said, citing preliminary data. “There are a number of women, particularly lower-income women, expressing how hard it is to choose to stay in a job that puts them at risk versus quitting the job and not having enough food for their baby.”
Nearly 70 percent of the participants reported feeling worried about decreasing family income and more than 22 percent worried about food insecurity (though none had experienced it at the time of the survey). Dr. Jelliffe-Pawlowski worried that women were not necessarily getting the psychological care they needed: “If you can’t feed your family, seeking out mental health care is not your top priority.”
She also said more than 84 percent of women reported moderate to severe anxiety about giving birth during a pandemic. “Many women do not want to get tested because they will be stigmatized or separated from their baby or not allowed to have people in the room to support them,” she said. She added that similar visiting rules often hold true for babies in the NICU after being born preterm during the pandemic: Only one parent can be present in a 24-hour period. “It’s heart-wrenching to see families go through those choices.”
Dr. Jelliffe-Pawlowski is particularly interested in how stress impacts births and long-term outcomes for children as psychological stress is highly associated with preterm birth. After the attacks of September 11, 2001, the risk of preterm births almost doubled for people living near or working at the site of the fallen towers. She’s also concerned about long-term effects of stress and anxiety on maternal bonding during the pandemic.
Margaret Howard, a psychologist at Women & Infants Hospital in Providence and postpartum depression researcher at Brown University thinks it is absurd for pregnant women who test positive for an infectious virus to bear any guilt or stress associated with their diagnosis: “Are moms in a special category where they are expected to not get Covid? What about a sinus infection? Hay fever? Cancer? Why is Covid a moral failing for mothers?”
When Erica Evert, a pregnant mom in northern Virginia, received her postive Covid-19 test result, it didn’t make sense. She was near the end of her pregnancy, and hadn’t left the house in four and a half months, except for ob-gyn appointments to check on the baby.
“My first thought was, is this a false positive? I feel fine. And my second reaction was to start bawling,” said Evert. She was scheduled to have a cesarean section with her second baby and the test was merely a formality — until it was a life-changing event.
The hospital gave her a choice: She could deliver the next day and be treated as a Covid-19 patient — separated from her baby with no skin-to-skin contact, per the hospital’s policies. Or she could wait 10 days from the date she received the positive test result and deliver with her regular plan. She had four hours to make a choice she wasn’t expecting. “I kept thinking: am I going to make a decision that results in my child dying?” said Evert."