Perinatal mental health of Indigenous pregnant persons and birthing parents during the COVID-19 pandemic

Abstract

Perinatal mental health has worsened since the onset of the COVID-19 pandemic. Limited studies have included Indigenous perinatal individuals despite them being more likely to develop perinatal mental health challenges pre-pandemic. 1 The purpose of this study was to identify pandemic-related stressors affecting Indigenous pregnant persons and birthing parents and assess levels of depression and anxiety during COVID-19. We co-designed this cross-sectional study with the XXXXX, a midwifery clinic located on XXXXX. Ethics approval was received from the appropriate committees. Participants were eligible to participate if they were clients of the XXXXX, currently pregnant or postpartum, and aged 16 years or older. We collected data between November 2021 and April 2022. To identify pandemic-related stressors, we co-designed a bespoke questionnaire (α=0.82) with XXXXX leadership where participants rated the impact of 18 stressors over the past two weeks on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree), as well as coping behaviours in one open-ended question. Depression and anxiety were assessed using the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder-7 (GAD-7), respectively. Both have been validated and/or successfully used by Indigenous women. Questionnaires were completed during pregnancy and/or after delivery. Seventy participants completed questionnaires during pregnancy (n=43) and/or postpartum (n=39). On average, participants endorsed seven stressors during pregnancy and eight postpartum (Table 1 ). Most participants (82.9%) were worried about COVID-19 infection, although only 28.0% were worried about being infected at a clinic visit. Nearly 55% of participants found parenting to be stressful and nearly one-third were overwhelmed with home-schooling their children. Many participants endorsed birth/delivery-related stressors including being unable to participate in traditional perinatal celebrations (58.5%), not being able to have postpartum support from female kinship (53.6%), and how COVID-19 affected their birth experience (46.3%). Concerns that their partner would be unavailable during the birth were less common (23.2%). Table 1 Stressors and mental health of perinatal participants during the COVID-19 pandemic Pandemic-Related Stressors Pregnant n=43 n (%) Postpartum n=39 n (%) Birth/Delivery stressors 1. I am upset that I will not be or was not able to participate in typical pregnancy/postpartum celebrations (e.g., baby shower, social gatherings) 19 (44.2%) 29 (74.4%) 2. I am worried that my mother, aunties, sisters, and other community members will not be or were not able to support me during the birth and for the first 10 days at home 18 (41.9%) 26 (66.7%) 3. I am worried about how the pandemic will affect or has affected my birth 20 (46.5%) 18 (46.2%) 4. I am worried that my partner may not be or was not available during the birth 9 (20.9%) 10 (25.6%) Child-related stressors 5. Parenting has been stressful during the pandemic 23 (53.5%) 22 (56.4%) 6. I am overwhelmed with home-schooling my children 14 (32.6%) 11 (28.2%) COVID-19-related stressors 7. I am worried about me, my baby, or a loved one getting COVID-19 35 (81.4%) 33 (84.6%) 8. I am worried about getting COVID-19 at a clinic visit 12 (27.9%) 11 (28.2%) Economic stressors 9. I am worried about loss of income as a result of the pandemic 15 (34.9%) 19 (48.7%) Healthcare stressors 10. I am worried about the reduction in prenatal/postnatal medical visits due to the pandemic 15 (34.9%) 18 (46.1%) 11. My poor internet access prevents me from having virtual healthcare appointments 5 (11.6%) 6 (15.3%) Resource access-related stressors 12. I am worried about the lack of delivery services (for food, other items) available in my community 13 (30.2%) 14 (35.9%) 13. I am finding it difficult to purchase items online 8 (18.6%) 11 (28.2%) General Well-being 14. My physical activity levels have decreased since the pandemic 25 (58.1%) 30 (76.9%) 15. I have thought about getting mental health help during the pandemic 21 (48.8%) 16 (41.0%) 16. My mental health has worsened since the pandemic 16 (37.2%) 18 (46.1%) 17. I am worried about increased conflict in the home due to stay-at-home orders 9 (20.9%) 12 (30.8%) 18. I feel guilty sharing news of my pregnancy or birth of my baby due to the current pandemic 9 (20.9%) 7 (17.9%) Mental Health: Depression and Anxiety EPDS, Mean (SD) 7.79 (4.96) 9.38 (6.69) EPDS ≥13 (Probable Depression) 7 (16.3%) 10 (25.6%) GAD-7, Mean (SD) 5.72 (4.89) 7.74 (6.50) GAD-7 ≥10 (Moderate to Severe Anxiety) 8 (18.6%) 13 (33.3%) EPDS = Edinburgh Postnatal Depression Scale, GAD-7 = Generalized Anxiety Disorder-7, SD = Standard Deviation The majority of participants (65%) endorsed healthy coping mechanisms while some acknowledged using less healthy coping mechanisms, including overeating (54.0%), substance use (20.0%), and gambling (11.4%). Less healthy coping mechanisms were more frequently used after delivery. Approximately 21% of participants endorsed symptoms consistent with probable depression (EPDS ≥13 [16.3% in pregnancy, 25.6% in postpartum]), while 25.6% endorsed moderate to severe anxiety (GAD-7 ≥10 [18.6%, 33.3%]), and 41.5% reported that their mental health had worsened since the pandemic (37.2%, 46.1%). Indigenous perinatal individuals faced a range of pandemic-related stressors, but the majority used healthy coping mechanisms to maintain their mental health. The impact of some stressors they faced differed from other perinatal groups. For instance, fears about COVID-19 infection were higher 2 perhaps due to living in multigenerational households and a lack of clean water access affecting hand hygiene practices. Parenting was also a bigger stressor 2 possibly contributed to by more pandemic-related school closures occurring on-reserve. Delivery-related stressors were also more common 2 perhaps because the early postpartum period is a culturally sacred time for female family and community members to gather and provide support to mother and baby. In comparison to non-Indigenous perinatal individuals, 2 participants were less worried about partner absence during births, likely because clinic staff prioritized the presence of support persons at deliveries during the pandemic. Despite facing stressors, our participants reported lower levels of depression and anxiety than general perinatal samples in Canada. 3 Participants in our study may have fared better because of consistent receipt of culturally-supportive midwifery care, participants’ resiliency, or data collection occurring in the later stages of the pandemic. Culturally-safe midwifery care and other support services should continue to be encouraged for these participants to optimize their mental health during and beyond the pandemic.