COVID and the UK’s postnatal mental health crisis

Britain's new mothers have been traumatised by the effects of COVID-19 and the restrictions it has brought to their lives. This is creating a simmering mental health crisis amongst women that is going largely unacknowledged.

One of the reasons this is going unnoticed is due to the strength and resilience that mothers have intrinsically. There is so much adversity that they already face through motherhood that it is usually easier to plough on, and just cope. Even if mothers were to bring up the fact that they are struggling, the support can be hard to find.

We have read, seen or heard reports of how the isolation of COVID-19 restrictions affected workers, the elderly, school children, university students and even the babies born in lockdown, but there has been precious little said about the impact of these restrictions on women who are going through what was already one of the most challenging, most vulnerable times of their lives.

According to MBRRACE-UK's report on Saving Lives, Improving Mothers’ Care, mental health was one of the leading causes of maternal death in pregnancy and the first postnatal year, and this was before the added impact of the COVID-19 pandemic. They also note that many of the women who died from suicide or substance misuse faced multiple adversities.

This is not something that can be ignored or undervalued. This is a crisis that needs immediate attention before things get worse.

Women are traumatised

“Being female is the foremost risk factor for developing post-traumatic stress symptoms (PTSS) and depressive symptoms among adults and adolescents. Major stressors (e.g., health crises and natural disasters) can increase prenatal stress and make pregnant women particularly vulnerable.”

This was the opening of the abstract for a study looking at the impact of COVID-19 restrictions on pregnant women in Italy. In other words, being a woman is, at the best of times, stressful and correlated with higher stress-related mental health issues. This is often exacerbated in pregnancy when a combination of surges of hormones, a loss of control of one’s own body and a general sense of vulnerability can seriously impact someone’s mental health.

Once COVID came to Europe, Italy found itself at the epicentre. It had one of the first government-imposed lockdowns. For pregnant women, this meant support persons, including partners and other children, were not allowed in the obstetric maternity units, except in the actual birthing units. Like women in the UK, they had to go to appointments, have scans and even go through the early stages of labour without any personal support.

That study found that where previous studies showed 11.9% of new mothers showed postpartum depressive and post-traumatic stress symptoms, 30% of new mothers in the pandemic showed those symptoms. Another survey cited in this one said “up to 95% of pregnant women reported mild [post traumatic stress syndrome (PTSS)] and 61% moderate PTSS.”

In the UK, we’re not doing much better. The campaign organisation Pregnant Then Screwed looked at the impact of COVID restrictions on mums-to-be and found that nine in 10 said the restrictions in hospitals and health settings were “damaging their mental wellbeing”. A full 97% said “lockdown had increased their anxiety around childbirth.” COVID-related restrictions kept 85% of pregnant women’s partners away during scans and the early stages of delivery, and nine out of 10 of those felt this negatively impacted their mental health. Nearly 80% said their partner couldn’t join them in the early stages of labour, and of those, 97% felt it increased their levels of anxiety about giving birth.

The vast, vast majority - 94% - said they were stressed some or all of the time.

Both of our founders at Kensa health had babies during the pandemic and went through pregnancy in lockdown. It is one of the things that led to the creation of Kensa Health, so as a company we know first-hand the complexity of issues and emotions experienced by pregnant women and new mothers during the lockdown. Dr Rose Abbott describes how awful it was to attend her 12-week scan alone in April 2020 only 6 months after having lost her first baby due to stillbirth:

"I found all of my scans incredibly difficult and triggering having gone through the experience before of having an ultrasound scan where I was told my baby had died due to a placental abruption in October 2019. The ultrasound scans would have been difficult regardless, but not being able to have my husband with me made me feel even more vulnerable and alone. This 12-week scan was however particularly bad. The person scanning me that day had clearly not read my notes / seen the warning label on the front of my notes that should have prompted a little kindness or empathy. She was short and dismissive with me when I tried to tell her that I was extremely anxious. I was then further traumatised when the person doing my blood tests and paperwork did not even so much as look up let alone offer a kind word when asking the routine questions about previous pregnancies and previous children.

Working as a GP during COVID myself, I understood that it was a stressful and difficult time for all NHS staff, but this does not excuse the lack of empathy and dismissive nature of that appointment. I went on to need many ultrasounds - every two weeks from the third trimester and they were extremely difficult. Each time I had a fainting/vasovagal reaction whilst being scanned. I put this down in part to the negative and unsupportive interaction at the 12-week scan and partly because of all of the covid restrictions and PPE on top of what I had already been through."

It is important to acknowledge that it wasn't just the new mothers who were traumatised. Partners were also literally being left out in the cold, unable to be there for their loved ones and in some cases being made to wait unknowing what is happening to their partner and their child. When women did go into labour, partners couldn’t be with them in the early stages and we’re forced back into an archaic role of waiting outside or at home for the call. This breaks the much-needed support system for both parents, something that can have a lasting impact on their long term mental health and relationship.

Challenges with older siblings

If the women in question had more than one child, this added an extra layer of difficulty. All the restrictions were the same, but they also had to face the whole ordeal without the big siblings’ presence, too. This may not have impacted women with straightforward pregnancies too much; after all, we don’t often expect older children to be in the delivery room. But the older siblings missed out on the joyful and exciting experience of visiting their mum and the new baby at the hospital. For a straightforward pregnancy that could mean 1-3 days without seeing their mums.

However, many women don’t have straightforward pregnancies. They find they have to be hospitalised for days or even weeks on end. With COVID restrictions in place, many mothers are finding they have to cope with the anxiety of giving birth alone, in a hospital, during a pandemic, all while they can only watch their other children through a phone or tablet. As Ellen Davies wrote for Pregnant Then Screwed:

"I have seen comments about how women should be grateful in the age of technology that we can keep in touch in ways our parents or grandparents weren’t able to. Yes, that’s true, I can’t tell you how much FaceTime has kept me from plummeting altogether but no one in their right mind can think it’s the same as being able to hug and kiss your child on the daily?

It’s been a rollercoaster of emotions watching her on-screen. I’ve felt relieved that she seems to be bonding better with her dad and I can see how much she’s now relying on him to bring comfort rather than just the playtime fun, but there’s a weird jealousy that’s begun to creep in. Of course, I don’t want her to be miserable and crying that I’m not present, but I’m beginning to watch her detach herself from me as she talks and I’m scared that when I do finally return (which at this rate could be another 10 days away) our sacred bond will be broken especially if my return involves the addition of the new baby."

She wrote an update where she explained that, due to surgeons’ schedules, she was in the position of either having a planned c-section 11 days before her baby was due or having to stay in hospital three full weeks until the surgeons were next available to do a planned c-section. For her older child’s benefit, she chose to have her baby early. Although she got to go home earlier, things were not easy. Her post-surgery recovery and slightly early baby meant that her older child still struggled to bond with her on her return.

The restrictions and distance, combined with a new baby, have made a great hurdle for all involved: mum, partner, older child and new baby.

Baby loss during the pandemic

It is clear pregnancy and having a baby during the pandemic have been almost universally distressing, Women suffered through appointments, treatments, scans, surgeries and childbirth often alone and with over-stressed nurses and doctors working on understaffed wards.

How much more impossible, then, must it have been for those who lost a baby at this time?

Even more devastating is the fact that one study shows a four-fold increase in stillbirths during the pandemic. This is mostly attributed to the reduction in antenatal care. After all, in-person appointments were changed to video appointments wherever possible, and many ‘unnecessary’ appointments were missed altogether. Moreover, some midwives and health visitors cut their home visits almost entirely, so very often, critical signs were missed until it was too late.

One woman spoke to the news website The Conversation about her story. She was pregnant three times during the pandemic, but she lost two of the pregnancies. She said,

“I found out my first baby had died during a scan. I was all alone as my husband wasn’t allowed in the hospital and there was no mental or physical follow up. Not knowing why was the hardest thing.”

After the loss of her baby, she found herself alone and isolated, with only her work to hold on to. In her case, she has had a successful, healthy pregnancy since, but that doesn't take away from the trauma she experienced. Or diminish the potential lasting impact that will have on her mental health and relationship with her partner and new baby.

The long-term health consequences of this trauma

The simple fact is that pregnant women and their families have been let down tremendously during the pandemic. One study shows that more than half of respondents felt negatively about their pregnancies during the first wave, due to rushed or fewer appointments, a lack of in-person appointments, unsympathetic healthcare workers, the refusal to let partners attend appointments and the use of PPE. The lack of caring antenatal care has also been linked to the increase in stillbirths, as mentioned above.

Those are not the only long-term effects of the pandemic and lockdown on pregnant women, their babies and their families. In an international meta-analysis, depressive symptoms in pregnant women rose from 26% before January 2020 to 34.2% in February 2020. A similar increase in anxiety was seen, too. It also showed that pregnant women showed a significant decrease in all three levels of physical activity (vigorous, moderate and walking). This is important because exercise is one of the most effective non-medicinal treatments for depressive symptoms.

In the short term, the effects are obvious. Long term implications of maternal mental health are only just beginning to be understood. Poor mental health in mothers has been shown to go hand-in-hand with significant problems for their children. These can include an increase in preterm birth, low birth weights and behavioural problems in childhood. In later life, children of mothers with depression tend to interact with others less, have more trouble concentrating and have more negative responses to strangers. By the age of 16, they are more likely to have depression themselves and have poorer academic performance.

The researchers who conducted the meta-analysis above pointed out that the pandemic is likely to result in a decrease in access to mental health services. This, combined with worsened diet and falling out of the habit of exercise, is a ticking time bomb for many mothers.

What can be done?

While it is still massively under the radar, there are campaigns set up to try to tackle the issues we've talked about in this blog. The wonderful Maternal Mental Health Alliance has produced a rapid evidence review of the impact of COVID-19 on maternal mental health. The full report and their calls for action can be found on their website, this includes:

1. Ministers to protect and enhance services supporting perinatal mental health, including voluntary sector groups

2. Relevant bodies to re-assess the true level of demand in light of the pandemic

3. Research to be commissioned on the pandemic’s ongoing impact, including for women and babies of colour, and those from disadvantaged backgrounds.

Getting Help

Key messages for women and their families from Reports | NPEU > MBRRACE-UK:

Signs to be aware of – red flag symptoms (in yourself, a loved one, or a friend):

• Do you have new feelings and thoughts which you have never had before, which make you disturbed or anxious?

• Are you experiencing thoughts of suicide or harming yourself in violent ways?

• Are you feeling incompetent, as though you can’t cope, or estranged from your baby? Are these feelings persistent?

• Do you feel you are getting worse, or at risk of getting worse?

Speak out as early as possible if you or your partner or friend have any of these symptoms.

The first step to dealing with any of the issues raised here is to talk. If you are struggling to put this into words then it could help you to write a letter or a journal of what you have been through and how you are feeling. This can help you to formulate and process some of your thoughts and prepare you if you go on to talk about this with others.

If you do not feel able to talk about this with your partner/family/friends then try to speak with a health professional. This might be your GP or health visitor or midwife. If you have been through a traumatic birth at any time in the past then you are eligible for referral to the confidential midwife run NHS Birth Reflections which should provide review & professional support.

If you have generally had a hard time it can help to talk to other mums about their experience of childbirth as they are more likely to understand what you have been through. This can be difficult if you have not joined parent and baby groups due to COVID. However, there are online groups and now in-person activities have started again you might find some support through these.

If you are suffering from symptoms of low mood, anxiety, insomnia, nightmares, flashbacks, intrusive thoughts, or thoughts of harming yourself or others it is important to get help as soon as possible. There is a lot that can be done to support you. If you have not already talked to a health professional then it is critical that you speak to your GP or seek advice via NHS 111 if they are not available.

Places you can go for help

If you feel like you are struggling with your own mental health during pregnancy or after the birth or loss of your child, the Royal College of Psychiatrists has a great page full of useful advice.

If you are under the care of a mental health service, they advise checking your care plan to see who you should call. If you aren’t under the care of a mental health team or if you can’t reach anyone, you can contact your GP, NHS 111 or your local mental health trust.

There are also organisations that offer extra, specialised support for you and your family:

• The Royal College of Obstetricians and Gynaecologists – This page has lots of COVID-related information for pregnant women and their families

• Action on Postpartum Psychosis – They provide one-to-one peer support for women experiencing postpartum psychosis, as well as their partners and families. Email app@app-network.org

• Bipolar UK – Here is some coronavirus advice specifically for pregnant women with bipolar disorder, or you can email info@bipolaruk.org

• Maternal OCD – This organisation can help women with perinatal obsessive-compulsive disorder. Call their helpline (0845 390 6232) or email support@ocdaction.org.uk

• The PANDAS Foundation – Parents with perinatal mental illness can call the helpline (0808 1961 776) or email info@pandasfoundation.org.uk. They also provide support to families

• Anxiety UK – This page has useful information on what they are calling ‘coronanxiety’. You can also phone the helpline (03444 775 774) or check out their website for more ways to get in touch

• Beat Eating Disorders – This page discusses how to get help with eating disorders during COVID. They have a helpline (0808 801 0677), as well as digital support

• Royal College of Psychiatrists – The RCP have lots of useful leaflets covering all sorts of issues around pregnancy and mental health on the page ‘pregnancy - before, during and after'

• Tommy’s – This site has a lot of useful advice and support. It also has a section where parents share their stories of loss, including experiences during lockdown.

• PIPKIN Perinatal Imaging Partnership with Families – This organisation is conducting a long-term, large-scale study of the experiences of families who had a new baby during COVID. You can sign up to participate or learn more on this page.

The KENSA course to help women following traumatic birtH Experience

In addition to the resources above, we at KENSA are currently developing an online course to help women heal from traumatic childbirth. It will include information relevant to how COVID has and continues to impact childbirth and how to deal with this. This will also offer access to a private online community of other mothers who have also been through birth trauma.

Sign up now to hear more about the course when it’s available