key: cord-0687414-xgbsh0lc
authors: Vatcheva, Tzanka; Mostaert, Anne; Van Ingelgem, Valérie; Henrion, Elisabeth; Legros, Ludovic
title: Impact of COVID‐19 pandemic on postpartum depression among mothers of extreme and early preterm infants
date: 2021-09-08
journal: Int J Gynaecol Obstet
DOI: 10.1002/ijgo.13859
sha: 1939ed884276312602205c13b14dcc7387a33721
doc_id: 687414
cord_uid: xgbsh0lc

OBJECTIVE: To examine the impact of the coronavirus disease 2019 (COVID‐19) pandemic and the resulting isolation measures on the risk of postpartum depression (PPD) after preterm birth. METHODS: This is a cross‐sectional study of mothers of extreme and early preterm infants who completed the Edinburgh Postnatal Depression Scale (EPDS) at the standardized 3–6 months follow‐up consultation for preterm infants. Mothers assessed during the COVID‐19 pandemic (n = 34; from April 1, 2020 to March 31, 2021) were compared with an antecedent control group (n = 108; from January 1, 2017 to December 31, 2019). A multivariable logistic regression model was used to examine the relationship between the pandemic and the risk of PPD (EPDS score ≥13). RESULTS: The prevalence of depressive symptoms was significantly higher in the COVID‐19 study group (26% versus 12%, P = 0.043). The multivariable logistic regression model showed a significant association between the COVID‐19 pandemic and the risk of PPD (adjusted odds ratio 3.60, 95% confidence interval 1.06–12.59, P = 0.040). CONCLUSION: Among mothers of extreme and early preterm infants, the COVID‐19 pandemic was independently associated with a higher risk of PPD. This confirms the need for a close and long‐term follow up of maternal psychological health after preterm birth.

prenatal consultations, and excluding family and visitors from postpartum units. All these measures resulted in mothers' social isolation, which, associated with health and economic uncertainties, may be the background of psychiatric and affective disorders. 1 Over the last year, several studies have documented maternal psycho-emotional distress linked to the COVID-19 pandemic. 2 To our knowledge, no studies have focused specifically on the impact of the COVID-19 pandemic on psychological distress following preterm birth. Overall, during the pandemic, the prevalence of preterm birth (before 37 weeks of gestation) has not significantly changed, but seems to have decreased in high-income countries. 4 Under normal conditions, mothers of preterm infants already show a higher risk of depression in the immediate postpartum period. [5] [6] [7] Hence, we may assume that the pandemic has worsened the risk factors of PPD linked with preterm birth. Indeed, prematurity is a stressful experience, which leads to prolonged hospitalization and parental concerns about their child's health. After preterm birth, the restrictive measures that were imposed in the Neonatal Intensive Care Units (NICU) and the social isolation after hospital discharge might increase the risk of depressive symptoms. Moreover, PPD is related to several complications impacting both maternal health and infant's development, 6, 8 and its consequences on infant's development will be all the more important because preterm infants are already at risk of neurodevelopmental delay. 9 Therefore, it is paramount to analyze the impact of the COVID-19 pandemic on PPD in this specific population in order to implement early targeted interventions. The aim of this study is twofold: to determine the prevalence of depression symptoms following preterm birth during the COVID-19 pandemic and to highlight an eventual association between the pandemic and the risk of PPD.

In Belgium, a standardized follow-up program for extreme and early preterm infants (<32 weeks of gestation) and/or infants with a very low birth weight (<1500 g) is planned at corrected ages 3-6 months, 9-14 months, 22-26 months, and 4.5-5.5 years. In our Follow-up Center, mothers of preterm infants are systematically assessed by a psychologist at theconsultation at 3-6 months, and the child is neurologically assessed by a physiotherapist. Consequently, we performed a non-concurrent cross-sectional study including all mothers assessed at the 3-6 months corrected age follow-up consultation, between April 1, 2020 and March 31, 2021 (COVID-19 study group), and between January 1, 2017 and December 31, 2019 (control group). The COVID-19 study period was chosen based on the start of the first Belgian lockdown on March 18, 2020. Mothers assessed between January and March 2020 were not included in this study to limit the potential interference between the two study periods.

The exclusion criteria were the inability of mothers to read and/or write French.

As part of the follow-up program, all data concerning birth conditions, perinatal history, and follow-up evaluation of preterm infants were encoded prospectively and anonymously in the databases of the Newborn College. The clinical information used for this study was collected directly from these databases. Clinical information included both maternal demographic and pregnancy data, as well as delivery mode and perinatal infant history during NICU hospitalization.

PPD represents the end of a continuum of severity of symptoms.

Maternal depressive symptoms were assessed using the French version of the Edinburgh Postnatal Depression Scale (EPDS). 10 The EPDS is specifically designed for perinatal depression because it does not include confounding items about somatic depressive symptoms (such as sleep or appetite changes), common in the prepartum and postpartum periods. It is a 10-item self-report questionnaire that can be easily completed in less than 5 min by mothers. Responses to items are scored from 0 to 3, with a maximum score of 30. Scores of 13 or more are usually used to identify women with clinical major depression symptoms. In a recent meta-analysis, the cut-off score of 13 showed a sensitivity of 0.66 and a specificity of 0.95 to detect major depression among pregnant and postpartum women, whereas the cut-off of 10 had a sensitivity of 0.85 and a specificity of 0.84. 11 The same results were described in a previous systematic review, confirming the high screening accuracy of the EPDS. 12 

The statistical analysis was performed using the statistical package Considering the different inclusion lengths between the control and the study group (respectively, 3 years versus 1 year), the homogeneity of the control group was examined to exclude any statistical bias. The population's characteristics of the control group were compared year by year using χ 2 test for the categorical variables and one-way analysis of variance test for the continuous variables.

A multivariable logistic regression model was used to examine the relationship between the independent and dependent variables, while adjusting for confounding. Confounding factors included in the multivariable model were chosen as follows: well-known risk factors of PPD and factors significantly associated with the COVID-19 period (prevalence statistically different between the COVID-19 study group and the control group). Odds ratios (OR) adjusted for the confounding factors were calculated by the multivariable model, with their 95% confidence interval (95% CI). Table S1 ). The clinical and sociodemographic characteristics of the two groups are described in Table 1 . The populations' characteristics were similar between the two periods, except for a decrease of multiple pregnancies and an increase of pre-eclampsia and Apgar score less than 5 at 5 min in the COVID-19 study group. No preterm infant has tested positive for COVID-19. One infant was isolated from his parents from day 66 to day 80 because his mother was diagnosed with COVID-19.

His mother showed no symptoms of depression at the follow-up assessment (EPDS score 7). The prevalence of symptoms of major PPD (EPDS score ≥13) was significantly higher in the COVID-19 study group than in the control group (respectively 9/34 [26%] versus 13/108 [12%], P = 0.043).

After adjusting for confounding factors, the multivariable logistic regression model showed a significant association between the COVID-19 pandemic period and the risk of major PPD, defined by EPDS score of 13 or more, (adjusted OR 3.60, 95% CI 1.06-12.59, P = 0.040). The confounding factors included in the multivariable logistic regression model were the following: maternal age, education and history of affective disorder, parity, multiple pregnancy, adverse pregnancy outcomes, cesarean section, Apgar score less than 5 at 5 min, and breastfeeding at discharge. No significant interactions between these other variables and the risk of PPD were found (results shown in Table 2 ).

This study found that mothers of early and very preterm infants as- 18, 19 Third, this pandemic has deeply impacted the global economy and increasing numbers of women have become unemployed or had to take on childcare responsibilities because of nursery and school closure. 20 This situation can lead to a decrease in families' income, which was significantly associated with higher scores on the EPDS among postpartum mothers. 17 Nevertheless, some studies showed an improvement in maternal psychological health during the COVID-19 pandemic, which highlights the role of the socio-cultural environment of the mothers. 21 Indeed, some postpartum mothers might have benefited not only from greater family support during quarantine, but also from a closer mother-child attachment due to their relative isolation from the external world.

This study specifically focuses on the mental health of mothers of very and early preterm infants. As preterm birth already increases the risk of depressive postpartum symptoms, it is fundamental to pay special attention to this vulnerable population during the current pandemic. Indeed, this pandemic may worsen the risk factors of PPD initially linked to prematurity, such as adverse pregnancy and neonatal outcome, anxiety about child health, and prolonged separation of the mother-child dyad during neonatal hospitalization. 22 Moreover, it is essential to identify and detect maternal depression after preterm birth, so that prematurity does not lead to a double penalty for infant development. The preterm infant is already

at risk of neurodevelopmental delay, and PPD might be responsible for an impaired mother-child bonding, which might affect the later cognitive, behavioral, and social-emotional development and physical health of the infant. 8, 23 However, the choice to target a specific population of mothers affected by a preterm birth could reduce the statistical impact of COVID-19 on PPD in this study, as additional problems do not necessarily result in additional distress above a certain threshold of medical co-morbidities. 7 This "ceiling-effect" might also hide potential impacts of the other traditional risk factors of PPD. Another specificity of this study has been the choice to recruit mothers through the standardized follow-up consultation for preterm infants, preventing a population selection bias, but excluding mothers of deceased infants. Moreover, this late evaluation at 3-6 months (infant's corrected age) allows us to decrease potential confounding symptoms of other affective disorders linked to preterm birth and long-term hospitalization, such as simple adjustment disorder with depressed mood and post-traumatic symptoms.

In addition, this late evaluation might take more account of the longlasting social isolation of mothers than psychological assessments made in the first week postpartum, as realized in the studies cited above. 3, 15, 16 Furthermore, this study evaluated mothers during an entire year during the COVID-19 pandemic, so avoiding the seasonal impact on depressive symptoms.

The first limitation of this study is its monocentric retrospective construction. The sample is small and geographically specific, limit- In conclusion, the results of our study indicate that the COVID-19

pandemic and the resulting restrictive measures had increased the risk of PPD among mothers of extreme and early preterm infants.

As we know, PPD may interfere with the cognitive, behavioral, and social-emotional development of preterm infants that are already at risk of poor health condition and neurodevelopmental impairment because of their prematurity. This vulnerable population needs to be carefully followed, because the secondary socio-economic impacts of the pandemic are still unknown. Therefore, longitudinal long-term studies will be necessary to further understand the impact of the ongoing COVID-19 pandemic on the emotional distress of mothers.

The results described in this paper rely on data from the databases of the Newborn College, which is maintained by the Belgische 

The authors have no conflicts of interest.

TV, EH, and LL conceived the study idea. All authors contributed to the study design. AM and LL performed the data collection. LL TA B L E 2 Multivariable logistic regression models for the association between the COVID-19 pandemic and postpartum depression symptoms (Edinburgh Postnatal Depression Scale score ≥13) 

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Additional supporting information may be found online in the Supporting Information section. How to cite this article

performed the statistical analysis. TV and LL drafted the first version of the manuscript. All authors have discussed the results and revised this manuscript critically for important intellectual content.All authors have read and approved the final manuscript.