Mental Health During Pregnancy and Postpartum in the COVID-19 Pandemic: What 1,123 Women's Experiences Tell Us About Depression, Anxiety, and PTSD

Table of Contents

• Key Points
• Background: Why This Research Matters
• Study Methods: How the Research Was Conducted
• Who Participated in the Study
• Key Findings: What the Researchers Discovered
• How These Rates Compare to Other Studies
• Clinical Implications: What This Means for Patients
• Study Limitations: What This Research Couldn't Prove
• Recommendations for Patients and Providers
• Frequently Asked Questions
• Source Information

Key Points

• In 1,123 U.S. pregnant and postpartum women, 36.4% had depression, 22.7% anxiety, and 10.3% PTSD symptoms.
• Pre-existing mental health diagnoses raised risk 1.6–3.7 times for clinically significant symptoms during the pandemic.
• High COVID-19 health worries raised risk 2.6–4.2 times, independent of mental health history.
• High grief from lost pandemic experiences raised risk 4.8–5.5 times, the strongest association.
• Routine screening for depression, anxiety, PTSD, worries, and grief is recommended for perinatal patients.

Background: Why This Research Matters

The COVID-19 pandemic disrupted daily life for millions of Americans, with the U.S. death rate approaching 200,000 by September 2020. But beyond the direct effects of the virus itself, the pandemic dramatically altered everyday routines and major life milestones for nearly everyone. This period was marked by heightened stress, uncertainty, fear, and grief.

Researchers quickly documented increases in depression, anxiety, PTSD, anger, and fear across many segments of the population. However, experts raised particular concerns about vulnerable populations, including people with certain sociodemographic backgrounds and specific age groups. Among those considered most vulnerable: pregnant women and women who had recently given birth.

This focus on perinatal women (a term that covers both pregnancy and the postpartum period) makes sense for several reasons. In normal circumstances, approximately 10-20% of women experience mental health concerns during the perinatal period, according to the National Institute for Health and Care Excellence. While pregnancy and motherhood are often positively regarded, this life stage carries an increased risk for emotional complications, including symptoms of depression, anxiety, and trauma-related disorders, all of which can worsen with increased stress.

The pandemic added uniquely stressful conditions for perinatal women, including:

• Concerns about the risk of COVID-19 infection during pregnancy and after birth
• Worries about transmitting the virus to infants and other family members
• Altered prenatal care due to physical distancing and quarantine guidelines
• Disrupted access to doulas, nighttime nurses, and other perinatal professionals
• Reduced social support, which is especially critical after birth
• Grief over losing shared experiences, such as having a support person during labor or in-person visits from friends and family

The transitional nature of the perinatal period makes it an especially vulnerable time for women with a history of mental health problems, even without major life stress. During the pandemic, these women faced additional challenges, including potential disruption of ongoing mental health treatment. Of particular concern were those with a history of mood and anxiety disorders, which are common in the perinatal population.

Importantly, treating maternal mental health is not just about the mother. Mood and anxiety symptoms during pregnancy and the postpartum period have been linked to subsequent outcomes for both mothers and infants. Understanding the contributors to maternal psychiatric distress during the pandemic became a public health priority.

Study Methods: How the Research Was Conducted

This study, known as the Perinatal Experiences and COVID-19 Effects Study (PEACE), used a cross-sectional design, meaning data was collected at one point in time rather than following women over a period. The survey was conducted online between May 21, 2020, and August 17, 2020.

Eligible participants were U.S. women over age 18 who were either in their second or third trimester of pregnancy or who had given birth within the previous six months. Recruitment occurred primarily online through email distribution lists, social media (particularly Facebook groups), and word of mouth. Women were told the purpose of the survey was to "learn more about the effects of COVID-19 on women during the perinatal period (pregnancy and postpartum)," as it related to "stress, well being, resilience, and social support during this unprecedented time."

After providing informed consent, participants completed a 30-to-40-minute online REDCap survey. The survey included standardized measures for assessing:

• COVID-19-related experiences
• Family-social risk
• Resilience
• Perceived relationship with fetus/infant
• Health outcomes

To ensure data quality, the researchers implemented human verification and attention checks throughout the survey. Four study staff members additionally inspected responses visually for irregularities, such as completing multiple surveys within minutes of each other, nonsensical language, or identical email addresses, patterns that indicated programmed responses or bots. These responses were removed before analyses. All study procedures were approved by the Institutional Review Board at Mass General Brigham.

The study measured three main areas: COVID-19-related health worries, grief from pandemic losses, and mental health outcomes.

How Health Worries Were Measured

COVID-19-related health worries were assessed using four items from the Coronavirus Health Impact Survey (CRISIS). Participants rated how worried they were about contracting the virus, their friends and family becoming infected, and their physical and mental health being affected by COVID-19, on a scale of 1 (not at all) to 5 (extremely). The measure showed very good reliability (Cronbach's alpha = 0.85). Women who averaged "very" or "extremely" worried (total score greater than 16) were classified as having "high" levels of worry.

How Grief Was Measured

Maternal grief and perceived loss of meaningful experiences were assessed with a six-item measure, plus one additional item unique to the perinatal period. Several items were adapted from the Inventory of Complicated Grief, a well-established tool. The questions covered feelings about lost experiences due to the pandemic, including missing significant life events, limited support from family and friends due to social distancing, and loss of resources. The additional perinatal-specific question explored sadness about being unable to fully celebrate the pregnancy or birth of their child with loved ones. Participants rated their agreement on a scale of 1 (strongly disagree) to 5 (strongly agree). This measure showed good reliability (Cronbach's alpha = 0.78). Women who averaged "agreed" or "strongly agreed" (total score greater than 28) were classified as having "high" levels of grief.

How Mental Health Was Measured

The researchers used three widely validated tools:

1. Depression: The 20-item Center for Epidemiologic Studies-Depression scale (CES-D) assessed symptoms over the past week. A score of 16 or higher indicated clinically significant depression symptoms.
2. Generalized Anxiety: The Generalized Anxiety Disorder scale (GAD-7) evaluated the frequency of anxiety symptoms over the past two weeks, with total scores ranging from 0 to 21. A cutoff of 10 or higher indicated clinically significant anxiety.
3. PTSD: The PTSD Checklist—Civilian Version (PCL-C), a validated 17-item measure, assessed how much participants had been bothered by trauma-related problems in the past month. A cutoff of 45 indicated clinically significant PTSD symptoms.

Tracking Pre-Existing Mental Health Conditions

Women were asked whether they had ever received a diagnosis of depression, generalized anxiety disorder, or PTSD from a mental health professional before their pregnancy. Response options were: "No"; "Suspected, but not diagnosed"; "Yes, diagnosed but not treated"; and "Yes, diagnosed and treated." For analysis, "Suspected, but not diagnosed" was combined with "No," and the two "Yes" options were combined into a single "Diagnosed" category for each condition. These diagnoses were not mutually exclusive, meaning women could have had more than one.

Statistical Approach

The researchers conducted a series of logistic regression analyses, both unadjusted and adjusted. Adjusted models included sociodemographic variables (maternal age, race, education, income, living arrangements, and whether it was the mother's first pregnancy), the date participants completed the survey, and any history of pre-existing mental health diagnoses. They also calculated the number of days between March 13, 2020 (when COVID-19 was formally declared a pandemic in the U.S.) and the date each participant began the survey, to account for how pandemic duration might affect experiences. All analyses were performed using SPSS 26.0, and only women who completed the entire survey were included.

Who Participated in the Study

A total of 1,123 U.S. women participated in this study. Here is a detailed breakdown of their demographic characteristics:

• Perinatal status: 54.2% were pregnant, while 45.8% were in the postpartum period (within 6 months of giving birth). Among postpartum women, infants averaged 11.6 weeks of age, and 7.9% of babies were born premature (before 37 weeks).
• Maternal age: Average age was 33.10 years (standard deviation 3.77).
• Race: The large majority, 89.9%, were White. Black or African American women made up 0.9%, Hispanic or Latino women 3.6%, Asian and Pacific Islander women 3.5%, and 2.1% identified as Other.
• Education: 92.1% were at least college-educated. Specifically, 7.9% had less than a college degree, 30.7% had a college degree, 41.6% had a master's degree, and 19.8% had a doctorate.
• Household income: 13.4% earned under $74,999 per year, 41.5% earned $75,000-$149,999, 26.7% earned $150,000-$224,999, and 18.3% earned over $225,000. Approximately 45% had household incomes of $150,000 or above.
• Living arrangements: 98.0% were living with their spouse or partner.
• First pregnancy: For 42.4%, this was their first pregnancy.
• Trimester: Among pregnant participants, 39.3% were in their second trimester and 60.7% in their third.
• Timing: On average, survey responses took place between 3-4 months after COVID-19 was designated a pandemic. The average number of days between the pandemic declaration (March 13, 2020) and survey completion was 111.10 days (standard deviation 23.69).

Key Findings: What the Researchers Discovered

High Rates of Clinically Significant Mental Health Symptoms

The study found strikingly high rates of mental health symptoms among participants:

• 36.4% reported clinically significant symptoms of depression (CES-D score above 16) over the past week
• 22.7% reported clinically significant symptoms of generalized anxiety (GAD-7 score of 10 or higher) over the past two weeks
• 10.3% reported clinically significant symptoms of PTSD (PCL-C score above 45) over the past month

These figures are striking when compared to the general population. In non-pandemic circumstances, roughly 10-20% of women experience mental health concerns during the perinatal period. The depression rate of 36.4% found here is nearly double the upper end of that range.

Pre-Existing Mental Health Diagnoses Were Common

Many women in the study had been diagnosed with mental health conditions before their pregnancy:

• 17.5% reported a prior depression diagnosis
• 24.5% reported a prior generalized anxiety diagnosis
• 4.1% reported a prior PTSD diagnosis

Having a pre-existing diagnosis significantly increased the likelihood of scoring above clinical thresholds during the pandemic. Women with any pre-existing mental health diagnosis were 1.6 to 3.7 times more likely to experience clinically significant depression, generalized anxiety, or PTSD symptoms.

Specifically, the adjusted models showed:

• A pre-existing depression diagnosis was significantly associated with a greater likelihood of current clinically significant depression (Odds Ratio [OR] = 1.91, 95% Confidence Interval [CI] = 1.30-2.81, p < 0.01).
• A pre-existing generalized anxiety diagnosis was significantly associated with a greater likelihood of all three conditions: depression (OR = 1.58, CI = 1.12-2.22), anxiety (OR = 2.74, CI = 1.88-4.00, p < 0.001), and PTSD (OR = 1.73, CI = 1.05-2.85, p < 0.05).
• A pre-existing PTSD diagnosis was significantly associated with current PTSD symptoms (OR = 3.73, CI = 1.76-7.90, p < 0.01).

To put this in plain language: women with a past generalized anxiety diagnosis were nearly three times more likely to experience clinically significant anxiety during the pandemic than women without that history. Women with a past PTSD diagnosis were more than 3.7 times more likely to experience clinically significant PTSD symptoms.

COVID-19 Health Worries Were Strongly Linked to Mental Health Symptoms

Approximately 18.2% of women reported high levels of COVID-19-related health worries, meaning they were, on average, "very" or "extremely" worried about contracting the virus, family members becoming infected, and the virus affecting their physical and mental health.

These high-worry women were 2.6 to 4.2 times more likely to score above clinical thresholds for mental health symptoms. The specific odds ratios were:

• Depression: women with high health worries were 3.41 times more likely (CI = 2.42-4.81, p < 0.001)
• Generalized anxiety: 4.23 times more likely (CI = 2.99-6.08, p < 0.001)
• PTSD: 2.56 times more likely (CI = 1.62-4.06, p < 0.001)

These results were significant even after adjusting for sociodemographic factors, pandemic duration, and pre-existing mental health diagnoses, which means the association between health worries and mental health symptoms was not simply due to women who already had mental health conditions being more worried.

Grief Was Even More Strongly Linked to Mental Health Symptoms

Approximately 8.8% of women reported high levels of COVID-19-related grief, meaning they, on average, "agreed" or "strongly agreed" with statements about losing meaningful experiences, feeling stunned or dazed, feeling that life is empty, feeling bitter about lost routines, and being sad about not fully celebrating their pregnancy or birth with loved ones.

These women were 4.8 to 5.5 times more likely to score above clinical thresholds, the strongest association found in the study:

• Depression: 4.82 times more likely (CI = 2.91-8.00, p < 0.001)
• Generalized anxiety: 4.75 times more likely (CI = 2.95-7.62, p < 0.001)
• PTSD: 5.45 times more likely (CI = 3.26-9.10, p < 0.001)

Again, these findings held even after accounting for pre-existing mental health conditions and other demographic factors, suggesting that grief from pandemic-related losses was an independent risk factor for poor mental health outcomes.

Other Demographic Associations

The study also explored whether demographic factors were linked to mental health outcomes. Most demographic variables were not significantly associated with symptoms in the adjusted models, but a few patterns emerged:

• Hispanic or Latino women had higher odds of PTSD symptoms compared to White women (OR = 3.02, CI = 1.17-7.20, p < 0.05).
• Higher education levels appeared to show a trend toward lower risk of depression and PTSD, though most of these associations did not reach statistical significance.
• Higher household income showed a pattern of lower risk across all three outcomes, but again, most of these associations were not statistically significant.
• Maternal age, living with a partner, and whether it was a first pregnancy were not significantly associated with mental health symptoms.

How These Rates Compare to Other Studies

The researchers compared their findings to other research to place the results in context.

Depression rates were higher than pre-pandemic U.S. samples. The 36.4% rate of clinically significant depression in this study is considerably higher than the generally accepted pre-pandemic prevalence of up to 20% for perinatal depression. In a pre-pandemic U.S. sample, 24% of pregnant women and 16% of postpartum women had probable depression (Goyal et al., 2010). Among a largely Hispanic sample of postpartum women, 33% scored in the probable depression range (Gress-Smith et al., 2012).

However, the rates were comparable to another pandemic-era study: a Canadian sample of women with children aged 0-18 months, assessed from mid-to-late April 2020, found that 33.2% had probable depression based on CES-D scores (Cameron et al., 2020). This similarity suggests the elevated depression rates may reflect a broader pandemic effect on perinatal mental health.

Anxiety and PTSD rates also deserve attention. In this study, 22.7% of women scored above clinical thresholds for generalized anxiety and 10.3% for PTSD. These figures highlight the broad mental health impact of the pandemic on perinatal populations.

Clinical Implications: What This Means for Patients

This study has several important implications for maternal mental health care, particularly during public health crises.

First, the high rates of depression (36.4%), anxiety (22.7%), and PTSD (10.3%) signal a mental health crisis among perinatal women during the pandemic. These rates mean that in a typical obstetrics waiting room during this period, roughly one in three pregnant or postpartum patients may have been experiencing clinically significant depression, and one in five may have had clinically significant anxiety. Providers should consider routine mental health screening during all prenatal and postpartum visits, especially during times of heightened stress.

Second, women with pre-existing mental health diagnoses are particularly vulnerable. The pandemic appears to have exacerbated symptoms in this group, and the study authors note that the pandemic may have impeded women's ability to continue or seek mental health treatment. Women with a history of depression, anxiety, or PTSD should be proactively offered ongoing support and check-ins during pregnancy and the postpartum period. They may also benefit from help navigating telehealth options or other accessible treatment formats.

Third, COVID-19-related health worries and grief may increase the likelihood of mental health symptoms even among women without pre-existing mental health concerns. This is a critical finding because it suggests the pandemic's psychological toll extended to previously healthy women. Providers should not assume that only women with psychiatric histories are at risk, but should rather assess all perinatal women's pandemic-related worries and losses.

Fourth, the strong link between grief and mental health symptoms (4.8-5.5 times higher likelihood) is especially noteworthy. Many women experienced profound grief from missing out on expected birth experiences, baby showers, postpartum support, and family celebrations. This grief may have been dismissed as minor compared to the larger pandemic crisis, but the data show it was strongly associated with clinically significant mental health symptoms. Providers should acknowledge and validate these losses, which may include grief over the loss of a "normal" pregnancy or postpartum experience.

Fifth, maternal mental health matters for both mother and baby. Mood and anxiety symptoms during pregnancy and postpartum have been linked to subsequent maternal and infant outcomes. Addressing these symptoms is therefore not just about maternal wellbeing but also about infant health and development.

Study Limitations: What This Research Couldn't Prove

Like all research, this study has important limitations that should be considered when interpreting the findings.

First, this was a cross-sectional study, meaning data was collected at a single point in time. This design cannot establish cause and effect. While the researchers found strong associations between health worries, grief, and mental health symptoms, causation cannot be inferred. It's possible, for example, that pre-existing (but undiagnosed) mental health conditions made some women more prone to both worrying and experiencing symptoms, rather than the worries themselves causing the symptoms.

Second, the sample was not representative of the broader U.S. perinatal population. The participants were overwhelmingly White (89.9%), college-educated (92.1%), living with a partner (98.0%), and relatively affluent, with approximately 45% earning over $150,000 annually. This limits the generalizability of the findings to women of color, women with lower incomes or education levels, and those without partner support, who may face different or additional stressors during a pandemic.

Third, mental health diagnoses were self-reported. Women were asked whether they had been diagnosed by a mental health professional prior to pregnancy, but the researchers did not verify these diagnoses through medical records. Some women classified as not having a pre-existing diagnosis may have had undiagnosed conditions.

Fourth, the data was collected between May and August 2020. This represents a specific window of the pandemic. Experiences may have differed significantly during other phases of the pandemic, such as the initial surge, later waves, vaccine availability, and post-vaccine periods.

Fifth, the study relied on internet-based recruitment. This method may have introduced selection bias, potentially excluding women without internet access or those not active on social media or email lists. Participants who chose to join a study about COVID-19's effects on perinatal mental health may also have been more distressed than the general perinatal population.

Sixth, high levels of depression, anxiety, and PTSD symptoms do not equal a clinical diagnosis. The validated screening tools used in this study are reliable indicators of clinically significant symptoms, but a formal diagnostic interview would be needed to confirm actual mental health disorders.

Recommendations for Patients and Providers

Based on the study's findings, the researchers offer several recommendations for clinical practice and for perinatal women themselves. The authors specifically state that "providers should develop strategies for addressing health-related worry and grief within their practice."

For Healthcare Providers

1. Screen all perinatal patients for depression, anxiety, and PTSD symptoms routinely, not just those with known mental health histories. Given that 36.4% of women in this study had clinically significant depression symptoms, universal screening is critical.
2. Ask specifically about pandemic-related health worries and grief experiences. These were strongly associated with mental health symptoms, even among women without pre-existing diagnoses. Simple questions like "What have you missed out on due to the pandemic?" or "How worried are you about COVID-19 affecting you or your baby?" may open important conversations.
3. Validate women's grief and loss experiences. Many women feel their losses (such as not being able to have a support person during labor) are trivial compared to the larger pandemic. Providers can normalize and acknowledge these feelings, which may help prevent or reduce mental health symptoms.
4. Pay special attention to women with pre-existing mental health diagnoses. These women were 1.6 to 3.7 times more likely to experience clinically significant symptoms. Proactive outreach, adjusted treatment plans, and ensuring continuity of mental health care are essential.
5. Offer flexible treatment options, including telehealth, which can address barriers to care during a pandemic while maintaining physical distancing.
6. Consider Hispanic and Latino women as a potentially higher-risk group for PTSD. The study found a significantly elevated odds ratio (OR = 3.02) for PTSD symptoms in this group, suggesting targeted screening and support may be warranted.

For Perinatal Women

1. Know that your feelings are common and valid. If you're feeling depressed, anxious, or traumatized during your pregnancy or postpartum period, you are far from alone. In this study, more than one in three women experienced significant depression symptoms.
2. Talk to your healthcare provider. Share your worries about your health and your baby's health, and tell them if you're grieving lost experiences. These conversations are important and can lead to helpful support.
3. If you have a history of depression, anxiety, or PTSD, be especially mindful of your wellbeing. Consider reaching out to your mental health provider early, even before symptoms become severe, to discuss how you're coping and ensure your treatment plan is still working.
4. Seek help for grief. If you're grieving the loss of expected pregnancy or birth experiences, your feelings matter. Support groups (including online options) for pandemic-era mothers may be particularly helpful.
5. Remember that screening tools used in studies identify symptom levels, not your worth or your ability to be a good parent. Reaching out for help is a sign of strength, not weakness.

For Families and Friends

If you know someone who is pregnant or has recently had a baby during this pandemic, your support matters. You can help by:

• Acknowledging the losses and disappointments she may be experiencing, without minimizing them
• Checking in regularly, even through virtual means
• Encouraging her to talk to her provider about any mental health concerns
• Helping with practical needs (meals, childcare, errands) in ways that respect physical distancing guidelines

Frequently Asked Questions

What made mental health symptoms more likely in pregnant and postpartum women during the pandemic?

Women with pre-existing mental health diagnoses were 1.6 to 3.7 times more likely to have significant symptoms. Those with high COVID-19-related health worries were 2.6 to 4.2 times more likely, and those with high grief from lost pandemic experiences were 4.8 to 5.5 times more likely.

Which risk factor was most strongly linked to depression, anxiety, and PTSD in perinatal women?

Grief from lost pandemic experiences had the strongest link, according to the study. Women with high levels of grief were 4.8 times more likely for depression, 4.75 times for anxiety, and 5.45 times for PTSD, compared to those with lower grief, even after adjusting for other factors.

Did women without a history of mental health problems also experience symptoms during the pandemic?

Yes. High COVID-19 health worries and grief were strongly associated with clinically significant depression, anxiety, and PTSD symptoms even after accounting for pre-existing mental health diagnoses and other demographic factors. This suggests the pandemic's psychological toll affected previously healthy perinatal women as well.

What should I do if I'm pregnant or recently gave birth and feel depressed, anxious, or traumatized?

Talk to your healthcare provider about your worries and any grief from missed experiences, such as not celebrating your pregnancy or birth with loved ones. If you have a history of depression, anxiety, or PTSD, consider reaching out early. These feelings are common and valid, and support can help.

What limitations should I keep in mind when interpreting this study's findings?

The study was cross-sectional, so it cannot prove cause and effect. Participants were mostly White, college-educated, and living with a partner, so results may not apply to all groups. Also, mental health diagnoses were self-reported, and screening tools indicate symptoms, not a formal clinical diagnosis.

When should a pregnant or postpartum woman with depression, anxiety, or PTSD symptoms seek a second opinion?

A second opinion can be useful if you are pregnant or recently gave birth and have symptoms of depression, anxiety, or PTSD. In a large survey during the pandemic, 36.4% of perinatal women had clinically significant depression, 22.7% had generalized anxiety, and 10.3% had PTSD. Women with a pre-existing mental health diagnosis were 1.6 to 3.7 times more likely to cross clinical thresholds, and pandemic-related grief was even more strongly linked to symptoms. If you have such a history or feel your worries or losses are not being fully addressed, a second opinion can help confirm your diagnosis and treatment plan. Diagnostic Detectives Network provides independent expert second opinions.

Source Information

Original article title: Risk factors for depression, anxiety, and PTSD symptoms in perinatal women

Authors: Cindy H. Liu, Carmina Erdei, and Leena Mittal

Journal: Psychiatry Research, Volume 295 (2021), Article 113552, available online November 4, 2020

Affiliations: Department of Newborn Medicine, Brigham and Women's Hospital; Department of Psychiatry, Brigham and Women's Hospital; Harvard Medical School, Boston, MA, USA

Study name: Perinatal Experiences and COVID-19 Effects Study (PEACE, www.peace-study2020.com)

Corresponding author: Cindy H. Liu, chliu@bwh.harvard.edu

This patient-friendly article is based on peer-reviewed research. The original study was funded and conducted at Brigham and Women's Hospital and Harvard Medical School. Data was collected from May 21 to August 17, 2020, and the study was approved by the Institutional Review Board at Mass General Brigham.

This article is intended for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. If you are experiencing symptoms of depression, anxiety, or PTSD, please contact your healthcare provider or a mental health professional. If you are in crisis, call 911 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).