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Associations among Postpartum Posttraumatic Stress Disorder Symptoms and COVID‐19 Pandemic‐Related Stressors

Introduction Coronavirus disease 2019 (COVID‐19) pandemic‐related stressors (eg, exposure, infection worry, self‐quarantining) can result in heightened levels of distress and symptoms of postpartum posttraumatic stress disorder (PTSD). Methods Using a cross‐sectional descriptive design, we collected survey data from a convenience sample of 670 postpartum persons who gave birth to a newborn during the first 6 months of the COVID‐19 pandemic in the United States. The presence of PTSD symptoms was measured using the 21‐item Birth Memories And Recall Questionnaire (BirthMARQ) and defined as an affirmative rating for each item (score of 5 to 7 on a 1 to 7 agreement scale). Symptoms counts were computed for each of the 6 BirthMARQ domains, 2 symptom clusters (intrusive; mood and cognition alterations), and the total number of symptoms. Symptom counts were analyzed using descriptive statistics. We explored associations among COVID‐19 experiences (self‐quarantine behaviors, infection worry, exposure) and counts of PTSD symptoms using negative binomial regression models while controlling for postpartum depression screening scores, neonatal intensive care unit admissions, number of weeks postpartum, race, and marital status. Results Almost 99% of participants reported experiencing at least one of 21 PTSD symptoms (mean, 8.32; SD, 3.63). Exposure to COVID‐19 was associated with a 34% greater risk for experiencing intrusive symptoms, specifically, symptoms of reliving the birthing experience as if it were happening now (47% greater risk). Worry surrounding COVID‐19 infection was associated with a 26% increased risk for experiencing intrusive recall symptoms in which birth memories came up unexpectantly. COVID‐19 quarantining behaviors were not significantly related to increasing PTSD symptoms. Many of the demographic variables included were associated with increasing PTSD symptoms. Discussion Screening perinatal persons for PTSD is critically important, especially during public health crises like the COVID‐19 pandemic. The integration of comprehensive mental health screening, including specific screening for trauma and symptoms of PTSD, across health care settings can help improve delivery of quality, patient‐centered care to postpartum persons.


INTRODUCTION
Nearly one in 4 postpartum persons report symptoms of posttraumatic stress disorder (PTSD) during the postpartum period. 1,2 Postpartum PTSD symptoms often emerge following a threat to maternal or newborn health (eg, emergency cesarean birth, fetal demise, hemorrhage) 3,4 but can also be triggered by a traumatic experience before or during pregnancy. 5 PTSD symptoms include intrusive re-experiencing of past traumatic events including childbirth (eg, flashbacks, nightmares) and mood and cognition alterations such as anxiety, hypervigilance, irritability, and feelings of detachment from reality. 6 In the context of the coronavirus disease 2019  pandemic, postpartum persons can experience a variety of PTSD symptoms, signaling emotional dysregulation that could negatively affect their mental health, wellbeing, and relationships with partners 7 and their newborn or infant. 8 Overall risk factors for postpartum PTSD include fear of childbirth, adverse childhood experiences, prenatal health concerns (eg, preeclampsia, gestational diabetes, infant congenital abnormalities), and lack of social and/or emotional support. 5,9 Pandemic sequelae, such as social distancing, stayat-home orders, unemployment, and increased dependent care responsibilities, are similar to previously established perinatal risk factors for postpartum PTSD. For example, social distancing and stay-at-home orders can contribute to decreased social support, placing postpartum persons at increased risk for postpartum PTSD. These pandemic-related stressors, introduced early in the pandemic, could have significantly elevated maternal mental health challenges 10 and resulted in heightened levels of distress 11 and mental illness among perinatal persons. [12][13][14][15][16][17] Postpartum PTSD can result in poor maternal-infant bonding, decreased maternal self-efficacy, and strained partner relationships. [18][19][20] Furthermore, postpartum PTSD can adversely affect subsequent pregnancies, including increased risk for intrauterine growth restriction, premature birth, and ✦ Giving birth during coronavirus disease 2019  can contribute to a traumatic birth experience for postpartum persons and increase the number of posttraumatic stress disorder (PTSD) symptoms experienced.
✦ Exposure and worry surrounding COVID-19 infection can put postpartum persons at higher risk for experiencing PTSD symptoms.
✦ Considering the presence of PTSD symptoms in approximately 99% of our sample, it is essential clinicians screen for postpartum PTSD in addition to depression.
low birth weight. [20][21][22] Considering the adverse effects of PTSD on subsequent pregnancies, and because pandemic sequelae can mirror pre-established postpartum PTSD risk factors, it is critical to evaluate the association of COVID-19 pandemic experiences with PTSD symptoms. With this knowledge, midwives, perinatal nurses, obstetricians, and perinatal mental health clinicians can begin to identify and/or develop clinical guidelines, resources, and supports to improve screening persons for postpartum PTSD, refer to treatment as indicated, and equip perinatal persons and their families with resources and knowledge. Known associations among various mental health outcomes (eg, depression, anxiety, PTSD), 23 in addition to perinatal risk factors for PTSD, suggest that pregnancy during COVID-19 can create traumatic birth memories. Understanding how traumatic birth affects postpartum mental health is critical to providing patient-centered care that is effective and of high quality. Additionally, understanding the relationship between COVID-19 and postpartum PTSD can inform trauma-informed care approaches to minimize PTSD symptoms in subsequent pregnancies after the pandemic. Accordingly, we conducted the COVID-19 Maternal Attachment, Mood, Ability, and Support (COVID-19 MA-MAS) study to explore and describe perinatal mental health during the early stages of the COVID-19 pandemic in the United States. During the first wave of COVID-19 in the United States, many states began imposing temporary stayat-home orders and mask mandates in public places, whereas hospitals and clinics developed and implemented strict visitation policies and other infection control measures. Using data from the COVID-19 MAMAS study, the purposes of this current study were to (1) explore the presence of PTSD symptoms among postpartum persons who gave birth during the first wave of the COVID-19 pandemic in the United States and (2) explore relationships among PTSD symptoms and general stressors of the COVID-19 pandemic (eg, exposure to COVID-19 infection, worry surrounding COVID-19 infection, self-quarantining and isolation).

Design
This study was part of the COVID-19 MAMAS study, which used a cross-sectional design to collect survey data from postpartum persons who gave birth to a newborn between February 1, 2020 (after the United States declared COVID-19 a public health emergency), 24 and July 8, 2020. Data collection took place in June and early July of 2020 and included participants who gave birth during the initial surge of COVID-19 cases in the United States, which peaked in April 2020. 25 The COVID-19 MAMAS study collected data on several selected perinatal health outcomes, including postpartum anxiety and depression, traumatic birth memories, social and emotional support, parental self-efficacy, and parent-infant bonding. Demographic information, including COVID-19 experiences (eg, exposure to COVID-19 infection, worry surrounding infection risk, self-quarantining behaviors) and newborn information (eg, neonatal intensive care unit [NICU] admission), were also collected. This study explores relationships among participant experiences during the COVID-19 pandemic and postpartum PTSD symptoms of emotional dysregulation including mood and cognition alternations and intrusion. The study was approved by the University of Michigan Institutional Review Board.

Sample
The COVID-19 MAMAS study recruited a convenience sample of participants across the United States via social media pages and groups targeting postpartum persons. In addition to social media recruitment, one participating hospital in northern Ohio distributed flyers to postpartum persons discharged from the birthing center. Those interested in participating followed a link directing them to a web-based survey which screened for eligibility, provided study information, requested consent, and included all study measures. The survey was available online to any postpartum person meeting the following eligibility criteria: (1) ≥18 years of age; (2) lived in the United States or a US territory; (3) birthed a live newborn on or after February 1, 2020; and (4) could read and understand the English language.

Independent Variables
Independent variables were selected based on extant research and theoretical relationships with PTSD symptoms. Demographic variables were adapted from US Census items and previous research on PTSD in postpartum populations and included marital status (married or not married), race (white or not white), number of weeks postpartum at time of survey, and newborn admitted to a NICU (yes or no).
COVID-19 variables included (1) exposure to COVID-19; (2) worry about COVID-19 infection risk; and (3) selfquarantining behaviors. As there were no existing questions 2 Volume 0, No. 0, July 2022 to query COVID-19 domains at the time of the study, we developed items measuring these selected COVID-19 constructs following stakeholder input from pregnant and postpartum persons not participating in the study, clinicians (eg, labor, postpartum, and neonatal nurses; obstetricians), and researchers with expertise in perinatal research. COVID-19 exposure, worry surrounding infection risk, and selfquarantining behaviors could contribute to higher levels of PTSD symptoms. Confirmed exposure or fear of exposure to COVID-19 could have significantly altered participants' perinatal experiences and resulted in heightened PTSD symptoms of intrusion and mood and cognition alterations. Furthermore, self-quarantining could have contributed to social isolation and lack of support during the postpartum period, resulting in alterations to prepandemic stress coping mechanisms (eg, exercising, social events with friends and family), limited or altered access to clinical support and resources (eg, in-person clinic visits, lactation support, postpartum support groups), and limited familial and community support. 26 COVID-19 exposure consisted of 3 items: (1) confirmed COVID-19 infection; (2) family member with confirmed COVID-19 infection; and (3) suspected COVID-19 infection but no test. For COVID-19 infection worry, we included 2 items: (1) worry of becoming infected and (2) worry of newborn or infant becoming infected. Two items measured selfquarantining behaviors: (1) self-quarantined during postpartum with their newborn or infant and (2) self-quarantined during postpartum without their newborn or infant. Participants selected all options applying to their perinatal experience by indicating yes or no for each item. For this study, we collapsed items by domain. For example, any positive response to COVID-19 infection worry was coded as 1 (worry present), and no positive response was coded as 0 (worry not present).
Because postpartum depressive symptoms have been linked to PTSD symptoms, we measured postpartum anxiety and depression using the 10-item Edinburg Postpartum Depression Scale (EPDS). 27 The EPDS is a widely used and extensively validated screening measure of postpartum anxiety and depression. Participants respond to each item on a 0 to 3 Likert-type scale (0 = yes, as much as I could; 1 = yes, some of the time; 2 = no, not very often; 3 = no, not at all). Seven items are reversed scored. A total score, which ranges from 0 to 30, is calculated by summing the scores across all items. Higher scores indicate heightened depressive symptoms. A score of 10 or greater is considered a positive screen for postpartum anxiety and depression, and follow-up is recommended for further clinical assessment. In our study, the EPDS demonstrated good internal consistency reliability (Cronbach's α = .88).

Dependent Variables
We measured self-reported postpartum PTSD symptoms using the Birth Memories and Recall Questionnaire (BirthMARQ). 28 BirthMARQ is a postpartum PTSD screening instrument that consists of 6 domains (emotional memory, reliving, centrality of memory, sensory memory, recall, and coherence) measuring the presence of intrusion symptoms (eg, distressing memories of childbirth, flashbacks) or symptoms of mood and cognition alterations (eg, negative emotions, decreased self-efficacy). 4 Participants rated their level of agreement with each item from 1 (strongly disagree) to 7 (strongly agree). Three items are reverse scored. For the purposes of this study, scores of 5 to 7 for each item (symptom) were coded as "symptom present," and scores of 1 to 4 were coded as "symptom not present." The number of symptoms were summed for the total scale, symptom cluster (mood and cognition alteration symptoms, intrusion symptoms), and each BirthMARQ domain (see Table 1). For our study, domains, symptom clusters, and total scale demonstrated acceptable to good internal consistency reliability (Cronbach's α = .75-.91) for all but the reliving domain (α = .67).

Data Analysis
Data were analyzed in RStudio (version 1.3.1093) using R version 4.0.3. Records with missing BirthMARQ data were listwise deleted by domain. Descriptive statistics (mean, SD, frequency, and percentage) were calculated for the demographics and symptom counts. To examine relationships between the key independent variables and each dependent variable (symptom counts for the total scale, symptom cluster, and domain), we estimated negative binomial regression models, a conservative analytic technique for predicting count variables. We controlled for marital status, race, number of weeks postpartum, NICU admission, and EPDS screening. We calculated incidence risk ratios with 95% CIs for each independent variable. Significance level was set at α < .05 for all analyses.

Participant Characteristics
After listwise deletion, our sample included a total of 670 participants (approximately 92% of the total sample). No significant differences were found between the included sample and those listwise deleted. Most of the sample was white (88.8%) and married (94.1%). Approximately 68% of participants worried about their own or their infant's COVID-19 infection risk. Roughly 2% were exposed to or infected with COVID-19. Additionally, 84% of participants self-quarantined during the postpartum period. Approximately 37% of participants scored ≥10 on the EPDS, which is considered a positive screen for postpartum depression. See Table 2 for full demographic information. Table 3 presents participants' experiences of symptoms by individual BirthMARQ item and domain. Table 4 presents participants' experience of symptoms by total scale and symptom cluster. The average number of symptoms experienced on the total scale was approximately 8 (out of 21), and only 1.1% of participants reported experiencing no symptoms. Participants reported experiencing relatively the same proportion of mood and cognition symptoms (mean = 4.49 out of 11) and intrusion symptoms (mean = 3.83 out of 10).    Table 5 shows that COVID-19 exposure was associated with an increased risk for experiencing more intrusion symptoms when compared with participants who were not exposed to COVID-19. Worry about COVID-19 infection and quarantining behaviors were not found to be associated with symptoms for the composite BirthMARQ, mood and cognition alterations, or intrusion clusters.

COVID-19 Variables
Demographic Variables Table 5 also shows that newborn admission to a NICU and positive screens for postpartum depression were associated with increased risk for greater symptomatology in each model. For instance, NICU admission was associated with a 1.17 times greater risk of having symptoms of mood and cognition alterations. Number of weeks postpartum at the time of survey completion was found to be significantly and inversely associated with intrusion symptoms. Race and marital status were not found to be significantly associated with symptoms for the composite BirthMARQ, cognition, or intrusion scales. Table 6 shows that COVID-19 exposure was significantly associated with reliving symptoms. Participants who indicated COVID-19 exposure were associated with a 1.47 times greater risk of experiencing more symptoms in this domain when compared with participants who did not indicate exposure to COVID-19. The most common reliving symptom reported was reliving the visual impressions had during the birth (83.8% of sample; see Table 3). Moreover, participants who worried about COVID-19 infection were associated with a 1.26 times greater risk for increased recall symptoms when compared with participants who were not worried about COVID-19 infection, like memories of birth coming up unexpectantly (34.4% of sample). Quarantining behaviors were not found to be significantly associated with any BirthMARQ domain.

COVID-19 Variables
Demographic Variables Table 6 also shows how the demographic characteristics are associated with each BirthMARQ domain. Screening positive for postpartum depression was associated with an increased risk for experience a greater number of PTSD symptoms in 3 of the domains (emotional memory, centrality of memory, and recall). However, a positive EPDS screen was associated with a lower risk of experiencing coherence symptoms. Newborn admission to a NICU was associated with increased risk for experiencing a greater number of symptoms in 3 domains (emotional memory, sensory memory, and recall). Time since birth (in weeks) at survey completion was significantly associated with a lower risk of sensory memory symptoms. Participants who were of color (nonwhite) were associated with a greater risk for experiencing more centrality of memory  symptoms when compared with white participants. Finally, participants who were not married were associated with a greater risk for experiencing more emotional memory symptoms when compared with participants who were married.

DISCUSSION
For participants who gave birth within the context of the early stages of the COVID-19 pandemic in the United States, self-reported infection worry and exposure were associated with an increased risk of experiencing a greater number of PTSD symptoms. Our findings indicate that COVID-19 experiences and associated pandemic sequelae during the early stages of the pandemic were associated with increased PTSD symptoms in postpartum persons, specifically symptoms related to reliving the birth experience such as sounds, feelings, and sights. Worry surrounding COVID-19 infection risk increased one's risk for experiencing recall symptoms, Journal of Midwifery & Women's Health r www.jmwh.org  such as memories of the birth experience coming to mind unexpectedly. Future studies are needed to describe and evaluate the effect of COVID-19 experiences on postpartum PTSD symptoms. It is likely that worry over infection risk or exposure to COVID-19 can increase anxiety during the perinatal period. For example, participants who worried about their infection risk could have been intensely fearful of giving birth to their newborn in a hospital during an infection surge and subsequently hyperaware of their birthing and postpartum experiences. Overall, the findings support the importance for midwives, perinatal nurses, obstetricians, and perinatal mental health clinicians to assess for PTSD symptoms in postpartum persons and provide resources and treatment as indicated. Our study includes participants birthing during the first wave of COVID-19 in the United States. PTSD symptoms and associated risk factors could be different at later stages of the pandemic. Because PTSD symptoms can reappear at a subsequent pregnancy, clinicians are strongly encouraged to consider the stage of the pandemic postpartum persons who previously gave birth as they assess for symptoms and develop a treatment plan. Furthermore, our findings underscore the importance of using traumainformed care approaches when caring for perinatal persons experiencing PTSD symptoms. [29][30][31] Not surprisingly, positive screens for postpartum depression and anxiety were related to greater risk for experiencing PTSD symptoms, specifically symptoms related to mood and cognition alterations. Previous studies have also demonstrated that higher scores on many BirthMARQ domains correlate with the presence of depressive symptoms. 28 Similar to Foley et al, 28 we found participants with depressive symptoms reported more mood and cognition alterations. Many studies have found individuals with depression report more negative memories and memories central to personal identity. 32,33 This is of critical concern because 1 in 3 participants in our sample screened positive for postpartum depression, which is noticeably higher than the rates reported prepandemic. 34 Other studies on postpartum depression during the COVID-19 pandemic have found similar dramatic increases. 11,14,15 Although our findings align with those of Foley et al, 28 we found that a positive screen for postpartum depression was associated with reduced risk for experiencing symptoms related to coherence. It is well established that individuals with depressive symptoms can also have trouble remembering details of past events, 35,36 which could explain this finding.
In our study, NICU admission was associated with a higher risk for experiencing a greater number of PTSD symptoms. We did not collect data on the reason for admission. It is possible that newborns were admitted for further assessment related to COVID-19 or to prevent infection if the mother or a member of the household tested positive for COVID-19. Furthermore, it is possible that participants with newborns admitted to a NICU had more traumatic births (eg, preterm, newborn requiring resuscitation at birth, emergency birth, genetic anomalies); unfortunately, this was not measured in our study. Parents of newborns admitted to a NICU have been known to experience depression, anxiety, and PTSD. 37,38 NICU admissions can result in parental anxiety concerning newborn health, decreased parental-infant bonding, and disruption of routine postpartum experiences, and these impacts can manifest during and following NICU hospitalization. 39 A potential pandemic-related contributor to the association of NICU admission to PTSD symptoms in our study could have been the implementation of strict hospital visitor policies in NICUs to limit infection spread and exposure among vulnerable neonates.
Increased weeks between birth and time of survey completion was associated with a 3% decrease each week in the number of symptoms in the sensory memory domain. This could be due to the effect of time on the presence and magnitude of these specific symptoms. Being a person of color and unmarried were associated with increased risk for emotional memory and centrality of memory symptoms; however, this finding is not well understood and warrants further investigation.

Implications for Policy and Practice
Our study results suggest the immediate need for integrating comprehensive screening processes for PTSD and depression among postpartum persons. Considering that 99% of our sample experienced at least one PTSD symptom during COVID-19, it is essential that perinatal care professionals (eg, midwives, obstetricians) screen for PTSD. It is estimated that 1 in 3 postpartum persons who screen positive for postpartum depression also meet criteria for PTSD. 40 Therefore, it is vital that screening for PTSD be done in addition to screening for depression. 41 Although our findings are in the context of the COVID-19 pandemic, many of the relationships identified in our study have been discussed prior to the pandemic. Thus, beyond the context of the COVID-19 pandemic, it is important to consider PTSD screening for all postpartum persons while providing trauma-informed care. [29][30][31] Although the American College of Gynecology recommends clinicians screen postpartum persons for depression, 42 there are currently no recommendations for screening postpartum persons for PTSD. The integration of comprehensive mental health screening across health care settings (eg, hospital, primary care) is critical to providing quality, patient-centered care.
Integrating screening in routine practice can be challenging. 43 Clinicians who lack resources for addressing positive screens could be reluctant to screen for PTSD. Additionally, clinicians could already be significantly burdened by the number of required screenings and assessments and could be less likely to implement PTSD screening because of an overburdened workload. Considering these challenges, we recognize that integrating perinatal mental health screening tools into existing clinical guidelines and screening schedules (eg, postpartum depression screening) could be one promising approach to encourage PTSD screening. Recently literature on postpartum PTSD has recommended using the 5-item Primary Care PTSD screening tool 44,45 alongside screening tools for postpartum depression (eg, EPDS). Additionally, increasing public awareness of perinatal mood and anxiety disorders is recognized as an important step in improving maternity mortality and morbidity outcomes in the United States (see Centers for Disease Control and Prevention's HEAR Her campaign, www.cdc.gov/hearher/index.html). Therefore, we recommend providing public health education on postpartum PTSD along with currently provided education on perinatal warning signs, such as postpartum depression and anxiety.

Strengths and Limitations
Although our study has many strengths, we recognize several limitations. Importantly, although our sample was relatively large and we collected data from participants across the United States, our study sample was a convenience sample and mostly white and married. Future studies are needed to investigate PTSD among more diverse populations. Furthermore, our findings are limited to the first 6 months of the COVID-19 pandemic in the United States. It is important to consider differences in policy and practice during the first 6 months of the pandemic that could have affected participant's responses (eg, limited information regarding COVID-19 and pregnancy, support person limitations during birth and hospitalization, state responses and local infection rates). Finally, our study only included live births and did not assess for additional sources of birth trauma beyond the context of the COVID-19 pandemic in the models (eg, birth complications, prior history of mental illness, adverse childhood experiences). Despite these limitations, our study is one of first to describe the potential links between PTSD symptoms and perinatal experiences related to the COVID-19 pandemic.

CONCLUSION
Giving birth during the COVID-19 pandemic was associated with increased PTSD symptomatology in postpartum persons. Screening for PTSD in perinatal clinics is critically important to identify perinatal mental illness and provide adequate resources to those affected. The integration of comprehensive mental health screening, including specific screening for trauma and symptoms of PTSD, across health care settings can help provide quality, patient-centered care to postpartum persons.