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COVID-19, global inequality, and mental health in childbearing women: how to mitigate the triple hit?

As the coronavirus has spread across the globe and is likely to become the leading infectious cause of mortality, the inequalities in healthcare outcomes are becoming increasingly clear. Research shows that pregnant women who are older, from minority ethnic groups, who are overweight or obese, who have comorbidities or who live with socioeconomic deprivation are more likely to experience severe illness than women without these characteristics [1]. In addition, there is a reciprocal relationship between health inequality and mental disorders. In this edition a study among pregnant women in a low-income neighborhood in Spain and a study among teen mothers in Rwanda showed that almost half of them had clinically high levels of anxiety and depressive symptoms, which is 5-times higher compared to the general population [2,3]. An accumulation of four or more risk factors, including socio-economic deprivation, had highest predictive value of anxiety-depressive symptomatology [2]. These studies were performed before the pandemic, and it is not inconceivable that in these vulnerable groups both mental disorders and corona disease have increased because of their mutual relationship with socio-economic adversity. When inequality is high and a pandemic such as corona hits entire society, it can further strengthen the ‘inequality feedback loop’ in which lower education, income and health care resources lead to increasing rates of disease and mortality. In its turn, more disease, inclusive mental disorders, leads to less economic productivity, more poverty and less available health care in society. As a result, the gap between higherand lowerincome countries is likely to widen. Recently, a Lancet Commission for COVID-19 task force has formulated recommendations to increase global vaccine and therapeutics access, justice, and equity. Their recommendation for short and longer term are focused on access and affordability, global production, global governance, global health systems, a collaborative research network and combating anti-science [1]. Even when access to vaccines and treatment are improved on a global level, childbearing women remain of particular concern. Although current vaccines have been extensively tested on animal models and human, there still exists no human trial data about the safety of using these vaccines in pregnancy [4]. If we combine this uncertainty about safety of vaccination with the single fact that childbearing women, even without a pandemic, are at increased risk for mental health disorders, especially when they live in less favorable socio-economic circumstances, we should place urgency on global research specifically focusing on the interplay between covid-19, global inequality, and women’s mental health. This will also have a payoff by increasing positive health behavior through targeted education and offering safe, affordable, and effective interventions addressing not only physical, but also mental health. For example, a study in this edition showed that higher levels of maternal mindfulness were related to less subjective stress, depression, anxiety and the severity of physical discomforts during pregnancy, irrespective of maternal age, ethnicity, education level, marital status, employment status and total household income or parity [5]. Global investment in increasing health and decreasing inequality during the current pandemic should therefore not only focus on access to vaccines and treatment, but also on mental wellbeing, particularly in childbearing women.