Maternal mental health concerns during the COVID-19 pandemic in Iran: a content analysis study

According to the definition of the World Health Organization (WHO) "Maternal mental health is a state of well-being in which the mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her community" [1]. During pregnancy and postpartum various factors affect maternal mental health, one of which is the occurrence of stressful events [2]. The most recent stressful crisis is the COVID-19 disease since December 31, 2019 [3]. The COVID-19 pandemic has severely disrupted people's lives and has had a tremendous and deep effect on human life. The measures taken to prevent this disease, such as various forms of physical distancing, quarantine, have caused a mental health crisis around the world [4‐6]. However, the severity of the problems caused by the pandemic has not been the same for all people, some groups are more vulnerable such as women during pregnancy and postpartum due to their special physical and psychological needs. During this period, they faced new challenges and concerns such as fear of getting the infection, vertical transmission to the fetus, limited access to pre-and post-natal care, reduced social support, and the existence of false information [7‐14]. There is evidence of the long-term mental health effects of previous pandemics and disasters [15‐17]. Evidence shows that there has been a significant increase in various mental health problems among the general population and vulnerable groups due to the COVID-19 pandemic [6]. It is obvious that the occurrence of stress, anxiety, post-traumatic stress, etc. disrupts maternal mental health, and causes a range of physical, mental, and behavioral disorders in both mothers and infants [18‐23]. Several qualitative studies in different countries such as Australia, Turkey, Ireland, Canada, and Iran have also investigated various aspects of COVID-19 in mothers [24‐30]. Given the extent of the COVID-19 pandemic, it is predicted that people's mental health will be affected by its direct and indirect psychological effects both presently and in the future [4, 31, 32]. As the world slowly regains control of COVID-19, it is timely and essential to explore the impact of COVID-19 on mental health, especially among vulnerable populations, around the world [33]. To deeply understand the concerns of Iranian healthy and the get infected women during pregnancy and postpartum, this study was designed and implemented with a qualitative approach and provided valuable insights into the experiences of these women.

Simultaneous and continuous data analysis led to the extraction of 23 subcategories, 11 categories, and two themes by performing thematic analysis: (1) Maternal mental health threats, (2) Inadequate access to the required information.

The themes and categories are shown in Table 5.

This article provides an in-depth insight into the mental health needs of mothers in Iran during the COVID-19 pandemic, which is presented for the first time. The results showed that mothers in addition to the typical worries related to pregnancy and postpartum experienced a lot of worries and anxieties during this time. Fear was the most common term used by them to describe mental health concerns during the pandemic, such as fear of death, fear of infection, fear of premature birth, fear of infant infection, etc. They had also been burdened by stress and confusion caused by the unprecedented circumstances of the pandemic. These feelings and concerns were caused by the perception of the great severity of the threat and the sense of uncertainty about the health and survival of the own, family, especially the fetus/baby, the unknown nature of the disease, the high mortality rate, and its unidentified effects on pregnancy, childbirth, and postpartum.

The findings of theme 1 indicated that the mental health of pregnant and postpartum women was affected by the pandemic. These threats can disrupt pregnancy and postpartum health and lead to abnormal experiences. Finally, they may cause complications in the short and long term for mothers, children, and families [41‐49]. The main concern was the fear of own death or the death of the baby/fetus due to corona disease, which could be caused by the high lethality of this pandemic and the feeling of vulnerability caused by pregnancy. Almost all infected mothers and most of the healthy mothers expressed their fear of dying due to COVID-19. Ahorsu et al. in evaluating the psychometric properties of the scale of fear of COVID-19 concluded that the phrase "I am afraid of losing my life due to the coronavirus" had the highest factor loading [50]. Fear of death has also been found in other studies [51, 52]. The pandemic was a traumatic experience because it had a threatening nature and the resulting deaths had a negative impact on people's mental health [53]. The illness or death of friends or relatives due to the disease of COVID-19 was another stressor of COVID-19 in this study. The "infodemic" (a mass of information and sad news about COVID-19) by various sources and social media [54], was also another source of fear and anxiety among the participants. According to studies the anxiety and worries created by media were more than the awareness provided to prepare against this pandemic [30, 55‐57]. Limaye et al. claimed that the spread of misinformation about COVID-19 was facilitated by social media platforms [58]. As our study spanned from the conclusion of the initial wave to the midpoint of the subsequent wave, perhaps one reason for participants' fears is the severity of the pandemic, as well as a significant number of individuals who had been infected or had passed away. This result was in line with a study in Brazil [59]. Another was due to novelty and uncertainty about the pandemic process which has been emphasized in other studies [24, 60]. The newborn’s health was another important concern, for all participants. In fact, one of the essential reasons for the heightened anxiety of mothers regarding COVID-19 was the impact on the health of their unborn or newborn child. All of them, without exception, believed that their infection with COVID-19 will result in unsafe results such as intrauterine disease of the fetus or infection of the baby after delivery in the hospital and damage to the child's lungs. Consistent with our study, Barbosa-Leiker et al. showed that the fear of getting COVID-19 the baby in the hospital was one of the concerns expressed by pregnant and post-partum women (up to one year after delivery) in the USA [61]. Many individuals in our study expressed concern regarding their health, specifically in relation to potential lung injury caused by infection. Those who had a history of COVID-19 or knew somebody who did, experienced a higher level of fear and anxiety than the possibility of re-infection. This was in line with the studies conducted in Jordan, the UK, China, Canada, and Germany [58, 62‐65]. In our study, most of the participants even healthy mothers with no history of previous pregnancy complications were worried about the occurrence of pregnancy complications, such as premature birth and abortion. Of course, those who had a history of such complications in previous pregnancies or in their relatives were more worried. Other studies showed that COVID-19 causes an increase in some pregnancy complications such as premature labor and abortion [66‐68]. One of the reasons for this is the unknown nature of the COVID-19 disease and its complications, and the other reason is perhaps talking with peers and hearing the experiences of those who had a history of these complications. This finding is in line with other studies [69, 70]. The participants in our study were forced to socially distance themselves from their friends and family due to the fear of contracting COVID-19 and this caused them to feel lonelier and lack of support. The absence of family and Loneliness during childbirth were other concerns of moms. Isolation appears to have had a deep effect on the participants, which highlighted the need for adequate support at the stages of pregnancy and postpartum. Loneliness and social distancing, which involves contact with loved ones and friends, increase stress, anxiety, and depression and have been reported by pregnant and postpartum women in some studies [71‐76]. Since pregnant and postpartum women are more vulnerable to the negative consequences of loneliness and isolation [77, 78], it is necessary to pay attention to the provision of social support especially in critical situations such as the recent pandemic [64, 79]. Maternal care providers can play a role to reduce these negative effects by offering various ways such as counseling, prenatal yoga, and birth classes online and others. [80]. Due to the unprecedented circumstances of the COVID-19 pandemic, participants in this study had heightened expectations from healthcare providers. In addition to the standard pregnancy and postpartum care, they required sufficient support and dedicated time for their inquiries. Also, particularly new mothers were anxious about infant healthcare. They needed more support and help from healthcare providers. This result was in line with other studies [81‐83]. This highlights the importance of healthcare providers being responsive and more attentive to the needs of participants in times of crisis. In order to prevent possible infection in Iran, like other countries [29, 54, 79, 84, 85], the number of pregnancy and post-natal visits decreased. Face-to-face childbirth preparation classes were closed, and information was available offline, through educational CDs and booklets. Of course, there was a special hotline in the Ministry of Health to respond to the needs of mothers and pregnant women 24 h a day, but nevertheless, participants stated that they should receive education related to pregnancy, childbirth, and postpartum as before. And they wanted the classes to be held face-to-face and with a small number. Those who were infected with COVID-19 expected that during the quarantine period, they would definitely have an in-person pregnancy visit or a daily phone call with the obstetricians because they believed that they were very worried about the health of their fetus. On the other hand, they refused to go to health centers and especially hospitals on time due to the fear of contracting COVID-19. It seems that this paradox may have been due to the concern of the participants about the health of the fetus and the high stress caused by the COVID-19 pandemic. On the one hand, they were worried about the health of their fetus, and on the other hand, they did not go to health and treatment centers due to the fear of the possibility of contracting COVID-19 and endangering the health of the fetus. Because some believed that if they get infected, the fetus will be harmed, or that they themselves will be harmed or even die, and in this case, their child or children will be left without a mother.

The findings of Theme 2 highlighted the importance of paying attention and the availability of accurate information from reliable sources. Due to various factors, such as a decrease in the number of pre and postnatal visits and the closure of in-person pregnancy and childbirth classes and etc. participants had limited interaction with healthcare providers. This resulted in a lack of knowledge and information about COVID-19, as well as pregnancy and postpartum-specific information, which led to participants more experienced stress and worry. Therefore, access to correct information is very useful and vital in a pandemic situation [86].

The results of our research were in line with several studies in different countries such as Ireland, Turkey, Iran, China, and the UK which, from various aspects, identified the deficiencies and information needs of pregnant and postpartum women during the COVID-19 pandemic and its consequences [24, 87‐92].

In this study, the Internet and social networks were the dominant media for accessing this information, yet many of them were concerned about the validity of the information. All of them generally wished for more information that was available from valid resources such as healthcare professionals. Researchers from other countries also reached this conclusion in their studies [86, 93, 94]. Therefore, one factor for the great fear of COVID-19 disease is the lack of information and misinformation [60]. Examining and comparing the results of this study with various studies from other countries indicates that the mental health of pregnant women and new mothers has been greatly affected by the direct and indirect consequences of the COVID-19 pandemic. Many quantitative and qualitative studies were from different aspects. In some cases, the problems were common, but in some cases, they were special, which seems to be due to the time to conduct studies, and the cultural, organizational, and economic differences of different countries. Now that the world is almost moving towards the post-pandemic era, it is suggested that policymakers take advantage of the many results of research conducted all over the world to plan various necessary measures to maintain, promote or improve the mental health of this vulnerable group.

In this study, we tried to have maximum diversity in the participants. They were in the groups with coronavirus disease, recovered, pre-pregnancy coronavirus disease, and spouse infection. Most interviews were conducted by telephone due to pandemic conditions. Therefore, it was not possible to take field notes and observe the participant's behavior and record non-verbal data. Moreover, the saturation of the interview was achieved with more interviews. Due to the spread of the COVID-19 pandemic and the fear of infection, some mothers were reluctant to participate in the study, and some did not go to the health centers for visiting entirely. Consequently, there may be data that has gone unnoticed. Maternal healthcare providers should try to address these concerns in various ways, such as informative yet empathetic messages, psychological, and social support, and others. At the same time, policymakers should design and implement appropriate programs and measures to improve mothers' mental health and prevent negative experiences, especially in critical situations. Hence, it seems that identifying the needs and concerns of mothers in crisis can help policymakers to plan effectively to increase mental health care and support during future epidemics and emergencies. Therefore, the findings of the present study will be useful in planning the promotion of women's mental health during pregnancy and postpartum, especially in critical situations (disaster settings and/or high-risk pregnancy situations). In this regard, this project is suggesting the following items to the National Maternal Health Policymakers to put more stress on maternal mental health well-being:

Suggestions for future studies:

Based on the study's findings, particularly the explained concerns, it is recommended to create and implement a maternal mental health training program, during the pandemic. Additionally, it is suggested to design and evaluate a tool to measure maternal mental health concerns, using the definition provided by these findings.

Although much attention has been paid to the physical health consequences of COVID-19, mental health has unfairly received less attention. There is a need to prepare research and healthcare infrastructure to investigate the effects of the COVID-19 pandemic on mental health, which requires proper research, especially for vulnerable groups [37]. Our findings showed that the mental health concerns of women in pregnancy and postpartum during the COVID-19 pandemic are diverse and in the form of mental and emotional problems and information needs that are not met. These concerns, directly and indirectly, significantly impact threatened maternal mental health during the COVID-19 pandemic.