Introduction

Psychiatric disorders are caused by a combination of factors such as stress, genetics and environment. Since these factors are increasingly present in the daily life of contemporary women, they suffer mentally more than men in societies with higher levels of gender inequity (Yu, 2018). In this context, women are almost twice as likely to suffer from mental illnesses as men (APA, 2017). An Italian study conducted during the early stage of the COVID-19 pandemic found a higher prevalence of posttraumatic stress symptoms in females (47.6% vs. 34.2%) (Rousset et al., 2021). Neuroendocrine factors (Christiansen & Berke, 2020), age, high rates of violence against women and associated chronic diseases are also related to the higher prevalence of mental illness in women. Therefore, mental disorders are the main cause of healthy life-years lost among women between 15 and 24 years of age (Senicato et al., 2018).

With the outbreak of the novel coronavirus (SARS-CoV-2) pandemic in 2020, environmental factors and stress began to exert an increased interference in the health of the population, modifying the daily lives of people. The new virus was first identified in Wuhan, China, in December 2019 and in 2020 spread to the whole world, causing the disease called COVID-19 (Dhama et al., 2020). People infected with COVID-19 have symptoms ranging from weak flu to more serious and fatal illness due to a severe acute respiratory syndrome that mainly affects the lower respiratory tract. As the transmission occurs through contact with secretions of infected individuals, the disease spread rapidly throughout China and then throughout the world (Esakandari et al., 2020).

Currently, most countries are adopting prevention and control measures to prevent the spread of the virus, including isolation, social distancing and quarantine, which consist of classic public health measures to prevent the transmission from person to person. Quarantine is one of the oldest and most effective methods for controlling outbreaks of communicable diseases and consists of restricting the movement of people so as to avoid exposure to a contagious disease (Wilder-Smith & Freedman, 2020).

In this context, the pandemic brought psychological implications not only directly related the contagion, but also to measures to contain the spread of the disease. The absence of the habitual routine and lower social and physical contact with other people can cause frustration and a sense of isolation from the rest of the world, promoting distress (Brooks et al., 2020). These conditions can lead to depressive, anxiety, psychotic or paranoid disorders and may even have suicide as an outcome (Ornell et al., 2020). In addition, confinement has implications for interpersonal relationships, especially in family relationships, prompting situations of violence (Schmidt et al., 2020).

A trauma can be defined as a stressful event outside the boundaries of the usual human experience involving an intense perception of threat to life. Thus, the COVID-19 pandemic and its consequences can be considered traumatic events due to the changes in routine, social distancing, constant exposure to losses, and fear of being infected (Restauri & Sheridan, 2020). Exposure to traumatic and stressful events can lead to the development of acute stress disorder and posttraumatic stress disorder, related to symptoms such as anxiety, sleep changes and somatic complaints (Figueira & Mendlowicz, 2003). Posttraumatic stress disorder (PTSD) is a complex mental health condition (Sareen, 2014) that has a substantial impact on the individual and society (Mellor et al., 2022).

Parents, and especially mothers, were a group particularly affected during the pandemic. They have faced additional demands, such as economic difficulties, social restrictions, homeschooling and home office activities, and child care (Racine et al., 2021). Studying the effects of the pandemic on the mental health of mothers with young children is fundamental to avoid the intergenerational transmission of mental health problems (Gotlib et al., 2020). However, evidence about the harmful effects of the pandemic on maternal mental health is still scarce (Abufhele et al., 2022) and, in Brazil, no study evaluating posttraumatic stress in mothers has been developed.

In view of the current pandemic situation of increased stress and burden of tasks for mothers, the objective of this study was to evaluate the factors associated with posttraumatic stress symptoms in mothers during the COVID-19 pandemic. The study will provide health authorities with greater knowledge about the appropriate measures to be taken in the current situation, including public awareness campaigns and control measures in order to improve the coping strategies.

Methods

The present study consisted of a cross-sectional survey based on a web-based self-administered questionnaire between Aug. 9 and Oct. 8, 2020. Data were collected between the first two waves of COVID-19 in Brazil. During this period, the number of COVID-19 cases and deaths were decreasing in Brazil, but the population still maintained social distancing and followed other biosafety protocols (Stein et al., 2021). As our dependent variable was posttraumatic stress, we chose precisely this period to conduct the study because it represented the moment following the initial stress caused by the pandemic. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement for reporting observational studies (Elm et al., 2014).

The questionnaire was elaborated and implemented in Google Forms and its link was published electronically via WhatsApp and social networking sites (Facebook and Instagram). All participants were encouraged to disclose the survey link to people they knew who fit the inclusion criteria. The homepage of the online questionnaire had the invitation to participate in the survey, information about the inclusion criteria, objectives, procedures of the study, and the informed consent form. All participants needed to read the consent form and choose the “agree” option to start completing the questionnaire, otherwise the questionnaire would not be provided. The inclusion criteria were: minimum age of 18 years, mother of one or more child and/or adolescent kid (from zero to 18 years), residence in Brazil, and access to the Internet to answer the questionnaire.

The electronic questionnaire included the following data:

  • - Sociodemographic data: age (continuous), marital status (with/ without a partner), schooling (≤ 11 years of schooling/ >11 years of schooling), the region of residence in Brazil (Midwest/ North/ Northeast/ South/ Southeast), current employment (no/ yes), health professional working in the pandemic (no/ yes/ not applicable), became unemployed in the pandemic (no/ yes / not applicable), family income, greater childcare burden during the pandemic (no/ yes), number of children (continuous).

  • - Health characteristics: use of medications (no/ yes), self-report of neuropsychiatric diseases (e.g. depression, anxiety, panic disorders, and other mood disorders) (no/ yes), self-report of gastrointestinal diseases (no/ yes), daily sleep duration in hours (continuous), satisfaction with life (little satisfied/ more or less satisfied / very satisfied).

  • - Symptoms of posttraumatic stress: assessed by the Impact of Event Scale - Revised (IES-R), validated in Brazil (Caiuby et al., 2012). The IES-R aims to track the symptomatology of posttraumatic stress disorder experienced in the last seven days. It consists of 22 items measured on a Likert scale with scores from 0 to 4 in each question. The total score ranges from 0 to 88. A score of 5.6 was used as a cut point to identify the presence of symptoms of posttraumatic stress (Caiuby et al., 2012). The IES-R is divided into three subscales to assess the symptoms of avoidant behaviors (avoidance subscale - questions 5, 7, 8, 11, 12, 13, 17, 22), intrusive memories (intrusion subscale - questions 1, 2, 3, 6, 9, 14, 16, 20) and anxiety (hyperarousal subscale – questions 4, 10, 15, 18, 19, 21). Good internal consistency was found for the total (Cronbach’s α: 0.93 to 0.96) and subscale scores (α = 0.75 to 0.94; α = 0.85 to 0.88; and hyperarousal α = 0.87 to 0.91) (Caiuby et al., 2012; Creamer et al., 2003; Malinauskiené & Bernotaite, 2016).

The data was downloaded to Excel® and exported for analysis in SAS 9.4 software. Initially they were described using absolute frequencies and percentages (qualitative variables) and mean and standard deviation (quantitative variables). Crude and adjusted Poisson regression models with robust variance (Zou, 2004) were used to analyze the factors associated with symptoms of posttraumatic stress (score > 5.6 in IES-R). Variables with p-value ≤ 0.20 in the crude analysis were selected for the adjusted models. A p-value ≤ 0.05 was considered to be statistically significant in the adjusted model.

The research was anonymous and received approval from the ethics committee of the [blinded for review]. Informed consent was obtained from all the participants. No potential conflict of interest was reported by the authors.

Results

The questionnaire was answered by 822 mothers during the stipulated data collection period. Table 1 shows the characterization data of the mothers participating in the research for the total sample and divided into groups with and without symptoms of posttraumatic stress. The mean age of the women was 37.11 years, the majority had a partner, had > 11 years of schooling, lived in the Southeast region of Brazil, were employed during the data collection period, and were not a health professional. A total of 5.84% of mothers were unemployed during the pandemic. The most prevalent family income ranged between 760 USD and 1900 USD. The average number of children per mother was 1.77, and 83.82% of them reported feeling more burdened to care for their children during the pandemic. Most did not make continuous use of medications and did not report neuropsychiatric or gastrointestinal diseases. They slept on average six hours per night, and most were more or less satisfied with life.

Table 1 Characterization of mothers with children and adolescents during the pandemic according to the presence of symptoms of posttraumatic stress (n = 822)
Full size table

The prevalence of symptoms of posttraumatic stress was 39.05% and the mean score in the instrument was 4.9 ± 2.6. Table 2 shows the crude and adjusted prevalence obtained in the models ratios for the presence of posttraumatic stress.

Table 2 Estimation of prevalence ratios for the presence of symptoms of posttraumatic stress in mothers of children and adolescents during the pandemic (n = 822)
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Greater age was associated with a lower prevalence of posttraumatic stress disorder (adjusted PR = 0.99; 95% CI: 0.97–0.99). Mothers living in the North region of Brazil had the highest prevalence of symptoms when compared to mothers from the other four regions. Not using medication (adjusted PR = 0.70; 95% CI: 0.53–0.93) and not having neuropsychiatric diseases (adjusted PR = 0.67; 95% CI: 0.57–0.79) were related to lower prevalence of posttraumatic stress disorder. Mothers who were little or more or less satisfied with life had a higher prevalence of posttraumatic stress when compared to those who were very satisfied with life.

Discussion

The pandemic increased the need for in-home and out-of-home care and this caused families with dependents, including children, to become one of the groups most burdened by the confinement and social isolation. In the family nucleus, women end up assuming a greater share of the burden of care, leading to high levels of depressive symptoms, anxiety, posttraumatic stress and perception of loneliness (Ausín et al., 2020).

A study developed in Brazil showed that women presented significantly higher levels of anxiety, depression and posttraumatic stress disorder than men. Although the gender per se is an important biological factor, the fact that the need to reconcile work with childcare and household chores, which ultimately impacts career progression and salary, affects more women than men has to be taken into account (Calegaro et al., 2022).

The results of the present study provide worrying evidence of negative psychological responses of mothers during the COVID-19 pandemic, since 39.05% had symptoms of posttraumatic stress. The psychological implications generated by COVID-19 may be longer lasting and more prevalent than the physical illness (Ornell et al., 2020).

The sociodemographic profile of the mothers evaluated in the present study are close to those of Jordanian mothers reported by Malkawi et al. (2020), who analyzed the level of depression, anxiety and stress symptoms and their possible associations with demographic and lifestyle variables.

In the present study, the elements that were associated with symptoms of posttraumatic stress were greater age, geographical area of residence, presence of neuropsychiatric illnesses, use of medications,, and degree of satisfaction with life during the period of data collection.

A study conducted in China that evaluated psychological stress in nurses who worked on the front line during the COVID-19 pandemic using the IES-R found a prevalence of 27.2% of stress symptoms in women and 18.0% in men (Master et al., 2020). Another study conducted in China, in the areas most affected by the pandemic, using another instrument, also found a higher prevalence of symptoms of posttraumatic stress in women (Liu et al., 2020). Public health strategies should consider this difference between sexes and focus on preventing mental problems, especially among women (Liu et al., 2020).

Women are more likely to develop psychological symptoms than men (Campos et al., 2020). Current literature suggests that the prevalence of PTSD is higher among females (Bonsaksen et al., 2020; Liu et al., 2020; Rousset et al., 2021). This greater vulnerability can be explained by the fact that women are more likely to have negative changes in cognition or mood, ruminate negative emotions, experience prolonged anguish, higher psychological distress, and have grater difficulty to find coping strategies (Almeida & Kesller, 1998; Campos et al., 2020; Liu et al., 2020). Evidence suggests that the oscillation in ovarian hormone levels may justify the greater sensitivity of women to emotional stimuli, leaving them more vulnerable to psychological disorders (Soni et al., 2013).

In a cross-sectional study addressing emotional exhaustion related to parents of children aged 0–13 years during COVID-19 blockade, more than 80% of the sample presented high levels of psychological distress and 17% reported significant exhaustion (Marchetti et al., 2020). The greater psychological distress demonstrated by mothers may indicate that women have experienced an additional source of stress in the attempt to balance their family and professional demands (Marchetti et al., 2020).

Some studies presented different results from the ones found here. For example, greater age has been described as a risk factor for posttraumatic stress disorder (Li et al., 2020; Liang et al., 2019), explained by the responsibilities and concerns for others that increase with age (Jiang et al., 2020). In other studies, no relationship was identified between age and PTSD (Cofini et al., 2015). Similarly to the present study, a study conducted in China indicated that older adults experienced less posttraumatic stress than younger adults after the COVID-19 outbreak (Jiang et al., 2020). Therefore, the literature is controversial regarding the relationship between these variables. The positive relationship between posttraumatic stress and younger age can be explained by the fact that older people may have already gone through other traumatic moments in life and these experiences help them deal better with stress. Another explanation is the lower use of the Internet by older people, which contributes to generating a lower information overload (Jiang et al., 2020).

The large territorial extension of Brazil may contribute to widespread dissimilarities between the regions of the country. In the present study, mothers from the North region had a higher prevalence of posttraumatic stress symptoms, which may be related to economic, cultural and information differences between regions. Of the total Brazilian population, 42.1% live in the Southeast, 27.1% in the Northeast, 14.3% in the South, 8.7% in the North and 7.8% in the Midwest (Instituto Brasileiro de Geografia e Estatística [IBGE], 2022a). The area of the North region corresponds to 45% of the national territory, but is the second smallest in number of inhabitants (IBGE, 2022a). The North is the region with the lowest percentage of white people and the highest of young people. In 2020, the populations of the North and Northeast regions presented the lowest average monthly household income (IBGE, 2021). The large territorial extension and the low average income, in addition to the lack of resources, had negative consequences for the health of the population during the pandemic in the North region. The region has fewer physicians, ICU beds and respirators (Mendonça et al., 2020). The city of Manaus, the most populous in the region, was the one with the highest excess deaths rates for natural ((Orellana et al., 2021a) and respiratory causes ((Orellana et al., 2021b) at the beginning of the pandemic in relation to cities in other regions of the country. People living in places with a high prevalence of infections believe they are at higher risk, a factor that can lead to severe psychological distress (Ozamiz-Etxebarria et al., 2020). A study conducted in China (Sun et al., 2021) found that individuals living in Hubei Province, the area most affected by the coronavirus outbreak, reported the highest level of posttraumatic stress symptoms. These indicators help us understand the higher prevalence of posttraumatic stress symptoms in mothers living in the North region of Brazil.

An association between use of medications and PTSD was found in the present study. Some studies have mentioned the use of medications by people with PTSD, including not only medications to treat the disease itself, but also analgesics (Schwartz et al., 2006) and medications to treat insomnia and nightmares (Sareen, 2014). These patients are often polypharmacy users, using other medications in addition to psychotropics (Mellor et al., 2022). Due to the possible consequences of polypharmacy, regular monitoring of the prescribed drugs and frequent dialogue with prescribers are necessary. Furthermore, health professionals need to place greater emphasis on implementing non-pharmacological interventions, such as psychosocial interventions and physical activity (Mellor et al., 2022), which can provide a better quality of life for these people.

We observed that the prevalence of symptoms of posttraumatic stress was related to the health of the mothers, since women who did not have neuropsychiatric diseases had a lower prevalence of such symptoms. An association between physical symptoms such as fever, chills and headache and a greater psychological impact of the pandemic and a correlation between history of chronic disease and considerably higher levels of PTSD symptoms have been reported (Wang et al., 2020). A study developed in Southern Brazil indicated a higher risk of development of mental disorders among women of younger age, with a previous diagnosis of mental disorder, and who were not health workers (Duarte et al., 2020). Previous studies highlighted possible risk variables that could negatively impact the mental health of the female population over the period of social distancing, namely, being a young adult, having a history of anxiety and depression, using medications, and being unemployed (Souza et al., 2020). These predictions are in line with the findings of the present study, since we found that women with greater age, without previous neuropsychiatric diseases, and who did not use medications had a lower prevalence of symptoms of posttraumatic stress.

The spread of COVID-19 happened in a sudden way, causing fear and restricting the freedom of people, thus weakening emotional and social relationships (Forte et al., 2020). It is reasonable to expect that individuals with neuropsychiatric diseases experienced a further greater impact on their mental health. Health aspects should be considered to avoid the development or worsening of PTSD symptomatology (Forte et al., 2020). In this dramatic period of pandemic, every human being is at risk of psychological damage, but the most vulnerable groups are children and adolescents, the elderly, minority groups, less favored socioeconomic groups, women and people with pre-existing mental health problems (Perrin et al., 2009).

People with a previous mental health condition may experience exacerbate symptoms when experiencing a pandemic situation. Moreover, traumatic events increase the risk of developing PTSD (Goodman et al., 2001). People with severe mental illnesses may be the most affected by the pandemic (Usher et al., 2020; Wilson et al., 2019), especially as many rely on medical follow-up and programs that may have been disrupted due to restrictions imposed by the pandemic (Usher et al., 2020).

It has already been reported that the COVID-19 pandemic pose several challenges in the field of public health associated with a high level of stress, both in the general population and in people with previous mental disorders (Banerjee, 2020; Xiang et al., 2020). Some authors pointed out that people with mental disorders had a higher tendency to experience greater stress and psychological distress during the quarantine when compared to people without these disorders (Iasevoli et al., 2020). Besides the fact that people with mental disorders have greater psychic vulnerability, there is the difficulty to access treatment during the pandemic (Shigemura et al., 2020). Thus, attention to the presence of sadness and anxiety during the pandemic among people with or without mental disorders may contribute to the definition and/or orientation of specific public policies for risk groups (Barros et al., 2020).

Satisfaction with life is a personal judgment that encompasses some fields of life such as health, work, housing conditions, social relations, autonomy, among others. Satisfaction with life is assessed through the comparison between the actual life and a pattern established by the individual (Joia et al., 2007). The mothers interviewed in the present survey who declared that they were little or more or less satisfied with life had a higher prevalence of symptoms of posttraumatic stress. A study identified that women less satisfied with social support were more susceptible to psychiatric conditions (Gaino et al., 2019). This shows that mothers with the worst general health, work conditions, and social support are more likely to develop PTSD.

Some limitations have to be considered in the analysis of the results of this study. As an online questionnaire was used for data collection, this method may have limited the participation of mothers who do not have access to Internet-dependent communication vehicles. In 2019, 80.5% of the Brazilian women were internet users, and in 2021 the percentage was 85.6% (IBGE, 2022b). Another aspect is that the analysis considered only a period of approximately two months in the early pandemic, and did not cover the beginning and outcome of the isolation period during the pandemic. Thus, the data cannot be generalized to other periods of the pandemic. Another limitation is that some variables – such as use of medications, presence of neuropsychiatric diseases and gastrointestinal diseases – were self-reported. In addition, because the study had a cross-sectional design, there was no evaluation of symptoms before the onset of the pandemic and this prevents the determination of causal relationships. However, the results are consistent with the literature on the theme, although few studies have been conducted specifically with mothers of children and adolescents during the early period of the pandemic.

In the care process, it is important to note the values, representations, practices, meanings and experiences lived, considering the biopsychosocial character of the phenomena that make up the process of illness. This is especially true in the case of the vulnerable population analyzed in this study, which is often neglected, since few studies have been directed to this public, especially in countries such as Brazil. Supporting women to improve their mental health and helping them to overcome the COVID-19 pandemic can have a positive reflection on children in the medium and long term (Abufhele et al., 2022). In the current context, post-pandemic managers must provide targeted support and ensure efficient use of resources to support maternal mental health as well as child well-being (Racine et al., 2021).

The results of the present study suggest that the COVID-19 pandemic has a far reaching psychological impact. The data showed that the prevalence of symptoms of posttraumatic stress in mothers was high and associated with age, region of residence in the country, use of medications, neuropsychiatric comorbidities, and satisfaction with life. The data obtained must be interpreted in such a way as to overcome the biological-visible dimension, transcending the physical aspects of illness.

This study points to the need to (re)think public mental health policies in Brazil so as to contribute to a (re)structuring of health services in order to accommodate the diverse demands of mental suffering in effective lines of care in mental health services, especially in the psychosocial care network of public health services in Brazil, anchored in the psychosocial care model.