Of the 675 participants who completed the entire survey, 371 (55%) responded to at least one free-text item (Table 1). Most were white (91.9%) and married (94.9%), and delivered a term infant (91.6%). A slightly smaller proportion of participants responding to free-text items breastfed their infants (81.1%) compared to the total sample completing the survey (85.1%) [χ2(1) = 4.3588; p = 0.04]. No other significant differences in demographics were observed.
We identified five major themes: (1) Heightened emotional distress; (2) Adverse breastfeeding experiences; (3) Unanticipated hospital policy changes shifted birthing plans; (4) Expectation vs. reality: “mourning what the experience should have been;” and (5) Surprising benefits of the COVID-19 pandemic to the delivery and postpartum experience. Minor themes supported each of the major themes (Table 2).
Heightened Emotional Distress
Participants expressed significant mental health concerns and, without prompting, attributed these concerns to the COVID-19 pandemic. They frequently discussed “maternal guilt” related to restricting their infant from engaging in traditional, pre-pandemic activities (e.g., visits with family, walks outside, running errands). Some participants described “maternal guilt” as: (1) feeling guilty for not providing their infants with normal newborn experiences and (2) feeling guilty for providing these experiences during the pandemic. For example, “I’ve been unable to go out with my baby, at first at all, but now without feeling fear or extreme guilt for risking my baby’s health for some time outside, or in a store, or around people at all.”
Not only did the pandemic contribute to higher levels of reported emotional distress, but it also created a barrier to accessing and using pre-pandemic coping mechanisms. Women described a sudden and dramatic shift in how they coped with challenges and stressors, mainly due to the inability to engage in pre-pandemic activities (e.g., going to the gym, engaging with friends). Unable to access their normal, pre-pandemic coping mechanisms, women reported high levels of emotional distress, anxiety, and isolation. “I have not had my usual outlets to turn to when I get stressed, such as going to the gym, out to dinner with friends or my husband, or going shopping”.
Several women described a lack of traditional postpartum social support resulting from stay-at-home orders and social distancing mandates. Infection control recommendations and mandates contributed to low levels of emotional support as they navigated postpartum mood and anxiety challenges. Further, stay-at-home orders and social distancing mandates contributed to decreased assistance in the home and increased postpartum stress. “Lack of support due to Covid-19 has definitely made me feel more stressed and the adjustment to new motherhood more difficult than if I was able to have friends and family around and able to help more.”
Adverse Breastfeeding Experiences
Although many breastfed or provided human milk to their infants, several reported poor breastfeeding outcomes due to the pandemic. Many participants reported a significant lack of breastfeeding support and resources (e.g., lactation consultants, provider support, other breastfeeding moms) during the COVID-19 pandemic. Some stated telehealth applications to provide lactation support both in the hospital and at home were provided; however, they reported telehealth support was not helpful and caused them additional stress.
…part of my difficult experience stems from the fact that I have had difficulty breastfeeding, due to issues that a lactation consultant could have helped with, but I couldn’t get that help due to being unable to physically see the lactation consultant.
In addition, they reported concerns and guilt regarding their limited breastmilk supply and attributed supply issues to heightened stress caused by the pandemic. “Because of the stress and sadness of this event, my breastmilk supply stopped. This experience, because of COVID, [was] very difficult for my family and I.”
Unanticipated Hospital Policy Changes Shifted Birthing Plans
Maternal birthing plans were significantly impacted during the COVID-19 pandemic. Unanticipated and sudden changes in hospital policies related to COVID-19 (e.g., mask wearing, visitor policies, exposure-related safety concerns), led to birthing experiences outside of their desired plans. In some cases, patients changed their birthing location from an in-hospital to an out-of-hospital birth in order to reduce COVID-19 exposure and improve social support (more visitors, doulas). Of note, some reported electing for inductions in order to “avoid being in the hospital when cases surge.”
I opted for a 39-week induction because I was terrified the hospitals would be overrun and I’d have to give birth without my husband there to support me. The induction ended up failing and I had an emergency c-section, I often wonder if that would have happened if I had waited to go into labor naturally in a non-COVID world.
Participants mentioned numerous protocols and policies that limited support persons and visitors, required masks to be worn during labor, mandated COVID-19 testing, and increased personal protective equipment worn by healthcare personnel. One participant reported that facemask requirements during labor caused her emotional distress because “the first time [she] held [her] baby, he could not see [her] whole face.” Visitor restrictions, especially restrictions not allowing any support persons to visit, resulted in additional sadness and feelings of isolation for women. Although recognizing visitor restrictions as important for controlling viral transmission, participants noted restrictions resulted in less support during labor and the postpartum period (e.g., inability to have doulas, maternal mother, and/or partner attend the birth). “I wasn’t able to have my mom in addition to my partner in the delivery room with me, which was very hard emotionally, since I had never gone through birth before.”
Expectation vs. Reality: “Mourning What the Experience Should Have Been”
Women described feeling an immense sense of isolation and difficulty navigating postpartum life, which was considered quite different from what they expected. Previously imagined expectations for motherhood (e.g., celebrating baby’s birth, receiving familial help) were diminished and women described an inability to experience support, community, and regular activities which they envisioned. “I feel like I’m mourning what the experience should have been while I cope with what it actually is.”
Some found it difficult to make family-centered decisions while balancing necessary safety boundaries. Participants who decided to prohibit visitors from entering their home faced emotional distress and described a “deep sense of loss.”
We are not letting our baby see grandparents yet and this is very difficult for us and them. Aside from not having the help we were counting on, and missing them, I feel guilty and pressured because they are respecting but don’t understand or agree with our decisions.
Surprising Benefits of the COVID-19 Pandemic to the Delivery and Postpartum Experience
Some described positive aspects of giving birth during the COVID-19 pandemic. Due to stay-at-home orders and hospital visitor restrictions, they described increased and protected bonding opportunities with their infant and partner. Participants positively described the concentrated time with their infant and partner as a more relaxing birth experience with decreased stress related to entertaining visitors immediately following birth and after transitioning home.
I actually enjoyed the alone time that my husband and I got to experience while in the hospital and the first couple of weeks due to the quarantine for the virus. It allowed us to spend time together and figure out how to be first-time parents.