Close
About
FAQ
Home
Collections
Login
USC Login
Register
0
Selected
Invert selection
Deselect all
Deselect all
Click here to refresh results
Click here to refresh results
USC
/
Digital Library
/
University of Southern California Dissertations and Theses
/
Pregnancy in the time of COVID-19: effects on perinatal mental health, birth, and infant development
(USC Thesis Other)
Pregnancy in the time of COVID-19: effects on perinatal mental health, birth, and infant development
PDF
Download
Share
Open document
Flip pages
Contact Us
Contact Us
Copy asset link
Request this asset
Transcript (if available)
Content
Pregnancy in the Time of COVID-19:
Effects on Perinatal Mental Health, Birth, and Infant Development
by
Alyssa R Morris
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PSYCHOLOGY)
August 2022
Copyright 2022 Alyssa R Morris
ii
Acknowledgments
This work has been supported by an NSF Graduate Research Fellowship Grant (DGE-
1418060; Alyssa Morris), American Psychological Association (APA) Dissertation Award
(Alyssa Morris), Society for a Science of Clinical Psychology (SSCP) Dissertation Award
(Alyssa Morris), University of Southern California Gold Dissertation Fellowship Award (Alyssa
Morris), and the USC Center for the Changing Families: Small Grants for COVID-19 (Alyssa
Morris). Additional support for this project came from the NIH-NICHD R01HD104801 (Darby
Saxbe, PhD), NSF CAREER #1552452 (Darby Saxbe, PhD), and USC Zumberge Special
Solicitation: Epidemic & Virus Related Research and Development Award (Darby Saxbe, PhD).
I want to thank my dissertation committee, Dr. Darby Saxbe, Dr. Gayla Margolin, Dr.
Chris Beam, Dr. Amy West, and Dr. Frank Manis, for their expertise, support, and feedback
throughout this project. They have each supported my growth and development as a clinical
scientist in a variety of ways throughout my graduate career.
I would like to especially thank Dr. Darby Saxbe, my dissertation chair, for her
outstanding mentorship not only on this project but over the last five years of my graduate
education. I have grown so much as a clinical scientist over the last five years, and I owe much
of that growth to her support and guidance. It has been an honor to work with and learn from
you.
I want to extend an enormous thank you to the graduate students, lab managers, and
research assistants of the NeuroEndocrinology of Social Ties (NEST) Lab, past and present. My
lab mates have not only provided insights and feedback to enhance this project but also
friendship and emotional support. The graduate school journey is not one to be completed alone.
I am beyond appreciative to have taken this journey alongside NEST graduate students, Hannah
iii
Khoddam, Geoff Corner, Sarah Stoycos, Mona Khaled, Narcis Marshall, Sofi Cardenas, Lizzie
Aviv, Yael Waizman, and Gabe Leon. I also want to thank NEST lab managers, Katie Horton,
Nia Barbee, Pia Sellery, and Melissa Reyes, and NEST research assistants, in particular Van
Truong, Lila Haddan, Divya Jeyasingh, Shreya Sridhara, Emma Herzig, Monica Orozco, and
Vanessa Campuzano, who have been integral in data collection for this project.
I am so fortunate to have experienced graduate school with such brilliant and supportive
colleagues and friends. I am a better researcher, clinician, and friend as a result of their insights,
feedback, and support. In addition to my colleagues mentioned above, I want to thank others who
have supported, challenged, celebrated, and commiserated with me along the way, including,
Kelly Durbin, Hannah Rasmussen, Shubir Dutt, Annemarie Kelleghan, Mariel Bello, Yehsong
Kim, Isabel Sibel, Katie Galbraith, and Laura Fenton.
I want to thank my partner, Bert Foster, for his unwavering support as I complete the
final steps of my graduate training and for celebrating each academic milestone along the way.
Finally, I want to express my deepest gratitude to my parents, Lonnie and Cindy Morris, and my
sister, Megan Morris. I would not be who I am, both professionally and personally, without each
of you. I feel so grateful to have been able to pursue this path, and I attribute much of that to the
immeasurable support I have received from my family.
iv
Table of Contents
Acknowledgements ......................................................................................................................... ii
List of Tables ................................................................................................................................. vi
List of Figures ............................................................................................................................... vii
Abstract ........................................................................................................................................ viii
General Introduction ........................................................................................................................1
References ............................................................................................................................4
Study 1: Mental Health and Prenatal Bonding in Pregnant Women During the COVID-19
Pandemic: Evidence for Heightened Risk Compared with a Pre-pandemic Sample? .....................6
Current Study .....................................................................................................................10
Methods..............................................................................................................................11
Results ................................................................................................................................15
Discussion ..........................................................................................................................16
References ..........................................................................................................................21
Table 1.1 ............................................................................................................................26
Table 1.2 ............................................................................................................................27
Table 1.3 ............................................................................................................................28
Table 1.4 ............................................................................................................................29
Study 2: Prenatal Social Contact during the COVID-19 Pandemic is Associated with Infant Birth
Weight ............................................................................................................................................30
Current Study .....................................................................................................................35
Methods..............................................................................................................................37
Results ................................................................................................................................42
Discussion ..........................................................................................................................44
References ..........................................................................................................................50
Table 2.1 ............................................................................................................................58
Table 2.2 ............................................................................................................................59
Table 2.3 ............................................................................................................................60
Table 2.4 ............................................................................................................................61
Figure 2.1 ...........................................................................................................................62
Study 3: Differences in Infant Negative Affectivity During The COVID-19 Pandemic ..............63
Current Study .....................................................................................................................69
Methods..............................................................................................................................70
Results ................................................................................................................................76
Discussion ..........................................................................................................................77
References ..........................................................................................................................85
Table 3.1 ............................................................................................................................94
Table 3.2 ............................................................................................................................95
Table 3.3 ............................................................................................................................96
v
Figure 3.1 ...........................................................................................................................97
General Discussion ........................................................................................................................98
References ........................................................................................................................101
vi
Tables
1.1 Participant Characteristics and Demographics ........................................................................26
1.2 Analysis of Covariance and for Pandemic and Pre-pandemic Samples on Measures of
Depressive Symptoms, Anxiety Symptoms, Perceived Stress, and Prenatal Bonding .................27
1.3 Estimated Marginal Means for Pandemic and Pre-Pandemic Samples on Measures of
Depressive Symptoms, Anxiety Symptoms, Perceived Stress, and Prenatal Bonding .................28
1.4. Partial Correlations Between Social Impact and Contact and Mental Health and Bonding
Adjusted for Maternal Age, Days Pregnant, Racial/Ethnic Minority Status, and Educational
Attainment ......................................................................................................................................29
2.1 Demographics ..........................................................................................................................58
2.2 Zero Order Correlations ..........................................................................................................59
2.3 Changes to Social Contact, Breakdown by Type of Social Group .........................................60
2.4. Regression analyses with 5000 bootstrap samples predicting birth weight based on social
contact within the pandemic group ................................................................................................61
3.1 Demographics ..........................................................................................................................94
3.2 Zero Order Correlations ..........................................................................................................95
3.3 Bootstrapped regression analyses for prediction of negative affectivity based on mental
health variables across the full sample and based on social contact within the pandemic sample
........................................................................................................................................................96
vii
Figures
2.1 Breakdown of participant responses when asked about their contact with family, friends,
coworkers, and community as compared with before the COVID-19 pandemic ..........................62
3.1 Estimated Marginal Means for Negative Affectivity in Pandemic and Pre-pandemic Groups
........................................................................................................................................................97
viii
Abstract
Study 1
We compared 572 pregnant women (319 first-time mothers) surveyed in spring 2020,
during the first wave of COVID-19 lockdowns in the United States, with 99 pregnant women (all
first-time mothers) surveyed before the pandemic (2014– 2020). Compared with the pre-
pandemic sample, women assessed during the pandemic showed elevated depression, anxiety,
and stress and weaker prenatal bonding to their infants. These findings remained significant
when restricting the pandemic sample to first-time mothers only and held after controlling for
race/ethnicity, education, and pregnancy stage. Average levels of depression and anxiety within
the pandemic group exceeded clinically significant thresholds, and women who estimated that
the pandemic had more negatively affected their social relationships reported higher distress.
However, pandemic-related changes to social contact outside the household were inconsistently
associated with mental health and with some positive outcomes (fewer depressive symptoms,
stronger prenatal bonding). Given that prenatal stress may compromise maternal and child well-
being, the pandemic may have long-term implications for population health.
Study 2
Social support and mental health during pregnancy have been associated with birth
outcomes such as infant birth weight. The COVID-19 pandemic has had drastic impacts both on
social connectedness and mental health, with evidence that pregnant women reported elevated
prenatal depression, anxiety symptoms, and stress during the height of pandemic lockdowns. To
date, no work has explored whether maternal social contact and mental health predict infant birth
weight during the COVID-19 pandemic. A sample of 262 pregnant U.S. women completed an
online questionnaire assessing social contact, depressive symptoms, anxiety symptoms, stress,
ix
and partner relationship satisfaction during the first wave of the COVID-19 pandemic. At three
months postpartum, they reported on birth weight and gestational age. All analyses controlled for
maternal age, education, race/ethnicity, and first-time parenthood. We found that maternal self-
reported decreases in social contact during the pandemic were significantly associated with lower
infant birth weight. This association was moderated by maternal prenatal depressive symptoms
but not by prenatal anxiety symptoms or stress. Partner relationship quality did not appear to
buffer the association between prenatal support and infant birth weight. Decreased social contact
during the COVID-19 pandemic has implications for maternal and infant health. Prenatal
maternal social contact appears to influence birth weight via impacts on maternal depressive
symptoms. Interventions aimed at bolstering social support and decreasing depressive symptoms
in perinatal populations are essential during and after the COVID-19 pandemic, as the social
restructuring occasioned by the pandemic may lead to lasting changes in social behavior.
Study 3
COVID-19 pandemic lockdowns have been associated with heightened mental health
risks in pregnant women and new parents. Given that maternal perinatal distress is a risk factor
for poorer infant socioemotional development, exploration of the potential effects of maternal
distress on infant temperament is warranted. We compared two samples: 263 U.S. women who
were pregnant during the COVID-19 pandemic and 72 U.S. women who were pregnant prior to
the pandemic. Women in each sample completed questionnaire measures assessing prenatal and
postpartum depressive symptoms via the Beck Depression Inventory-II, prenatal and postpartum
stress using the Perceived Stress Scale 14, and infant temperament at three months postpartum
using the Very Short Form of the Revised Infant Behavior Questionnaire. The pandemic sample
also answered questions regarding changes to social contact due to the pandemic. ANCOVA,
x
linear regression, mediation, and moderation analyses were conducted to explore relationships
between maternal mental health, social contact, and infant temperament variables. Analyses
controlled for baby’s age at three months, maternal age, maternal education, self-reported
race/ethnicity, and first-time parenthood. At three months postpartum, mothers rated infants born
during the COVID-19 pandemic as having significantly higher negative affectivity than did
mothers of infants born prior to the pandemic (F(1,324) = 18.28, p <.001). We did not find
differences in infant surgency or effort control. Maternal prenatal and postpartum stress and
depressive symptoms predicted infant temperament, and prenatal stress [0.13 (95% CI 0.01,
0.27)], postpartum stress [0.06 (95% CI 0.01, 0.13)], and prenatal depressive symptoms [0.07
(95% CI 0.00, 0.16)] mediated differences in infant negative affectivity between pandemic and
pre-pandemic samples. Pandemic group status did not moderate associations between prenatal
depressive symptoms and infant negative affectivity. Finally, mothers’ reports of decreased
postpartum social contact were significantly associated with more infant negative affectivity. We
found that mothers reported more negative affectivity among infants born during the COVID-19
pandemic as compared with infants born prior to the pandemic. Increased maternal distress
during the pandemic, specifically prenatal depressive symptoms and prenatal and postpartum
stress, appeared to explain these differences. We did not find that maternal distress during the
pandemic differentially impacted infant temperament as compared with pre-pandemic; instead,
these increases were due to increased levels of maternal mental health problems. Furthermore,
postpartum maternal social contact during the pandemic was associated with infant negative
affectivity, and this association was not explained by maternal distress.
1
General Introduction
The COVID-19 pandemic has had an unprecedented impact on almost every aspect of
life over the last two years. Women who have experienced pregnancy during the pandemic have
been particularly affected by pandemic-related lockdowns, which led to changes to prenatal care
and childbirth. Moreover, after birth, new parents faced dramatic reductions in social support,
with social distancing measures limiting others from providing instrumental support with baby
care. Thus, the impacts of societal upheaval, loss of social connection and community, and
increases in health-related anxieties during the COVID-19 pandemic have been particularly acute
for expectant and new parents. The perinatal period is a time of heightened vulnerability for
mental health problems, which the stress of the COVID-19 pandemic may have further
compounded. Initial work has shown a marked decrease in the emotional well-being of pregnant
women during the COVID-19 pandemic (Corbett et al., 2020; Davenport et al., 2020; Durankuş
& Aksu, 2020; Lebel et al., 2020; Milne et al., 2020). This is particularly concerning as maternal
mental health is not only an important aspect of women’s well-being but also impacts the
emotional and physical well-being of the baby, even before birth.
This dissertation is grounded in the fetal programming hypothesis, with a particular focus
on prenatal maternal mental health and social connection. The fetal programming hypothesis
posits that the prenatal period is a sensitive period for development, and the environment in utero
can have lasting influences throughout life (Barker, 1998). This hypothesis suggests that while
the systems and organs of the fetus are developing, they are sensitive to maternal hormonal
changes, which can make permanent alternations to the offspring's biological systems (Barker,
1998). Exposure to prenatal maternal stress is associated with poorer birth outcomes (Stein et al.,
2014; Walsh et al., 2019), alterations in brain structure and function (Buss et al., 2012; Tau &
2
Peterson, 2010), and differences in infant temperament (Graignic-Philippe et al., 2014; Huizink
et al., 2002). Thus, the prenatal period is a time of particular vulnerability and warrants focus on
both mothers' and babies' health. In addition to exploring increases in prenatal maternal distress
and decreases in social contact during the pandemic, this work assesses the impacts of these
factors on birth outcomes and infant temperament.
Previous research on the impacts of maternal mental health, coupled with initial findings
during the COVID-19 pandemic, suggests that maternal distress during the pandemic may be
linked to adverse birth outcomes and differences in infant developmental outcomes. However,
research in this area remains limited, and few studies have incorporated pre-pandemic
comparison groups. Thus, the primary aims of this dissertation are to 1) highlight how the
pandemic may have affected prenatal maternal mental health and demonstrate impacts on
maternal-fetal bonding, 2) assess the impacts of pandemic-related changes to maternal social
contact and mental health on infant gestational outcomes such as birth weight, and 3) explore
differences in infant temperament during the pandemic as compared with infants born before the
pandemic, as well as illuminates relationships between infant temperament and maternal mental
and social connection during the pandemic.
This dissertation project, the Coronavirus, Health, Isolation, and Resiliency in Pregnancy
(CHIRP) study, was launched on April 6
th,
2020, during the first wave of the COVID-19
pandemic. With its early launch, this project is on the leading edge of research exploring
maternal mental health and social contact during the COVID-19 pandemic. As one of the first
studies to explore maternal mental health during the pandemic, when only a small portion of the
population had contracted the virus, we are uniquely situated to explore the impacts of social
3
disconnection during pregnancy with limited confound from the effects of SARS-CoV-2
infection.
Moreover, we have continued to follow these families in the postpartum period to assess
birth and infant outcomes and have matched many of our measures to those used in the USC
Hormones Across the Transition to CHildrearing (HATCH) study, a pre-pandemic transition to
parenthood study. This dissertation work is one of the first projects to include a prospectively
designed study of perinatal maternal and infant health during the COVID-19 pandemic modeled
to align with a pre-pandemic comparison group. As we have followed families across the
pandemic, we have continued to refine our processes in conducting research during a global
pandemic, which is reflected in the increasing rigor of our methodology as we continue to
publish work from this study. For example, as we have collected more follow-up data, we have
developed more detailed fraud-detection procedures, meaning that our sample sizes vary slightly
across manuscripts.
The studies discussed in this dissertation explore the impacts of maternal mental health
and social contact during the COVID-19 pandemic on the maternal-fetal relationship, birth
weight, and infant temperament, building on and extending preliminary findings during the
COVID-19 pandemic, and contributing to our understanding of the impacts of perinatal distress
and social connect.
4
References
Barker, D. J. P. (1998). In utero programming of chronic disease. Clinical Science, 95(2), 115–128.
https://doi.org/10.1042/cs0950115
Buss, C., Davis, E. P., Shahbaba, B., Pruessner, J. C., Head, K., & Sandman, C. A. (2012). Maternal
cortisol over the course of pregnancy and subsequent child amygdala and hippocampus volumes
and affective problems. Proceedings of the National Academy of Sciences of the United States of
America, 109(20). https://doi.org/10.1073/pnas.1201295109
Corbett, G. A., Milne, S. J., Hehir, M. P., Lindow, S. W., & O’connell, M. P. (2020). Health anxiety
and behavioural changes of pregnant women during the COVID-19 pandemic. European Journal
of Obstetrics and Gynecology and Reproductive Biology, 249, 96–97.
https://doi.org/10.1016/j.ejogrb.2020.04.022
Davenport, M. H., Meyer, S., Meah, V. L., Strynadka, M. C., & Khurana, R. (2020). Moms are not
OK: COVID-19 and maternal mental health. Frontiers in Global Women’s Health, 1.
https://doi.org/10.3389/FGWH.2020.00001
Durankuş, F., & Aksu, E. (2020). Effects of the COVID-19 pandemic on anxiety and depressive
symptoms in pregnant women: a preliminary study. The Journal of Maternal-Fetal & Neonatal
Medicine, 1–7. https://doi.org/10.1080/14767058.2020.1763946
Graignic-Philippe, R., Dayan, J., Chokron, S., Jacquet, A. Y., & Tordjman, S. (2014). Effects of
prenatal stress on fetal and child development: A critical literature review. Neuroscience and
Biobehavioral Reviews, 43, 137–162. https://doi.org/10.1016/j.neubiorev.2014.03.022
Huizink, A. C., Robeles de Medina, P. G., Mulder, E. J. H., Visser, G. H. A., & Buitelaar, J. A. N. K.
(2002). Psychological measures of prenatal stress as predictors of infant temperament. Journal of
5
the American Academy of Child & Adolescent Psychiatry, 41(9), 1078–1085.
https://doi.org/https://doi.org/10.1097/00004583-200209000-00008
Lebel, C., MacKinnon, A., Bagshawe, M., Tomfohr-Madsen, L., & Giesbrecht, G. (2020). Elevated
depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic.
Journal of Affective Disorders, 277, 5–13. https://doi.org/10.1016/j.jad.2020.07.126
Milne, S. J., Corbett, G. A., Hehir, M. P., Lindow, S. W., Mohan, S., Reagu, S., Farrell, T., &
O’Connell, M. P. (2020). Effects of isolation on mood and relationships in pregnant women
during the covid-19 pandemic. Journal of Cleaner Production, 252, 610.
https://doi.org/10.1016/j.ejogrb.2020.06.009
Stein, A., Pearson, R. M., Goodman, S. H., Rapa, E., Rahman, A., McCallum, M., Howard, L. M., &
Pariante, C. M. (2014). Effects of perinatal mental disorders on the fetus and child. The Lancet,
384(9956), 1800–1819. https://doi.org/10.1016/S0140-6736(14)61277-0
Tau, G. Z., & Peterson, B. S. (2010). Normal development of brain circuits.
Neuropsychopharmacology, 35(1), 147–168. https://doi.org/10.1038/npp.2009.115
Walsh, K., McCormack, C. A., Webster, R., Pinto, A., Lee, S., Feng, T., Sloan Krakovsky, H.,
O’Grady, S. M., Tycko, B., Champagne, F. A., Werner, E. A., Liu, G., & Monk, C. (2019).
Maternal prenatal stress phenotypes associate with fetal neurodevelopment and birth outcomes.
Proceedings of the National Academy of Sciences of the United States of America, 116(48),
23996–24005. https://doi.org/10.1073/pnas.1905890116
6
STUDY 1
Mental Health and Prenatal Bonding in Pregnant Women During the COVID-19
Pandemic: Evidence for Heightened Risk Compared with a Pre-pandemic Sample?
Alyssa R. Morris, MA and Darby E. Saxbe, PhD
7
Introduction
In spring 2020, the COVID-19 pandemic transformed the global social landscape as the
need to maintain social distance quickly reshaped work, travel, and leisure behaviors. In
particular, the experience of pregnancy, birth, and new parenthood changed for many families
(Poon et al., 2020; Tran et al., 2020). In the early days of the pandemic, women preparing for
childbirth— often a time of joyful anticipation—reported fear and uncertainty. There were
restrictions on the number of people permitted to attend births, and some women delivered
infants alone, without partner or family support (Farewell et al., 2020; Morano & Calleja-Agius,
2020). Pregnant women also experienced disruptions to their prenatal medical care and to their
ability to seek social connection. The transition to parenthood often prompts an outpouring of
extended family and community support, but many expectant parents relinquished baby showers,
bris and christening ceremonies, and other rituals to help to mark their new baby’s arrival.
Although the pandemic engendered societal upheaval, loss of community and connection,
and increased health-related anxiety across a broad swath of the population, these experiences
may have been particularly acute for expectant parents, given heightened needs for both medical
and social support during the transition to parenthood (Saxbe et al., 2018). New parenthood is
also recognized as a time of vulnerability for mood and anxiety disorders, which can have
pervasive effects on both parent and child well-being (Biaggi et al., 2016; Stein et al., 2014).
Exploring impacts of the pandemic on perinatal mental health is thus a continued public-health
priority, even after the initial threat of COVID-19 recedes. In the current article, we compare
psychological distress levels in 572 pregnant women (319 first-time mothers), surveyed in spring
2020 at the height of social distancing behaviors in the United States, with a pre-pandemic
sample of 99 pregnant women.
8
Perinatal mental-health disorders are the most common pregnancy complication, and
prevalence ranges from 10% to 40% of women during the perinatal period (Biaggi et al., 2016).
These disorders have implications for the well-being of not only mothers but also their children,
including higher rates of birth complications and admission to the neonatal intensive care unit
(Stein et al., 2014). Moreover, risks to child development extend past the perinatal period. Two
reviews summarize a large body of work showing increased risks for psychological and
developmental problems in children born to mothers with perinatal mood and anxiety disorders
(Hoffman et al., 2017; Stein et al., 2014).
Implications of COVID for Perinatal Mental Health
Studies of pandemic-related stress have the potential to extend previous research on
prenatal exposure to mass disasters (e.g., natural disasters, terrorist attacks), which have been
linked with adverse long-term effects on maternal and infant health, including maternal mood
disorders and infant temperament and development (Harville et al., 2010). The COVID-19
pandemic is a particularly unusual population-scale event; although it entails acute threat to life
and loss of life, as would a natural disaster, it also occasioned a prolonged period of behavioral
change. Natural disasters often catalyze an increase in social affiliation and support as
communities come together to grieve and rebuild. But the pandemic necessitated sudden and
often dramatic reductions in social contact. Compounding this, pregnant women are categorized
as high risk and may have been advised to quarantine strictly (Fakari & Simbar, 2020). Social
support has been identified as a key buffer of risk for perinatal mental-health disorders and a
significant, consistent predictor of both mental and physical health in women during the perinatal
period (Biaggi et al., 2016; Emmanuel et al., 2012), yet during the COVID-19 pandemic, “safer-
at-home” orders limited access to social support and connection. Moreover, the pandemic also
9
introduced additional multifaceted stressors: caregiving and bereavement demands, economic
losses, and disruptions to work and medical care (Pfefferbaum & North, 2020). Thus, the acute
decrease in social support and additional stressors of the COVID-19 pandemic may present
unique risks for perinatal mental health compared with other large-scale disasters.
A few preliminary studies have reported that women experiencing pregnancy during the
pandemic described low mood (Milne et al., 2020) and heightened anxiety (Corbett et al., 2020)
in the context of the unique stressors of COVID-19. Specifically, Lebel and colleagues (2020)
found substantially elevated depression and anxiety symptoms in a sample of almost 2,000
pregnant women in Canada, of whom 37% reported clinically relevant symptoms of depression
and 57% reported clinically relevant symptoms of anxiety. Another Canadian survey study of
520 pregnant women reported similar rates; 40.7% of women reported depression above the
clinical threshold, and 72% of women reported moderate to high anxiety, significantly higher
rates than the women’s estimated pre-pandemic mental health, although with the caveat that the
pre-pandemic estimates may have been affected by retrospective reporting bias (Davenport et al.,
2020). A Stanford study found even higher rates of depressive symptoms; 51% of pregnant
women in the San Francisco Bay Area during the pandemic scored above the clinical cutoff
compared with 25% of a demographically matched pre-pandemic sample (King et al., 2020).
Moreover, a Turkish study found that 35.4% of women endorsed clinically significant depressive
symptoms in the early months of the COVID-19 pandemic, significantly higher than in pre-
pandemic control subjects (Durankus ̧ & Aksu, 2020). Another Turkish study conducted in June
and July 2020 found that 64.5% and 56.3% of women reported clinically significant symptoms
of anxiety and depression, respectively (Sut & Kucukkaya, 2021). Only one study to date has
focused exclusively on mental health in first-time mothers. This study found high levels of
10
distress among 49 U.S. women expecting their first child who were sampled between June and
July 2020 (McMillan et al., 2021). In sum, reports from the first wave of the pandemic indicate
elevated prenatal distress compared with existing pre-pandemic samples.
Mothers’ ability to bond with their unborn infants during the COVID-19 pandemic has
not yet been investigated. Prenatal stress and distress have been associated with poorer prenatal
bonding, which in turn may negatively affect the postpartum parent–child relationship (Glover &
Capron, 2017; Walsh et al., 2014). In addition, more work is needed to understand the
mechanisms of pandemic-related distress, such as changes in social contact and connectedness
associated with lockdowns. Studies of COVID-19 impacts can also benefit from specificity in
terms of timing and sample. For example, the May 25, 2020, murder of George Floyd sparked a
racial-justice movement that changed the cultural landscape just as COVID-19 was reshaping
social behavior. In the current study, we focus only on data collected within a 6-week period,
between April 6, 2020, and May 24, 2020, to limit the potentially confounding effects of these
and other geopolitical events. In addition, many published studies of perinatal women during the
COVID-19 pandemic have not considered parity, but first-time expectant mothers may have had
a different experience of the pandemic than women who were already mothers given that the
pandemic occasioned child-care disruptions that may have affected women with other children at
home.
The Current Study
We report on a survey of expectant parents conducted in spring 2020, during the first
wave of COVID-19 lockdowns in the United States. We hypothesized that, compared with a pre-
pandemic sample of pregnant women, the pandemic sample would report heightened levels of
psychological distress (depressive symptoms, anxiety symptoms, and perceived stress) and
11
decreased levels of prenatal bonding. We also tested whether pandemic-related changes to social
contact and social relationship quality would explain these differences. Our comparison sample
focused on first-time mothers; given the possibility that parity might affect the experience of
pregnancy during the pandemic, we tested all hypotheses twice, first with the full pandemic
sample and then with first-time mothers only.
Methods
Pre-pandemic comparison data were drawn from a sample of 100 couples recruited in
Los Angeles, California, between March 2014 and early February 2020 and followed from
pregnancy across the first year postpartum. All procedures were approved by a university
institutional review board. Eligible couples were expecting their first child, cohabiting, and able
to complete study measures in English. Couples completed two lab visits and a post-birth
hospital visit; data included in this article are drawn from the questionnaire battery administered
to pregnant women at the prenatal visit, which occurred in mid to late pregnancy. Couples were
recruited primarily through social media (e.g., Facebook pregnancy/parenting groups) and word
of mouth. Of the 100 first-time mothers recruited through this project, 99 had complete data on
all measures and were included in this article.
In April 2020, the questionnaire battery used in this study was adapted into an online
survey for expectant parents, the Coronavirus, Health, Isolation, and Resilience in Pregnancy
(CHIRP) study, launched on April 6, 2020. According to smartphone GPS data, the week of
April 7, 2020, represented the peak of “sheltering in place” behavior in the United States, during
which Americans spent 93% of their time at home (Schaul et al., 2020). For the present analyses,
we focused on responses collected within the first 6 weeks after the survey was launched. (We
excluded 24 pregnant mothers who responded to our survey after May 24, 2020, to avoid
12
potentially confounding effects of the May 25, 2020, murder of George Floyd, which occasioned
widespread racial-justice protests.) We dropped an additional 45 participants who completed less
than 28% of the survey. The resulting sample size for analyses was 572, of which 319 were first-
time mothers. Participants provided consent and completed a 20- to 30-min questionnaire
through the Qualtrics platform (http://www.qualtrics.com). All study procedures were approved
by the university institutional review board. Expectant parents were recruited via social media,
including posts on Twitter, Facebook, and Instagram; online pregnancy/parenting groups and
message boards; and paid advertising on Facebook and Instagram. Participants were
compensated through entry into a gift-card lottery. Per institutional review board guidance, after
completing the survey, participants were offered a downloadable list of mental-health resources,
including substance-abuse, suicide-prevention, and domestic-violence hotlines.
Participants
Participants in the pre-pandemic sample were recruited across the Los Angeles area and
were diverse and representative of the region, expecting their first child, and between 20 and 35
weeks pregnant at study entry. The pandemic sample was mostly based in the United States
(97.7%) and could participate at any point during pregnancy. Most participants were married
(84% of the pre-pandemic sample and 88% of the pandemic sample); rates of marriage or
cohabitation did not differ across the two groups. As shown in Table 1, the pre-pandemic sample
was more racial/ethnically diverse and slightly more educated than the pandemic sample.
Furthermore, the pre-pandemic sample was, on average, 3 to 4 weeks further along in their
pregnancies and 1 year older than the pandemic sample. We adjusted for these differences by
controlling for race/ethnicity, education, days pregnant, and maternal age in all analyses. There
13
were no significant moderating effects of race/ethnicity on levels of depression, anxiety, stress,
and bonding when comparing the two samples.
Measures
COVID-19 Impacts
We asked about exposure to COVID-19, COVID-19-related bereavement, and additional
behavioral and other impacts (for more details, see Morris et al. 2021). We operationalized
changes in social connection in two ways. First, participants were asked, “Overall, what impact
has COVID-19 had on your social relationships?” and responded on a 5-point scale (1 = very
negative, 3 = no impact, 5 = very positive). Next, participants were also asked, “As compared to
before COVID-19, how much total contact (including in-person, phone, or online) do you have
with the following people?” Participants were asked to respond to this question on a 5-point
scale (1 = much less, 5 = much more) in relation to their (a) neighbors/community members, (b)
coworkers, (c) friends, (d) families, and (e) partners. Responses across the first three groups were
averaged to create a total score reflecting social contact outside the household.
Depression
The Beck Depression Inventory (BDI-II; Beck et al., 1996), a 21-item self-report
questionnaire that has been used in many studies of depression, assesses mental and somatic
complaints related to depression, including loss of pleasure and changes to sleep and appetite.
Respondents rate items on a 4-point scale (0 = not at all, 3 = severely). Scores are summed so
that higher scores indicate worse depressive symptoms.
Anxiety
The state subscale of the State-Trait Anxiety Inventory (Spielberger, 2010), a well-
validated and widely used 20-item questionnaire measuring acute anxiety, uses a 4-point scale (0
14
= not at all, 3 = very much so) to rate items such as “I feel nervous” and “I am tense.” Responses
summed for a total score can range from 20 to 80, and higher scores reflect higher state anxiety.
Stress
The 10-item Perceived Stress Scale (Cohen et al., 1994) is the most widely used measure
of self-reported stress. Responses for each question (0 = never, 4 = almost always) are summed,
and higher scores reflect higher perceived stress.
Prenatal bonding was measured using the Antenatal Attachment Scale (AAS; Condon,
1993). The AAS, a 19-item self-report questionnaire, assesses expectant parents’ thoughts and
feelings about their developing baby over the past 2 weeks. All responses are on a 5-point scale
and are averaged into a total score; higher scores reflect stronger prenatal bonding (example
items: “I have thought about or been preoccupied with the baby” [1 = not at all, 5 = almost all
the time]; “When I have spoken about or thought about the developing baby I got emotional
feelings which were” [1 = very weak, 5 = very strong]).
Analyses
Analysis of covariance was used to assess differences in mental health and prenatal
bonding in the pre-pandemic and pandemic samples of pregnant women. Partial correlations
were used to assess the relationship between COVID-19-related changes in social connection and
prenatal mental health and bonding within the pandemic sample. All analyses controlled for
number of days pregnant, identification as a racial/ethnic minority, maternal age, and educational
attainment. Because not all participants completed every questionnaire item, sample sizes differ
slightly for each analysis, as indicated in the tables and text. All analyses were run twice, first
with the full pandemic sample and then with first-time mothers only.
15
Results
For descriptive statistics for both the pre-pandemic and pandemic samples, see Table 1.
At the time of the CHIRP survey, direct impacts of the pandemic were relatively low:
Approximately 95% of respondents had not experienced either a suspected or confirmed case of
COVID-19 or a COVID-19-related death of someone close to them. However, 97.7% of women
reported that their community had issued stay-at-home orders restricting large gatherings and
closing nonessential businesses. The majority of women also reported that the pandemic had a
negative impact on their social relationships; about 60% reported negative impacts on their social
relationships and reduced social contact with individuals outside their household, and almost
90% indicated an overall decrease in contact.
Mental Health
As shown in Table 2, women’s self-reported depressive symptoms, state anxiety, and
perceived stress were all significantly greater in the pandemic group compared with the pre-
pandemic group, both across the full sample and in first-time mothers only. As shown in Table 1,
levels of depressive symptoms and perceived stress were approximately 1 SD higher in the
pandemic sample compared with the pre-pandemic baseline; for anxiety, the difference was
about 1.8 SD. Within the pandemic sample, the mean BDI-II score of depressive symptoms
(15.46) exceeded the threshold (14) that has been used to indicate clinically significant
depression (Smarr & Keefer, 2011). Likewise, the mean anxiety score in the pandemic group
exceeded the clinical threshold that has been used with perinatal populations (Tendais et al.,
2014). In comparison, pre-pandemic means fell far below clinically significant thresholds.
Estimated marginal means that reflect these differences, after adjusting for covariates, are shown
in Table 3.
16
As shown in Table 4, mothers reporting more negative pandemic-related impacts on their
social relationships also reported higher levels of depressive symptoms, anxiety, and stress
(within both the full sample and first-time mothers only). Reductions in social contact because of
the pandemic were correlated with stress in the full sample of mothers. However, this association
became nonsignificant when the analysis was restricted to the sample of first-time mothers only.
Counterintuitively, first-time mothers reporting reduced social contact outside the household
reported fewer depressive symptoms. Social contact was not associated with anxiety in either the
full sample or the first-time-mother sample.
Prenatal Bonding
Also shown in Table 2 is that women who were pregnant during the pandemic reported
weaker prenatal bonding with their unborn infant compared with women who completed the
same bonding measure before the pandemic. This difference amounted to approximately two
thirds of a standard deviation, as shown in Table 1. Estimated marginal means reflecting
differences in prenatal bonding, after adjusting for covariates, are shown in Table 3. Mothers’
estimated impact of the pandemic on their social relationships was not associated with their
reports of prenatal bonding, as shown in Table 4. However, pandemic-related decreases in total
social contact outside the household were associated with stronger prenatal bonding. These
findings were consistent across the full sample and within first-time mothers only.
Discussion
We found that women experiencing pregnancy during the COVID-19 pandemic reported
significantly higher levels of psychological distress and weaker prenatal bonding with their
babies compared with a pre-pandemic sample of pregnant women. Strikingly, within our
pandemic sample, women’s depression and anxiety exceeded clinical thresholds. Women who
17
reported that the pandemic had a more negative impact on their social relationships also reported
more depression, anxiety, and stress, which points to pandemic-related decreases in social
connectedness as a potential mechanism explaining differences between pandemic and pre-
pandemic cohorts. However, pandemic-related changes in social contact outside the household
were not consistently associated with mental health. In fact, pandemic-related reductions in
social contact were actually associated with fewer depressive symptoms in first-time mothers and
with stronger prenatal bonding with infants in all mothers. Thus, mothers’ perceptions of
negative social impacts may be more strongly associated with their distress, whereas actual
changes in social contact outside the household yielded more mixed results. The ability to reduce
social contact may reflect occupational privilege, which is typically associated with better
mental-health and pregnancy outcomes. Our results suggest that research on social connection
and mental health during the pandemic should carefully consider global perceptions of negative
impact compared with more granular reports of social contact with others.
Given that prenatal mental-health problems are associated with a wide array of negative
developmental outcomes for children (Stein et al., 2014), this evidence for heightened distress in
pregnant women during the pandemic is of concern. Prenatal stress and distress may have long-
term effects on both maternal and infant health, as other research on population-scale disruptions
has suggested. Therefore, these findings may indicate risk to both mothers and infants in the
postpartum period and beyond. Our results were generally consistent across first-time mothers
compared with all mothers, which suggests that the pandemic had negative impacts on pregnant
women across the board.
In addition to significantly higher levels of mental health symptoms in our pandemic
cohort, we also found that women reported weaker prenatal bonding with their unborn babies.
18
This finding held after adjusting for duration of pregnancy and highlights the potential for future
challenges for this population given that prenatal mother-child bonding has been associated with
future bonding and parenting behaviors (Maas et al., 2016). We found that decreases in the
amount of social contact with community members, coworkers, and friends was associated with
stronger feelings of prenatal bonding. It is possible that decreased engagement with others may
result in more time spent thinking about and connecting with the unborn baby. Although we
found a relationship between social contact and prenatal bonding, we did not find a similar
relationship between prenatal bonding and perceptions of how the pandemic affected women’s
social relationships.
Conclusion
In this article, we sought to highlight perinatal mental health and prenatal bonding as
particular areas for concern and attention in the wake of the COVID-19 pandemic. We sought to
further extend the literature by exploring prenatal bonding and examining the impact of the
COVID-19 pandemic on social relationships and social contact as a potential mechanism for
these effects. Note that our pandemic sample was recruited during the first wave of COVID-19
lockdowns, when social-distancing measures were most widely adopted in the United States,
which allowed us to assess the impacts of social isolation more closely than in other samples
with a larger range of participation dates. Furthermore, this is one of the first studies to assess
rates of mental health and prenatal bonding in pregnant women transitioning to motherhood
during the COVID-19 pandemic.
Given the known detrimental impacts of poor maternal mental health on both mother and
infant outcomes (Harville et al., 2010), our findings of heightened risk for perinatal mental-
health problems, poorer prenatal bonding, and decreases in social connection during the
19
pandemic are of great concern. Efforts are needed to support pregnant and postpartum women
even as the pandemic resolves. Research should continue to track children born during and
shortly after the COVID-19 pandemic to assess potentially enduring effects of pandemic-related
prenatal stress.
Limitations
These data were collected cross-sectionally in spring 2020, shortly after many COVID-19
restrictions were implemented. Responses to this online survey came from a well-educated
convenience sample recruited across social media platforms. The comparison group was drawn
from an existing study and comprised only first-time mothers. Although this is a strength for our
analyses of first-time mothers only, it is a limitation of our larger analyses with the full pandemic
sample including non–first-time parents. In addition, our pandemic group was less
racially/ethnically diverse than our pre-pandemic sample and was not limited to geographic
region, compared with our pre-pandemic group, which was recruited from the Los Angeles area.
Furthermore, the pre-pandemic group participated in a more time-intensive, in-person study,
compared with the pandemic group, which participated in a 45-min online survey. Thus,
although we controlled for race/ ethnicity, age, days pregnant, and educational attainment, our
samples are not equivalent in background or motivation to participate in research. Given well-
documented associations between higher socioeconomic status and perinatal mental health in the
United States, a more ethnically/racially and socioeconomically diverse sample might reveal
even more striking levels of mental-health vulnerability
Future Directions
There is a clear need to follow up and explore the long-term implications of the perinatal
experience during the COVID-19 pandemic. Previous work highlights the pandemic’s
20
disproportionate impact on low-income communities and communities of color and suggests that
these impacts magnify preexisting disparities in maternal and infant health (Dongarwar et al.,
2020). Therefore, more work is needed to explore the impact of the pandemic in more
racially/ethnically diverse samples, and the need for mental-health services is likely even more
acute than reflected in the current data. Future work should follow families longitudinally to
better understand the effects of pandemic-related stress across time, explore effects on fathers
and children in addition to mothers, and assess potential positive changes linked with the
pandemic (i.e., more time at home with baby, greater ease of breastfeeding). In sum, research on
the mental-health and social dynamics of the COVID-19 pandemic can shed light on stress,
health, and resilience in pregnancy and beyond.
21
References
Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996). Comparison of Beck Depression
Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment,
67(3), 588–597.
Biaggi, A., Conroy, S., Pawlby, S., & Pariante, C. M. (2016). Identifying the women at risk of
antenatal anxiety and depression: A systematic review. Journal of Affective Disorders,
191, 62–77.
Cohen, S., Kamarck, T., & Mermelstein, R. (1994). Perceived stress scale. Measuring Stress: A
Guide for Health and Social Scientists, 10, 1–2.
Condon, J. (1993). The assessment of antenatal emotional attachment: Development of a
questionnaire instrument. British Journal of Medical Psychology, 66(2), 167–183.
Corbett, G. A., Milne, S. J., Hehir, M. P., Lindow, S. W., & O’Connell, M. P. (2020). Health
anxiety and behavioural changes of pregnant women during the COVID-19 pandemic.
European Journal of Obstetrics, Gynecology, and Reproductive Biology, 249, 96–97.
Davenport, M. H., Meyer, S., Meah, V. L., Strynadka, M. C., & Khurana, R. (2020). Moms are
not ok: COVID-19 and maternal mental health. Frontiers in Global Women’s Health, 1,
Article 1. https://doi.org/10.3389/fgwh.2020.00001
Dongarwar, D., Ajewole, V. B., Oduguwa, E., Ngujede, A., Harris, K., Ofili, T. U., Olaleye, O.
A., & Salihu, H. M. (2020). Role of social determinants of health in widening maternal
and child health disparities in the era of COVID-19 pandemic. International Journal of
Maternal and Child Health and AIDS, 9(3), 316–319. https://doi.org/ 10.21106/ijma.398
Durankus ̧, F., & Aksu, E. (2020). Effects of the COVID-19 pandemic on anxiety and depressive
symptoms in pregnant women: A preliminary study. The Journal of Maternal-Fetal &
22
Neonatal Medicine. Advance online publication.
https://doi.org/10.1080/14767058.2020.1763946
Emmanuel, E., St John, W., & Sun, J. (2012). Relationship between social support and quality of
life in childbearing women during the perinatal period. Journal of Obstetric, Gynecologic
& Neonatal Nursing, 41(6), E62–E70. https://doi.org/10.1111/j.1552-6909.2012.01400.x
Fakari, F., & Simbar, M. (2020). Coronavirus pandemic and worries during pregnancy; a letter to
editor. Archives of Academic Emergency Medicine, 8(1), Article e21. https://
doi.org/10.22037/aaem.v8i1.598
Farewell, C. V., Jewell, J., Walls, J., & Leiferman, J. A. (2020). A mixed-methods pilot study of
perinatal risk and resilience during COVID-19. Journal of Primary Care & Community
Health, 11, Article 2150132720944074. https://doi.org/10.1177/2150132720944074
Glover, V., & Capron, L. (2017). Prenatal parenting. Current Opinion in Psychology, 15, 66–70.
Harville, E. W., Xiong, X., & Buekens, P. (2010). Disasters and perinatal health: A systematic
review. Obstetrical & Gynecological Survey, 65(11), 713–728. https://doi
.org/10.1097/OGX.0b013e31820eddbe
Hoffman, C., Dunn, D. M., & Njoroge, W. F. M. (2017). Impact of postpartum mental illness
upon infant development. Current Psychiatry Reports, 19(12), Article 100. https://
doi.org/10.1007/s11920-017-0857-8
King, L. S., Feddoes, D. E., Kirshenbaum, J. S., Humphreys, K. L., & Gotlib, I. (2020).
Pregnancy during the pandemic: The impact of COVID-19-related stress on risk for
prenatal depression. PsyArXiv. https://doi.org/10.31234/ osf.io/3vsxc
Lebel, C., MacKinnon, A., Bagshawe, M., Tomfohr-Madsen, L., & Giesbrecht, G. (2020).
Elevated depression and anxiety symptoms among pregnant individuals during the
23
COVID-19 pandemic. Journal of Affective Disorders, 277, 5–13.
https://doi.org/10.1016/j.jad.2020.07.126
Maas, A. J. B. M., de Cock, E. S. A., Vreeswijk, C. M. J. M., Vingerhoets, A. J. J. M., & van
Bakel, H. J. A. (2016). A longitudinal study on the maternal–fetal relationship and
postnatal maternal sensitivity. Journal of Reproductive and Infant Psychology, 34(2),
110–121. https://doi.org/10.108
0/02646838.2015.1112880
McMillan, I. F., Armstrong, L. M., & Langhinrichsen-Rohling, J.
(2021). Transitioning to parenthood during the pandemic: COVID-19 related stressors and first-
time expectant mothers’ mental health. Couple and Family Psychology: Research and
Practice. Advance online publication. http://doi.org/10.1037/cfp0000174
Milne, S. J., Corbett, G. A., Hehir, M. P., Lindow, S. W., Mohan, S., Reagu, S., Farrell, T., &
O’Connell, M. P. (2020). Effects of isolation on mood and relationships in pregnant
women during the COVID-19 pandemic. European Journal of Obstetrics, Gynecology,
and Reproductive Biology, 252, 610–611.
Morano, S., & Calleja-Agius, J. (2020). Giving birth and dying alone in hospital during the
COVID-19 pandemic–a time for shifting paradigm toward continuity of care. Journal of
Perinatal Medicine, 48(6), 551–552.
Morris, A. R., Traube, D., Lakshmanan, A., West, A., & Saxbe, D. (2021). Perinatal mental
health during the COVID-19 pandemic: Evidence for heightened distress in pregnant
women highlights the need for novel interventions. PsyArXiv.
https://doi.org/10.31234/osf.io/j349z
24
Pfefferbaum, B., & North, C. S. (2020). Mental health and the COVID-19 pandemic. New
England Journal of Medicine, 383, 510–512. https://doi.org/10.1056/NEJMp2008017
Poon, L. C., Yang, H., Kapur, A., Melamed, N., Dao, B., Divakar, H., McIntyre, H. D., Kihara,
A. B., Ayres-de-Campos, D., Ferrazzi, E. M., & Di Renzo, G. C. (2020). Global interim
guidance on coronavirus disease 2019 (COVID-19) during pregnancy and puerperium
from FIGO and allied partners: Information for healthcare professionals. International
Journal of Gynecology & Obstetrics, 149(3), 273–286.
Saxbe, D., Rossin-Slater, M., & Goldenberg, D. (2018). The transition to parenthood as a critical
window for adult health. American Psychologist, 73(9), 1190–1200 https://
doi.org/10.1037/amp0000376
Schaul, K., Mayes, B. R., & Berkowitz, B. (2020, May 6). Where Americans are still staying at
home the most. The Washington Post. https://www.washingtonpost.com/
graphics/2020/national/map-us-still-staying-home-coro navirus/
Smarr, K. L., & Keefer, A. L. (2011). Measures of depression and depressive symptoms: Beck
Depression Inventory-II (BDI-II), Center for Epidemiologic Studies Depression Scale
(CES-D), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale
(HADS), and Patient Health Questionnaire-9 (PHQ-9). Arthritis Care & Research,
63(S11), S454–S466.
Spielberger, C. D. (2010). State-trait anxiety inventory. In The Corsini encyclopedia of
psychology (p. 1). John Wiley & Sons.
https://doi.org/10.1002/9780470479216.corpsy0943
25
Stein, A., Pearson, R. M., Goodman, S. H., Rapa, E., Rahman, A., McCallum, M., Howard, L.
M., & Pariante, C. M. (2014). Effects of perinatal mental disorders on the fetus and child.
The Lancet, 384(9956), 1800–1819.
Sut, H. K., & Kucukkaya, B. (2021). Anxiety, depression, and related factors in pregnant women
during the COVID-19 pandemic in Turkey: A web-based cross-sectional study.
Perspectives in Psychiatric Care, 57(2), 860–868. https://doi.org/10.1111/ppc.12627
Tendais, I., Costa, R., Conde, A., & Figueiredo, B. (2014). Screening for depression and anxiety
disorders from pregnancy to postpartum with the EPDS and STAI. The Spanish Journal
of Psychology, 17, Article E7. https://doi.org/10.1017/sjp.2014.7
Tran, N. T., Tappis, H., Spilotros, N., Krause, S., & Knaster, S. (2020). Not a luxury: A call to
maintain sexual and reproductive health in humanitarian and fragile settings during the
COVID-19 pandemic. The Lancet Global Health, 8(6), e760–e761.
Walsh, J., Hepper, E. G., & Marshall, B. J. (2014). Investigating attachment, caregiving, and
mental health: A model of maternal-fetal relationships. BMC Pregnancy and Childbirth,
14(1), Article 383. https://doi.org/10.1186/ s12884-014-0383-1
26
Table 1.1
Participant Characteristics and Demographics
Pandemic:
Full Sample
Pandemic:
First-Time Mothers
Pre-Pandemic
(all first-time
mothers)
Characteristic N = 572 N = 319 N = 99
Mother Age (years)
M = 32.21
(SD = 4.60)
M = 31.27
(SD = 4.67)
M = 31.19
(SD = 4.18)
Days Pregnant
M = 176.82
(SD = 61.27)
M = 171.46
(SD = 58.99)
M = 197.35
(SD = 29.14)
Reduced Social Contact Outside the
Household
M = 1.74
(SD = 0.82)
M = 1.83
(SD = 0.84)
-
Pandemic-Related Impact on Social
Relationships
M = 2.48
(SD = 0.91)
M = 2.51
(SD = 0.94)
-
Depressive Symptoms
M = 15.46
(SD = 9.22)
M = 15.91
(SD = 9.22)
M = 10.01
(SD = 5.93)
Anxiety
M = 48.05
(SD = 12.27)
M = 48.27
(SD = 11.81)
M = 30.25
(SD = 9.87)
Perceived Stress
M = 30.34
(SD = 5.43)
M = 30.11
(SD = 5.36)
M = 25.22
(SD = 4.64)
Prenatal Bonding
M = 3.74
(SD = 0.43)
M = 3.76
(SD = 0.45)
M = 3.98
(SD = 0.32)
Race / Ethnicity
White 80.2% (459) 80.6% (257) 47.5% (47)
Black / African American 5.4% (31) 5.0% (16) 5.1% (5)
American Indian / Alaska Native 0.3% (2) 0.6% (2) 1.0% (1)
Hispanic / Latino 6.1% (35) 5.3% (17) 24.2% (24)
Asian / Pacific Islander 5.6% (32) 6.9% (22) 17.2% (17)
Other / Decline to State 2.2% (13) 1.5% (5) 5.1% (5)
Highest Level of Education
High School / GED or less 7.7% (44) 5.8% (18) 2.0 (2)
Some College 10.1% (58) 8.5% (27) 8.1 (8)
Associate’s Degree 6.3% (36) 5.0% (16) 4.0 (4)
Bachelor’s Degree 29.0% (166) 33.2% (106) 38.4 (38)
Master’s Degree 26.0% (149) 26.6% (85) 36.4 (36)
Professional / Doctoral Degree 20.8% (119) 21.0% (67) 11.1 (11)
Note: Values are percentages with ns in parentheses unless otherwise indicated.
27
Table 1.2
Analysis of Covariance and for Pandemic and Pre-pandemic Samples on Measures of
Depressive Symptoms, Anxiety Symptoms, Perceived Stress, and Prenatal Bonding
Full Sample First-Time Mothers
Predictor df MS F p df MS F p
Depressive Symptoms
(BDI)
Intercept 1 5184.25 70.33
***
<.001 1 1961.68 28.59
***
<.001
Days Pregnant 1 44.83 .61 .436 1 0.13 0.002 .965
Racial/Ethnic Minority 1 188.73 2.56 .110 1 60.23 0.88 .349
Maternal Age 1 352.86 4.79
*
.029 1 40.62 0.59 .442
Maternal Education 1 777.29 10.54
**
.001 1 1456.34 21.22
***
<.001
Pandemic Group 1 1850.74 25.11
***
<.001 1 1967.61 28.67
***
<.001
Error 592 73.72 377 68.62
Anxiety Symptoms
(STAI-S)
Intercept 1 18984.42 134.71
***
<.001 1 12032.59 96.27
***
<.001
Days Pregnant 1 747.95 5.31
*
.022 1 628.39 5.03
*
.026
Racial/Ethnic Minority 1 80.02 0.57 .451 1 38.97 0.31 .577
Maternal Age 1 396.23 2.81 .094 1 20.67 0.17 .685
Maternal Education 1 413.36 2.93 .087 1 1475.92 11.81
***
<.001
Pandemic Group 1 23903.23 169.61
***
<.001 1 21448.71 171.61
***
<.001
Error 618 140.93 392 124.99
Perceived Stress
(PSS)
Intercept 1 9918.64 353.95
***
<.001 1 6748.34 257.14
***
<.001
Days Pregnant 1 118.88 4.24
*
.040 1 43.13 1.64 .201
Racial/Ethnic Minority 1 9.61 0.34 .558 1 0.19 0.01 .932
Maternal Age 1 151.09 5.39
*
.021 1 73.83 2.81 .094
Maternal Education 1 98.98 3.53 .061 1 212.45 8.10
**
.005
Pandemic Group 1 2091.09 74.62
***
<.001 1 1701.58 64.84
***
<.001
Error 649 28.02 405 26.24
Prenatal Bonding
(AEA)
Intercept 1 164.44 976.17
***
<.001 1 112.61 699.99
***
<.001
Days Pregnant 1 2.08 12.37
***
<.001 1 1.21 7.54
**
.006
Racial/Ethnic Minority 1 0.19 1.11 .292 1 0.17 1.08 .300
Maternal Age 1 3.03 17.99
***
<.001 1 6.20 38.51
***
<.001
Maternal Education 1 0.18 1.08 .299 1 1.61 10.01
**
.002
Pandemic Group 1 1.54 9.19
**
.003 1 0.77 4.80
*
.029
Error 577 0.17 355 0.16
Note:
*
p < 0.05;
**
p < 0.01;
***
p < 0.001
28
Table 1.3
Estimated Marginal Means for Pandemic and Pre-Pandemic Samples on Measures of
Depressive Symptoms, Anxiety Symptoms, Perceived Stress, and Prenatal Bonding
Full Sample First-Time Mothers
Pandemic Sample
Pre-Pandemic
Sample
Pandemic Sample
Pre-Pandemic
Sample
N M (SE) N M (SE) N M (SE) N M (SE)
Depressive
Symptoms
(BDI)
499
15.36
(0.40)
99
10.32
(0.91)
284
15.89
(0.51)
99
10.20
(0.89)
Anxiety
Symptoms
(STAI-S)
525
48.00
(0.52)
99
30.00
(1.26)
299
48.40
(0.66)
99
29.90
(1.20)
Perceived Stress
(PSS)
556
30.33
(0.23)
99
25.07
(0.56)
312
30.17
(0.30)
99
25.02
(0.54)
Prenatal
Bonding (AEA)
516
3.74
(0.02)
67
3.92
(0.05)
294
3.78
(0.02)
67
3.91
(0.05)
Note: Estimated marginal means are based on the analysis of covariance analyses shown
in Table 2
29
Table 1.4
Partial Correlations Between Social Impact and Contact and Mental Health and Bonding
Adjusted for Maternal Age, Days Pregnant, Racial/Ethnic Minority Status, and Educational
Attainment
Full Sample (N = 490) First-Time Mothers (N = 275)
Social Impact Social Contact Social Impact Social Contact
r p r p r p r p
Depressive
Symptoms (BDI) -.13
**
.005 .08 .086 -.14
*
.023 .14
*
.019
Anxiety Symptoms
(STAI-S) -.19
***
<.001 -.07 .147 -.19
**
.002 -.06 .309
Perceived Stress
(PSS) -.19
***
<.001 -.09
*
.046 -.24
***
<.001 -.08 .206
Prenatal Bonding
(AEA) .04 .375 -.16
***
<.001 .004 .946 -.18
**
.002
Note: Correlations are adjusted for maternal age, days pregnant, racial/ethnic minority status,
and educational attainment;
*
p < 0.05;
**
p < 0.01;
***
p < 0.001
30
30
STUDY 2
Prenatal Social Contact during the COVID-19 Pandemic is Associated with Infant Birth
Weight
Alyssa R. Morris, MA, Pia Sellery, BA, Van Truong, BA, Lila Haddan, Divya Jeyasingh, and
Darby E. Saxbe, PhD
31
Introduction
The COVID-19 pandemic drastically changed the experience of pregnancy, childbirth,
and parenthood for many families (Morris et al., 2022). Studies have found a higher prevalence
of adverse birth outcomes for individuals who contracted COVID-19 during pregnancy (Litman
et al., 2022); yet, even pregnant individuals who have not contracted COVID-19 are still affected
by the pandemic. Namely, many women pregnant during the pandemic have reported increases
in stress and reductions in social contact (Morris & Saxbe, 2021), a time when emotional and
instrumental support from friends and family is invaluable.
To date, no research has explored the relationship between social support and birth
weight during the COVID-19 pandemic, a time when social connection has been dramatically
affected. Initial work looking at rates of adverse birth outcomes during the COVID-19 pandemic
did not find increases in adverse birth outcomes in a large cohort of women who gave birth in the
U.S. during the first 16 months of the pandemic as compared to the prior year (Litman et al.,
2022). However, this overall finding may obscure an effect branching from more nuanced
differences at the individual level. The pandemic has affected individuals in a variety of different
ways depending on their lifestyles, making it likely that the pandemic-related effects on birth
outcomes are not universal, and may be related to differential changes in maternal social contact
and distress. Thus, work exploring birth outcomes during the pandemic in relation to changes in
social contact is needed. The current study examines the potential impact of maternal social
contact during the pandemic and infant birth weight.
Initial work shows that social support may play an important role in perinatal mental
health problems during the pandemic, with a study of Chinese women during the COVID-19
pandemic finding higher perceptions of social support to be significantly associated with lower
32
levels of anxiety (Yue et al., 2020). However, no work to date has explored the impact of
COVID-19-related decreases in prenatal social contact on infant birth outcomes.
Social Support and Birth Weight
Reductions in social support during the pandemic may have long-term consequences on
infant health. Research highlights that low levels of prenatal social support are a risk factor for
adverse birth outcomes, specifically low birth weight (Collins et al., 1993; Feldman et al., 2000;
Nkansah-Amankra et al., 2010; Orr, 2004; Wado et al., 2014). For example, in a study of 129
low-income pregnant women, researchers found that women with more extensive social
networks had babies with higher birth weights (Collins et al., 1993). Another study found that the
association between neighborhood disadvantage and low birth weight may be mediated by access
to social support, finding that low social support was an independent predictor of low birth
weight (Nkansah-Amankra et al., 2010). The relationship between low social support and low
birth weight has been shown in samples across the globe, including the United States (U.S.),
Ethiopia, Peru, Vietnam, and India (Feldman et al., 2000; Lee et al., 2019; Wado et al., 2014).
However, findings are still mixed. Researchers have found that greater social support is
associated with higher infant birth weight in women in foreign-born Latina women living in the
United States but not in European American or U.S.-born Latina women (Campos et al., 2008),
and other studies have failed to find any association between social support and birth weight
(Dunkel Schetter, 2011; Orr, 2004). Hence, while there is some evidence linking social support
and birth outcomes, more work is needed to explore associations between social support and
birth weight.
Perinatal Mental Health
33
There are multiple pathways by which prenatal social support may influence fetal health
and birth outcomes. Social support may motivate a mother to engage in positive health behaviors
that, in turn, improve her and her baby’s physical health (Campos et al., 2008). Alternatively,
social support may provide emotional, informational, and material resources to women during
pregnancy, a transitional period when information and support are essential (Bedaso et al., 2021;
Renbarger et al., 2021). One of the most compelling pathways by which maternal social contact
may be associated with infant birth weight is through impacts on prenatal stress, anxiety, and
depression. This may be due to increased fetal exposure to the stress hormone cortisol. Cortisol
is known to impact multiple facets of fetal development, including brain development (Beijers et
al., 2014; Glover, 2014, 2015). Additional potential pathways of effect include changes to
maternal immune activation, changes to maternal health behaviors (i.e., sleep, exercise, eating),
and genetic and epigenetic transmission (Beijers et al., 2014). While the exact mechanism is still
up for debate, and likely additive, there is clear evidence for the association between maternal
distress and offspring outcomes (Bussières et al., 2015; Rice et al., 2010; van den Bergh et al.,
2017).
Decreased prenatal social support may put women at risk for developing depression and
anxiety and reduce their ability to regulate stress (Bedaso et al., 2021; Dunkel Schetter, 2011;
Dunkel Schetter & Tanner, 2012; Duroux et al., 2021; Giesbrecht et al., 2013), and there is a
robust body of research linking prenatal mental health complications and infant birth
complications. In particular, there is strong evidence for a relationship between maternal
depression, anxiety, and stress, and infant birth weight (Dunkel Schetter, 2011; Field et al.,
2006). Infant birth weight is determined by both the degree of prematurity and the rate of fetal
growth, and recent work has highlighted the impacts of maternal mental health on both. For
34
example, research has shown that as exposure to prenatal stressful life events increases, infant
birth weight decreases (Wadhwa et al., 1993), and higher symptoms of depression and anxiety
are related to birth weight and growth (Bussières et al., 2015; Dunkel Schetter, 2011; Dunkel
Schetter & Tanner, 2012; Stein et al., 2014).
Moreover, there is strong evidence linking social isolation and loneliness to mental health
problems (Leigh-Hunt et al., 2017), and also evidence that mental health concerns have increased
during the pandemic, with studies finding that prenatal stress, anxiety, and depression are
substantially higher than levels in pre-pandemic groups (Caparros-Gonzalez & Alderdice, 2020;
Ceulemans et al., 2020; Corbett et al., 2020; Davenport et al., 2020; Groulx et al., 2021; Hessami
et al., 2020; Morris & Saxbe, 2021; Pfefferbaum & North, 2020). Research has documented that
40-44% of women pregnant during the COVID-19 pandemic reported low mood due to
loneliness and disconnection from friends and family (Farewell et al., 2020; Milne et al., 2020).
Thus, the relationship between social contact and low birth weight may be mediated by prenatal
distress.
A large body of research on natural disasters provides strong evidence from “natural
experiments” for the adverse effects of maternal prenatal stress on birth outcomes. A systematic
review of 49 studies of terrorist attacks, environmental/chemical disasters, and natural disasters
found that maternal prenatal disaster experience may reduce fetal growth (Harville et al., 2010).
More specifically, research on perinatal experiences during Hurricane Katrina and the World
Trade Center attacks of September 11th, 2001, found associations between perinatal stressors
and birth outcomes. One study found that women with high hurricane exposure during Hurricane
Katrina were at increased risk of having low birth weight infants and had higher rates of preterm
birth (Xiong et al., 2008). These authors highlight that severity and intensity of event exposure
35
may be the best predictor of adverse birth outcomes. Moreover, Lipkind and colleagues, who
studied birth outcomes of women pregnant during the World Trade Center Attacks, found that
expectant mothers who developed mental health problems following the attacks were more likely
to give birth to infants with lower birth weight and had higher rates of preterm birth (Lipkind et
al., 2010). These studies provide evidence that prenatal distress caused by large-scale societal
disruptions such as natural disasters are related to poorer birth outcomes, yet there is limited
research on the impacts of the most recent and widespread disruption, the COVID-19 pandemic.
Partner Relationship as a Buffer
The prenatal partner relationship may act as a buffer for the influence of prenatal stress
and mental health problems on infant outcomes (Rini et al., 2006). For example, researchers
found that depressed pregnant women who rate their relationship with their partner as more
supportive had better birth outcomes; they gave birth closer to 40 weeks gestation, and their
infants had higher Apgar scores upon delivery (Nylen et al., 2013). Thus, the quality of the
partner relationship during pregnancy may be protective for fetal development. The salience of
the partner relationship in buffering stress may be particularly important during the COVID-19
pandemic, given that pandemic lockdowns may have occasioned a reorganization of social
behavior. For example, during the first wave of lockdowns in spring 2020, we found that women
reported decreases in time with their larger social networks but increases in the time spent
interacting with their partners (Morris & Saxbe, 2021). Hence, the potential for partner
relationship satisfaction in buffering the effects of social disconnection on birth outcomes may
be particularly meaningful during the COVID-19 pandemic.
The Current Study
36
Given this background, the current study aims to explore birth outcomes in a sample of
infants born to individuals pregnant during the first wave of the COVID-19 pandemic.
Researchers have shown that prenatal social support is associated with infant birth weight
through processes involving fetal growth rather than the timing of delivery (Feldman et al.,
2000), and a systematic review found that disasters of various types may reduce fetal growth but
do not appear to affect gestational age at birth (Harville et al., 2010). Therefore, our key outcome
was birth weight adjusted for gestational age rather than birth weight or gestational age alone. To
our knowledge, this is the first study to explore the association between prenatal social contact
during the COVID-19 pandemic and infant birth weight, as well as the first to assess maternal
mental health as a mediator and prenatal relationship satisfaction as a moderator. The following
hypotheses were tested:
1. Women pregnant during the COVID-19 pandemic will report significant decreases in
social contact as compared to their pre-pandemic lifestyles.
2. Greater reductions in maternal prenatal social contact during the COVID-19
pandemic will be associated with lower infant birth weight.
3. Maternal prenatal stress, anxiety, and depressive symptoms will mediate the
relationship between social contact and birth weight.
4. Partner relationship satisfaction will moderate associations between social contact
and infant birth weight such that, among mothers who report lower prenatal
relationship satisfaction, the relationship between prenatal social contact and infant
birth weight will be stronger as compared with mothers who report higher prenatal
relationship satisfaction, for whom relationship satisfaction may buffer the
association for social contact and birth weight.
37
Methods
Pregnant individuals were recruited via social media, including posts on Twitter,
Facebook, and Instagram; online pregnancy/parenting groups and message boards; and paid
advertising on Facebook and Instagram to complete the online University of Southern California
Coronavirus, Health, Isolation, and Resiliency in Pregnancy (CHIRP) survey. Pregnant
individuals completed the prenatal survey during the first wave of the COVID-19 lockdowns in
the United States and were contacted to complete a follow-up survey at three-months
postpartum. Data collection began on April 6th, 2020, corresponding with peak “sheltering in
place” behavior in the United States (Schaul et al., 2020). We excluded prenatal data collected
after May 24th, 2020, from this analysis to avoid the potentially confounding mental health
effects of the widely reported murder of George Floyd on May 25th, 2020. Participants provided
consent and completed a 20–30-minute prenatal questionnaire through the Qualtrics platform and
were contacted again at three-months postpartum to complete a follow-up questionnaire.
Additionally, we requested consent to access birth records. All study procedures were approved
by the USC’s IRB (Institutional Review Board). Per IRB guidance, after completing the surveys,
participants were offered a downloadable list of mental health resources, including substance
abuse, suicide prevention, and domestic violence hotlines. Data were monitored for fraudulent
responses, and flagged data were excluded from all analyses. Responses were investigated if data
was invalid (i.e., four-digit zip code), the baby’s birthday exceeded their due date by over two
weeks, or there was a mismatch in data between prenatal and three-month surveys (i.e.,
respondents stated that they themselves were pregnant during the prenatal survey but that their
partner gave birth on the three-month survey). Additionally, participant emails were monitored
against fraudulent email lists, and the participant’s zip code was compared to their IP address.
38
Participants were contacted to clarify discrepancies and were excluded if major discrepancies
remained following attempted clarification.
Participants
Demographic data for participants can be found in Table 1. 366 women responded to
both the prenatal and three-month postpartum surveys, with a retention rate of 57.5% from
prenatal to postpartum. 36 of those cases were suspected to be fraudulent and excluded from the
analyses. An additional 17 subjects were excluded as they responded to the prenatal survey after
Mr. George Floyd’s murder, and 11 were excluded because they were living outside of the U.S.
We excluded an additional six subjects who had given birth to multiple infants (i.e., twins), a
factor which substantially impacts birth weight. To avoid any confounding effects of a COVID-
19 infection, we excluded 23 subjects who reported having a confirmed or suspected case of
COVID-19 at some point between the start of their pregnancy and three months postpartum.
While this may have captured subjects that contracted COVID-19 following birth, we did not
have granular enough data to distinguish the timing of COVID-19 infection, and thus, we took a
conservative approach in excluding all subjects who reported having COVID-19 at some point
prior to the three-month postpartum survey. Of the remaining 273 subjects, we excluded cases
without complete birth weight, social contact, and covariate data for a resulting sample size of
262. All subjects had complete prenatal stress data; however, because participants may have
skipped or dropped some measures or items, only 253 had complete anxiety symptoms data, 243
had complete depressive symptoms data, and 217 had complete relationship satisfaction data.
Demographic data for the current sample is shown in Table 1. Participants were recruited
at any point during pregnancy, with 6.6% of the sample in their first trimester, 50.2% in their
second trimester, and 43.2% in their third trimester of pregnancy. Of note, this sample was
39
predominantly white (80.8%) and highly educated, with 85.2% of the sample having a bachelor’s
degree or higher.
Measures
Birth Weight
As part of the three-month survey, participants were asked to report their infant’s weight
at birth in pounds and ounces, due date, and birth date. Reported birth weights were converted to
grams, and gestational age at birth was determined using birth date and due date. Adjusted birth
weight was calculated as birth weight divided by gestational age at birth.
We also asked participants to sign a release of information allowing the study team to
access their medical birth records directly from the hospital or birth center where the participant
delivered. For the 25.9% of the sample (54 participants) for whom we were able to obtain
medical birth records at the time of manuscript preparation, we compared participant-reported
with chart-reported birth weight. On average, mothers’ reports were within 0.78% of the birth
record recorded birth weight, with 88.9% of mothers reporting their infant’s birth weight within
1% of the birth record reported weight, with a range of 0% - 10% difference and median of 0.2%
difference. Additionally, 94.5% of parents reported gestational age at birth within three days of
the birth record report. These statistics confirm that our parent-reported data is largely accurate.
Of note, we only had information on infant sex for the subjects with birth record data. Because
we could not control for infant sex in our larger analyses, we confirmed that maternal prenatal
social contact was not systematically different based on infant sex in those with medical record
data; t(56) = -1.08, p = .283.
Social Connection
40
COVID-19 impacts on prenatal social contact were assessed by asking participants in the
pandemic group, “As compared to before COVID-19, how much total contact (including in-
person, phone, or online) do you have with …” 1) neighbors/community members, 2) coworkers,
3) friends, and 4) family. Responses were given on a five-point scale (“1, much less” to “5, much
more”), and a social contact score was created by averaging their responses across each of the
four sets of contacts. Reliability for our social contact score within our current sample was
acceptable (Cronbach’s alpha = .75).
Depressive Symptoms
Parental prenatal depressive symptoms were measured using the Beck Depression
Inventory-II (BDI-II; Beck et al., 1996), a 21-item self-report questionnaire that has been
comprehensively validated and widely used to assess mental and somatic complaints related to
depression, including loss of pleasure and changes to sleep and appetite. Respondents rate items
on a four-point scale ranging from “0, not at all” to “3, severely.” Scores are summed for a total
score ranging from 0 to 63, with higher scores indicating worse depressive symptomatology.
Anxiety Symptoms
Prenatal anxiety symptoms were assessed using the State Anxiety Inventory (STAI;
Spielberger, 2010), a widely used and well-validated instrument to assess current “state” or
momentary feelings of anxiety. Participants rate 20 items, such as “I feel nervous” and “I am
tense,” using a four-point scale (ranging from “Not at all” to “Very much so”). Responses
summed for a total score ranging from 20 to 80, with higher scores reflecting more anxiety
symptoms.
Stress
41
Prenatal stress was measured using the Perceived Stress Scale 14 (PSS-14; Cohen et al.,
1983). This is an extended version of the most widely used psychological instrument for
measuring perceived stress (the 10-item Perceived Stress Scale; Cohen et al., 1994) and includes
14 self-report items assessing the frequency of feelings around coping, emotion control, and
unexpected events. Responses for each question range from “0, never” to “4, almost always,”
and are summed for a score ranging from 0 to 56, with higher scores reflecting higher
perceptions of stress.
Partner Relationship Quality
Partner relationship quality is measured using the brief dyadic adjustment scale (DAS-7;
Spanier, 1976). This is a 7-item self-report measure that has been established as a well-validated
measure of romantic relationship quality. This scale includes a range of questions that assess
frequency and levels of disagreement, closeness and affection, and overall satisfaction in the
relationship. Total scores range from 0 to 36, with higher scores reflecting greater relationship
quality. Scores less than 21 are indicative of relationship distress (Hunsley et al., 2001), and this
cut-off was used to designate high and low relationship satisfaction.
Analyses
All analyses were conducted in IBM SPSS version 28 (IBM Corp., 2022). Zero-order
correlations, presented in Table 2, were used to assess relationships between all study variables
of interest. Assumptions of regression were tested through statistical testing and visual
inspection. Assumptions of homoskedasticity, normality, and linearity were adequately met, and
participant responses were assumed to be independent. Two low-birth-weight outliers were
identified and confirmed to be valid entries. Given the purpose of this study to assess for
associations between decreased social contact and lower birth weight, low-birth weight outliers
42
were not excluded from the analyses. Bootstrapping techniques with 5000 bootstrap samples
were used for all analyses to deal with outliers and to produce more robust results. Linear
regression was used to assess the association between social contact and birth weight. The
PROCESS macro (Hayes, 2017) was used to test for mediation effects (using PROCESS model
4) of each of our mental health variables and simple moderation effects (using PROCESS model
1) of relationship satisfaction. All variables were mean-centered prior to mediation and
moderation analyses. All regression, moderation, and mediation analyses were conducted,
controlling for days of fetal exposure to the pandemic, maternal age, first-time parenthood,
highest maternal education, and maternal identification as non-White. As shown in Table 2, birth
weight was not significantly associated with any single racial/ethnic identification within our
sample; however, to account for the impacts of experienced racism and discrimination, we felt it
important to include a covariate reflecting this. For parsimony, identification as non-White was
included in all models. Additional covariates included in our models, regardless of zero-order
correlation, included maternal age, first-time parenthood, and maternal education due to well-
established associations between these factors and birth weight (Buka et al., 2003; Goldenberg &
Culhane, 2007; Norbeck & Jean Anderson, 1989; Rini et al., 1999). Finally, variations in fetal
exposure to the pandemic were accounted for by including a “fetal exposure” variable, which
was calculated as the number of days between March 11
th
, 2020, the day the World Health
Organization declared COVID-19 a pandemic, and the infant’s birth date, as this may have
impacted the duration of prenatal social contact changes within the pandemic group.
Results
Social Contact During COVID-19
43
As shown in Table 3 and Figure 1, individuals pregnant during the first wave of the
COVID-19 pandemic indicated declines in the amount of time interacting with friends, family,
coworkers, and community as compared to before the pandemic. Between nearly 50% and 60%
of respondents indicated they had much less social contact with family, friends, coworkers, and
their greater community as compared with before the pandemic.
Social Contact and Birth Weight
Regression results are shown in Table 4. Consistent with our expectations, women who
reported that their social contact decreased during the pandemic subsequently delivered infants
of lower birth weight (B=76.69.09, SE = 37.31, p=.039).
Mental Health
As shown in Table 2, zero-order correlations indicate that higher depressive and anxious
symptoms are significantly associated with lower birth weight. Consistent with our hypothesis,
maternal prenatal depressive symptoms mediated the relationship between prenatal social contact
and birth weight, as the indirect effect of prenatal depressive symptoms on infant birth weight
was found to be statistically significant [Effect = 15.41, 95% CI (0.93, 36.54)]. Contrary to our
expectations, neither prenatal maternal anxiety symptoms nor stress mediated the association
between pandemic-related decreases in social contact and infant birth weight, as the indirect
effects of models testing the mediation of anxiety symptoms [95% CI (-0.71, 33.53] and stress
[95% CI (-1.66, 26.90)] both contained zero.
Relationship Satisfaction
Contrary to our expectations, maternal prenatal relationship satisfaction did not moderate
the association between social contact and infant birth weight [B= -174.34, 95% CI (-502.84,
154.16), p = .297].
44
Discussion
We found that the majority of women pregnant during the COVID-19 pandemic reported
substantial declines in the amount of time interacting with friends, family, coworkers, and
community members as compared to before the pandemic, and greater decreases in overall social
contact were associated with lower infant birth weights. Moreover, we found that prenatal
maternal depressive symptoms mediated the relationship between social contact and infant birth
weight. Hence, while it seems that social connection is, at first glance, a predictor of birth
weight, depressive symptoms may explain much of this association. Contrary to our
expectations, neither prenatal anxiety symptoms nor stress mediated the association between
prenatal social contact and infant birth weight. Furthermore, prenatal relationship satisfaction did
not moderate the association between social contact and infant birth weight.
Our finding that decreased prenatal social contact was associated with lower infant birth
weight highlights that contextual factors related to social distancing and social restricting during
the COVID-19 pandemic are important and relevant for birth outcomes. This finding furthers the
literature on social support, providing further evidence for the relationship between social
contact and birth weight, and extending the literature to explore the association during a period
when social contact is particularly disturbed. Further, our finding that depressive symptoms
mediated the association between prenatal social contact and infant birth weight is consistent
with the robust body of research connecting maternal mental health and birth outcomes and
suggests that social contact during the pandemic may not be directly influencing infant health,
but rather, may be affecting maternal and infant health outcomes via influences on maternal
mental health. As social behavior continues to be affected by the COVID-19 pandemic,
continued focus on social contact and maternal mental health must be considered in fields
45
interacting with perinatal populations. Finally, our findings suggest that partner relationship
quality did not appear to buffer the relationship between social disconnection and infant birth
weight.
Taken together, our findings suggest that interventions aimed at strengthening prenatal
social support and reducing depressive symptoms may be useful in supporting maternal and
infant health during the COVID-19 pandemic. Decades of research have shown that
interventions designed to increase maternal social support may show promise in improving birth
outcomes (Norbeck et al., 1996; Oakley, 1985). A randomized clinical trial of African American
women identified at risk for giving birth to infants with low birth weight found that a four-
session intervention aimed at providing social support through face-to-face conversations about
areas of need and related supports, meaning-making around the pregnancy, and self-esteem, was
effective in reducing the rate of low birth weight (Norbeck et al., 1996). Additional research has
emphasized the importance of identifying women’s social support needs during pregnancy
(Eapen et al., 2019). Given our findings of decreased social contact during the COVID-19
pandemic, special attention should be paid to the continued health of parents and infants born
during this period.
Strengths
Our study has a number of strengths. This study is the first to explore the relationship
between pandemic-related changes in social contact and maternal prenatal mental health with
birth outcomes among infants born during the first year of COVID-19 pandemic lockdowns.
Additionally, because the risk of contracting COVID-19 increases with more social contact, it
can be difficult to tease apart the impacts of decreased social contact and COVID-19 infection-
related outcomes. A major strength of this study is that we assessed pregnant women within the
46
first few months of the COVID-19 pandemic, when a small percentage of the population had
contracted COVID-19, and also asked our participants if they had developed COVID-19 again at
three months postpartum. We were able to exclude the limited number of suspected or confirmed
positive COVID-19 cases and circumvent the confounding relationship between social contact
and COVID-19 infection.
Another strength of this study was the exploration of birth weight adjusted for gestational
age rather than gestational age at birth or birth weight alone. This allows us to understand
potential mechanisms related to fetal growth rather than simply measuring the degree of
prematurity. Our findings are consistent with previous work finding that prenatal social support
is associated with infant birth weight through processes involving fetal growth rather than the
delivery timing (Feldman et al., 2000), as well as previous research showing that natural
disasters may reduce fetal growth, but do not appear to impact gestational age at birth (Harville
et al., 2010).
Limitations
Responses to this online survey came from a well-educated convenience sample recruited
across social media platforms. Given well-documented associations between higher
socioeconomic status and perinatal mental health in the U.S., we expect that a lower-SES sample
might reveal even more striking levels of mental health vulnerability. Indeed, the pandemic has
had disproportionate effects on African-American and Latinx individuals, who were
underrepresented in our sample (Evans, 2020; Tai et al., 2020). Therefore, the need for mental
health services is likely even more acute than reflected in our data.
Additionally, given the online method of recruitment, there is the possibility that
ineligible participants responded to our questionnaire or that respondents provided inaccurate
47
information. While this is a possibility, the study team developed and followed an extensive
protocol for identifying fraudulent data. Additionally, our comparison of a subset of the sample
with birth record data provides us with confidence in the accuracy of responses. Another
limitation with maternal report data is that mothers with more negative response bias are likely to
report more prenatal mental health problems, more social disconnection, and poorer infant
outcomes. As such, participant perception creates a confounding factor that must be
acknowledged as a limitation.
It is important to acknowledge that we did not have complete data for infant sex at birth,
a factor that impacts birth weight, and we could not control for this factor in our analyses.
However, for those with birth weight data available, maternal prenatal social contact was not
systematically different based on infant sex. Given this, we believe that infant sex would not
influence our conclusions.
Finally, our analyses tested the potential mediating effects of prenatal distress in the
association between social contact and birth weight. This design assumes that decreases in social
contact during the pandemic lead to distress; however, it is also possible that distress and fear
during the pandemic lead to decreases in social contact. Because we assessed social contact and
distress at the same time point, we cannot conclusively determine the directionality of this
relationship. However, the naturalistic design assessing these factors during the COVID-19
pandemic, when local and national restrictions were placed on social contact, provides a strong
basis for our interpretation. Future work should explore the directionality of the impacts of
distress and social contact during the COVID-19 pandemic by assessing each at multiple time
points.
Future Directions
48
Future studies should further probe the relationships between maternal prenatal social
contact and mental health during the COVID-19 pandemic and infant birth weight. For example,
it would be valuable to explore whether decreases in social contact during the COVID-19
pandemic drive symptoms of depression in pregnant individuals or if prenatal depression during
the pandemic contributes to further social withdrawal, and how much each factor may contribute
to infant birth weight. Additionally, future work may aim to understand additional factors that
may play a role, such as how differences in rates of COVID-19 in various communities may
impact this relationship.
As COVID-19 shifts to an endemic illness and we see lasting impacts on our social
world, the enduring impact of parental social connections and mental health on child
development should be considered. Previous research has shown that maternal mental health
during the first year postpartum may affect child physical development (Farías-Antúnez et al.,
2018), warranting continued exploration of the effects of parental social connection and mental
health on child’s growth and health.
Conclusion
Self-reported decreases in social contact in pregnant individuals during the COVID-19
pandemic predicted lower infant birth weight. Maternal prenatal depressive symptoms mediated
the relationship between prenatal social contact and infant birth weight, suggesting that
depressive symptoms related to decreases in social contact may drive reductions in birth weight.
Surprisingly, neither prenatal anxiety symptoms nor stress mediated the association between
social contact and infant birth weight, and partner relationship quality did not appear to buffer
the impacts of maternal prenatal social contact on infant birth weight. These findings highlight
49
how social contact and maternal mental health during the COVID-19 pandemic may impact birth
outcomes.
50
References
Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck depression inventory–II. Psychological
Assessment.
Bedaso, A., Adams, J., Peng, W., & Sibbritt, D. (2021). The relationship between social support and
mental health problems during pregnancy: a systematic review and meta-analysis. Reproductive
Health 2021 18:1, 18(1), 1–23. https://doi.org/10.1186/S12978-021-01209-5
Beijers, R., Buitelaar, J. K., & de Weerth, C. (2014). Mechanisms underlying the effects of prenatal
psychosocial stress on child outcomes: beyond the HPA axis. European Child and Adolescent
Psychiatry, 23(10), 943–956. https://doi.org/10.1007/s00787-014-0566-3
Buka, S. L., Brennan, R. T., Rich-Edwards, J. W., Raudenbush, S. W., & Earls, F. (2003).
Neighborhood support and the birth weight of urban infants. American Journal of Epidemiology,
157(1), 1–8. https://doi.org/10.1093/AJE/KWF170
Bussières, E. L., Tarabulsy, G. M., Pearson, J., Tessier, R., Forest, J. C., & Giguère, Y. (2015).
Maternal prenatal stress and infant birth weight and gestational age: A meta-analysis of
prospective studies. Developmental Review, 36, 179–199.
https://doi.org/10.1016/j.dr.2015.04.001
Campos, B., Schetter, C. D., Abdou, C. M., Hobel, C. J., Glynn, L. M., & Sandman, C. A. (2008).
Familialism, social support, and stress: positive implications for pregnant Latinas. Cultural
Diversity and Ethnic Minority Psychology, 14(2), 155–162. https://doi.org/10.1037/1099-
9809.14.2.155
Caparros-Gonzalez, R. A., & Alderdice, F. (2020). The COVID-19 pandemic and perinatal mental
health. Journal of Reproductive and Infant Psychology, 38(3), 223–225.
https://doi.org/10.1080/02646838.2020.1786910
51
Ceulemans, M., Hompes, T., & Foulon, V. (2020). Mental health status of pregnant and breastfeeding
women during the COVID‐19 pandemic: A call for action. International Journal of Gynecology
& Obstetrics, 151(1), 146–147. https://doi.org/10.1002/ijgo.13295
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of
Health and Social Behavior, 24(4), 385–396. https://doi.org/10.2307/2136404
Cohen, S., Kamarck, T., & Mermelstein, R. (1994). Perceived stress scale. Measuring Stress: A Guide
for Health and Social Scientists, 10, 1–2.
Collins, N. L., Dunkel Schetter, C., Lobel, M., & Scrimshaw, S. (1993). Social support in pregnancy:
Psychosocial correlates of birth outcomes and postpartum depression. Journal of Personality and
Social Psychology. https://doi.org/10.1037/0022-3514.65.6.1243
Corbett, G. A., Milne, S. J., Hehir, M. P., Lindow, S. W., & O’connell, M. P. (2020). Health anxiety
and behavioural changes of pregnant women during the COVID-19 pandemic. European Journal
of Obstetrics and Gynecology and Reproductive Biology, 249, 96–97.
https://doi.org/10.1016/j.ejogrb.2020.04.022
Davenport, M. H., Meyer, S., Meah, V. L., Strynadka, M. C., & Khurana, R. (2020). Moms are not
OK: COVID-19 and maternal mental health. Frontiers in Global Women’s Health, 1.
https://doi.org/10.3389/FGWH.2020.00001
Dunkel Schetter, C. (2011). Psychological science on pregnancy: stress processes, biopsychosocial
models, and emerging research issues. Annual Review of Psychology, 62, 531–558.
https://doi.org/10.1146/annurev.psych.031809.130727
Dunkel Schetter, C., & Tanner, L. (2012). Anxiety, depression and stress in pregnancy: Implications
for mothers, children, research, and practice. Current Opinion in Psychiatry, 25(2), 141–148.
https://doi.org/10.1097/YCO.0b013e3283503680
52
Duroux, M., Stuijfzand, S., Sandoz, V., & Horsch, A. (2021). Investigating prenatal perceived support
as protective factor against adverse birth outcomes: a community cohort study. Journal of
Reproductive and Infant Psychology. https://doi.org/10.1080/02646838.2021.1991565
Eapen, D. J., Wambach, K., & Domian, E. W. (2019). A qualitative description of pregnancy-related
social support experiences of low-income women with low birth weight infants in the midwestern
United States. 23, 1473–1481. https://doi.org/10.1007/s10995-019-02789-2
Evans, M. K. (2020). COVID’s color line — Infectious disease, inequity, and racial justice. New
England Journal of Medicine, 383(5), 408–410. https://doi.org/10.1056/NEJMp2019445
Farewell, C. v., Jewell, J., Walls, J., & Leiferman, J. A. (2020). A mixed-methods pilot study of
perinatal risk and resilience during COVID-19. Journal of Primary Care and Community Health,
11, 215013272094407. https://doi.org/10.1177/2150132720944074
Farías-Antúnez, S., Xavier, M. O., & Santos, I. S. (2018). Effect of maternal postpartum depression
on offspring’s growth. Journal of Affective Disorders, 228, 143–152.
https://doi.org/10.1016/J.JAD.2017.12.013
Feldman, P. J., Dunkel Schetter, C., Sandman, C. A., & Wadhwa, P. D. (2000). Maternal social
support predicts birth weight and fetal growth in human pregnancy. Psychosomatic Medicine,
62(5), 715–725.
Field, T., Diego, M., & Hernandez-Reif, M. (2006). Prenatal depression effects on the fetus and
newborn: a review. Infant Behavior and Development, 29(3), 445–455.
https://doi.org/10.1016/J.INFBEH.2006.03.003
Giesbrecht, G. F., Poole, J. C., Letourneau, N., Campbell, T., & Kaplan, B. J. (2013). The buffering
effect of social support on hypothalamic-pituitary-adrenal axis function during pregnancy.
Psychosomatic Medicine, 75(9), 856–862. https://doi.org/10.1097/PSY.0000000000000004
53
Glover, V. (2014). Maternal depression, anxiety and stress during pregnancy and child outcome; what
needs to be done. Best Practice and Research: Clinical Obstetrics and Gynaecology, 28(1), 25–
35. https://doi.org/10.1016/j.bpobgyn.2013.08.017
Glover, V. (2015). Prenatal stress and its effects on the fetus and the child: possible underlying
biological mechanisms. In Advances in Neurobiology (Vol. 10, pp. 269–283). Springer New
York LLC. https://doi.org/10.1007/978-1-4939-1372-5_13
Goldenberg, R. L., & Culhane, J. F. (2007). Low birth weight in the United States. The American
Journal of Clinical Nutrition, 85(2), 584S-590S. https://doi.org/10.1093/AJCN/85.2.584S
Groulx, T., Bagshawe, M., Giesbrecht, G., Tomfohr-Madsen, L., Hetherington, E., & Lebel, C. A.
(2021). Prenatal care disruptions and associations with maternal mental health during the
COVID-19 pandemic. Frontiers in Global Women’s Health, 2(April), 1–8.
https://doi.org/10.3389/fgwh.2021.648428
Harville, E., Xiong, X., & Buekens, P. (2010). Disasters and perinatal health: A systematic review.
Obstetrical and Gynecological Survey, 65(11), 713–728.
https://doi.org/10.1097/OGX.0b013e31820eddbe
Hayes, A. F. (2017). Introduction to mediation, moderation, and conditional process analysis: A
regression-based approach. Guilford publications.
Hessami, K., Romanelli, C., Chiurazzi, M., & Cozzolino, M. (2020). COVID-19 pandemic and
maternal mental health: a systematic review and meta-analysis. The Journal of Maternal-Fetal &
Neonatal Medicine. https://doi.org/10.1080/14767058.2020.1843155
IBM Corp. (2022). IBM SPSS Statistics for Macintosh (Version 28.0). IBM Corp.
Lee, H.-Y., Oh, J., Perkins, J. M., Heo, J., & Subramanian, S. v. (2019). Associations between
maternal social capital and infant birth weight in three developing countries: a cross-sectional
54
multilevel analysis of Young Lives data. BMJ Open, 9(10), e024769.
https://doi.org/10.1136/bmjopen-2018-024769
Leigh-Hunt, N., Bagguley, D., Bash, K., Turner, V., Turnbull, S., Valtorta, N., & Caan, W. (2017).
An overview of systematic reviews on the public health consequences of social isolation and
loneliness. Public Health, 152, 157–171. https://doi.org/10.1016/j.puhe.2017.07.035
Lipkind, H. S., Curry, A. E., Huynh, M., Thorpe, L. E., & Matte, T. (2010). Birth outcomes among
offspring of women exposed to the September 11, 2001, terrorist attacks. Obstetrics &
Gynecology, 116(4), 917–925. https://doi.org/10.1097/AOG.0b013e3181f2f6a2
Litman, E. A., Yin, Y., Nelson, S. J., Capbarat, E., Kerchner, D., & Ahmadzia, H. K. (2022). Adverse
perinatal outcomes in a large United States birth cohort during the COVID-19 pandemic.
American Journal of Obstetrics & Gynecology MFM, 4(3), 100577.
https://doi.org/10.1016/J.AJOGMF.2022.100577
Milne, S. J., Corbett, G. A., Hehir, M. P., Lindow, S. W., Mohan, S., Reagu, S., Farrell, T., &
O’Connell, M. P. (2020). Effects of isolation on mood and relationships in pregnant women
during the covid-19 pandemic. Journal of Cleaner Production, 252, 610.
https://doi.org/10.1016/j.ejogrb.2020.06.009
Morris, A. R., Herzig, S. E., Orozco, M., Truong, V., Campuzano, V., Sridhara, S., Sellery, P., &
Saxbe, D. E. (2022). Delivering alone in a pandemic: Anticipated changes to partner presence at
birth are associated with prenatal distress. Families, Systems & Health: The Journal of
Collaborative Family Healthcare, 40(1), 126–131. https://doi.org/10.1037/fsh0000679
Morris, A. R., & Saxbe, D. E. (2021). Mental health and prenatal bonding in pregnant women during
the COVID-19 pandemic: Evidence for heightened risk compared with a prepandemic sample.
Clinical Psychological Science. https://doi.org/10.1177/21677026211049430
55
Nkansah-Amankra, S., Dhawain, A., Hussey, J. R., & Luchok, K. J. (2010). Maternal social support
and neighborhood income inequality as predictors of low birth weight and preterm birth outcome
disparities: Analysis of South Carolina pregnancy risk assessment and monitoring system survey,
2000-2003. Maternal and Child Health Journal, 14(5), 774–785. https://doi.org/10.1007/s10995-
009-0508-8
Norbeck, J. S., Dejoseph, J. F., & Smith, R. T. (1996). A randomized trial of an empirically-derived
social support intervention to prevent low birthweight among African American women. Social
Science and Medicine, 43(6), 947–954. https://doi.org/10.1016/0277-9536(96)00003-2
Norbeck, J. S., & Jean Anderson, N. (1989). Psychosocial predictors of pregnancy outcomes in low-
income black, Hispanic, and white women. Nursing Research, 38(4), 204–209.
https://doi.org/10.1097/00006199-198907000-00004
Nylen, K. J., O’Hara, M. W., & Engeldinger, J. (2013). Perceived social support interacts with
prenatal depression to predict birth outcomes. Journal of Behavioral Medicine, 36(4), 427–440.
https://doi.org/10.1007/s10865-012-9436-y
Oakley, A. (1985). Social support in pregnancy: The “soft” way to increase birthweight? Social
Science and Medicine, 21(11), 1259–1268. https://doi.org/10.1016/0277-9536(85)90275-8
Orr, S. T. (2004). Social support and pregnancy outcome: A review of the literature. Clinical
Obstetrics and Gynecology, 47(4), 842–855.
https://doi.org/10.1097/01.GRF.0000141451.68933.9F
Pfefferbaum, B., & North, C. S. (2020). Mental health and the COVID-19 pandemic. The New
England Journal of Medicine, 383(6), 510–512. https://doi.org/10.1056/NEJMp2008017
56
Renbarger, K. M., Place, J. M., & Schreiner, M. (2021). The influence of four constructs of social
support on pregnancy experiences in group prenatal care. Women’s Health Reports, 2(1), 154.
https://doi.org/10.1089/WHR.2020.0113
Rice, F., Harold, G. T., Boivin, J., Van Den Bree, M., Hay, D. F., & Thapar, A. (2010). The links
between prenatal stress and offspring development and psychopathology: Disentangling
environmental and inherited influences. Psychological Medicine, 40(2), 335–342.
https://doi.org/10.1017/S0033291709005911
Rini, C., Dunkel Schetter, C., Hobel, C. J., Glynn, L. M., & Sandman, C. A. (2006). Effective social
support: Antecedents and consequences of partner support during pregnancy. Personal
Relationships, 13(2), 207–229. https://doi.org/10.1111/J.1475-6811.2006.00114.X
Rini, C. K., Dunkel Schetter, C., Wadhwa, P. D., & Sandman, C. A. (1999). Psychological adaptation
and birth outcomes: the role of personal resources, stress, and sociocultural context in pregnancy.
Health Psychology, 18(4), 333.
Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage
and similar dyads. Journal of Marriage and the Family, 38(1), 15.
https://doi.org/10.2307/350547
Spielberger, C. D. (2010). State‐Trait Anxiety Inventory. The Corsini Encyclopedia of Psychology, 1.
Stein, A., Pearson, R. M., Goodman, S. H., Rapa, E., Rahman, A., McCallum, M., Howard, L. M., &
Pariante, C. M. (2014). Effects of perinatal mental disorders on the fetus and child. The Lancet,
384(9956), 1800–1819. https://doi.org/10.1016/S0140-6736(14)61277-0
Tai, D. B. G., Shah, A., Doubeni, C. A., Sia, I. G., & Wieland, M. L. (2020). The disproportionate
impact of COVID-19 on racial and ethnic minorities in the United States. Clinical Infectious
Diseases. https://doi.org/10.1093/cid/ciaa815
57
van den Bergh, B. R. H., van den Heuvel, M. I., Lahti, M., Braeken, M., de Rooij, S. R., Entringer, S.,
Hoyer, D., Roseboom, T., Räikkönen, K., King, S., & Schwab, M. (2017). Prenatal
developmental origins of behavior and mental health: The influence of maternal stress in
pregnancy. Neuroscience and Biobehavioral Reviews.
https://doi.org/10.1016/j.neubiorev.2017.07.003
Wadhwa, P. D., Sandman, C. A., Porto, M., Dunkel-Schetter, C., & Garite, T. J. (1993). The
association between prenatal stress and infant birth weight and gestational age at birth: A
prospective investigation. American Journal of Obstetrics and Gynecology, 169(4), 858–865.
https://doi.org/10.1016/0002-9378(93)90016-C
Wado, Y. D., Afework, M. F., & Hindin, M. J. (2014). Effects of maternal pregnancy intention,
depressive symptoms and social support on risk of low birth weight: A prospective study from
Southwestern Ethiopia. PLoS ONE, 9(5). https://doi.org/10.1371/JOURNAL.PONE.0096304
Xiong, X., Harville, E. W., Mattison, D. R., Elkind-Hirsch, K., Pridjian, G., & Buekens, P. (2008).
Exposure to Hurricane Katrina, post-traumatic stress disorder and birth outcomes. American
Journal of the Medical Sciences, 336(2), 111–115.
https://doi.org/10.1097/MAJ.0b013e318180f21c
Yue, C., Liu, C., Wang, J., Zhang, M., Wu, H., Li, C., & Yang, X. (2020). Association between social
support and anxiety among pregnant women in the third trimester during the coronavirus disease
2019 (COVID-19) epidemic in Qingdao, China: The mediating effect of risk perception.
International Journal of Social Psychiatry. https://doi.org/10.1177/0020764020941567
58
Table 2.1
Demographics
Pre-Pandemic Pandemic
Demographics / Characteristics n Mean SD n Mean SD
Social Contact Score - - - 262 1.84 0.83
Birth Weight 75 3356.14 350.66 262 3397.43 481.28
Days Pregnant at Prenatal Survey 75 203.77 26.73 262 180.57 59.00
Days of Fetal Exposure to Pandemic 75 0 0.00 262 128.78 58.30
Maternal Age (years) 75 31.76 4.19 262 32.50 4.15
Depressive Symptoms 75 9.69 5.70 243 14.14 8.58
Anxiety State Symptoms 75 28.60 8.55 253 47.08 12.68
Stress Symptoms 75 21.17 6.25 262 28.42 7.91
n % n %
First Time Parents 75 100 141 53.8
Trimester at Prenatal Survey
First 0 0.0 17 6.5
Second 28 37.3 132 50.4
Third 47 62.7 113 43.1
Race / Ethnicity
White 36 48.0 210 80.2
Black 4 5.3 16 6.1
Hispanic / Latinx 15 20.0 20 7.6
American Indian / Alaska Native 1 1.3 0 0.0
Asian / Pacific Islander 14 18.7 12 4.6
Multiracial / Other 5 6.7 4 1.5
Education
Did Not Complete High School 0 0.0 1 0.4
High School Degree / GED 1 1.3 15 5.7
Some College 6 8.0 10 3.8
Associate Degree 2 2.7 10 3.8
Bachelor’s Degree 27 36.0 74 28.2
Master’s Degree 32 42.7 82 31.3
Professional / Doctoral Degree 7 9.3 70 26.7
59
Table 2.2
Zero-Order Correlations.
1 2 3 4 5 6 7 8 9
1. Birth Weight -
2. Social Contact .13* -
3. Depressive
Symptoms
-.18** -.17** -
4. Anxiety
Symptoms
-.14* -.16* .60** -
5. Stress
Symptoms
-.11 -.16* .65** .74** -
6. Days of Fetal
Exposure to
Pandemic
-.07 .05 -.05 -.13* -.13* -
7. Maternal Age .00 -.03 -.22** -.12 -.13* -.10 -
8. First Time
Parent
.12 -.08 .02 -.03 .05 -.15* .22** -
9. Highest
Education
.02 .07 -.22** -.01 -.07 .07 .33** -.07 -
10. Minority
Status
.06 .03 -.04 -.06 -.07 .12 -.07 -.02 -.02
11. Black .03 .11 -.10 -.12 -.09 .12 .00 -.01 -.07
12. Hispanic /
Latina
.03 -.15* .04 .03 .04 .03 -.16** .02 -.12
13. Asian /
Pacific Islander
.06 .18** -.08 -.08 -.12 .05 .07 -.09 .17**
14. Multiracial /
Other
-.02 -.10 .09 .07 .07 .02 .02 .07 .02
Note: * p < 0.05; ** p < .01
60
Table 2.3
Changes to Social Contact, Breakdown by Type of Social Group
Social Group
Much Less
% (n)
Somewhat Less
% (n)
About the Same
% (n)
Somewhat More
% (n)
Much More
% (n)
Family 48.9 (128) 16.8 (44) 20.2 (53) 10.7 (28) 3.4 (9)
Friends 57.3 (150) 20.6 (54) 13.0 (34) 6.9 (18) 2.3 (6)
Coworkers 59.5 (156) 17.9 (47) 17.2 (45) 2.3 (6) 3.1 (8)
Community 55.3 (145) 16.8 (44) 19.1 (50) 5.7 (15) 3.1 (8)
61
Table 2.4
Regression analyses with 5000 bootstrap samples predicting birth weight based on social contact within
the pandemic group (n = 262). R
2
= .02, F(6, 261) = 1.82, p = .095.
Model Variables B SE p CI (95%)
Constant
3199.62 237.62 <.001 2709.05, 3650.21
Social Contact 76.69 37.31 0.039 3.12, 148.54
Fetal Exposure to Pandemic -0.56 0.52 0.276 -1.56, 0.46
Maternal Age -4.06 7.02 0.562 -17.93, 9.84
First Time Parent
125.93 61.77 0.040 5.62, 244.35
Highest Education 13.67 26.00 0.600 -35.13, 67.45
Non-White Identification 75.78 77.56 0.322 -78.08, 229.87
62
Figure 2.1
Breakdown of participant responses when asked about their contact with family, friends,
coworkers, and community as compared with before the COVID-19 pandemic.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Much Less Somewhat Less About the Same Somewhat More Much More
Responses
Participant Reported Change in Social Contact during the Pandemic as
Compared with Pre-pandemic
Family
Friends
Coworkers
Community
63
STUDY 3
Differences in Infant Negative Affectivity During The COVID-19 Pandemic
Alyssa R. Morris, MA and Darby E. Saxbe, PhD
64
Introduction
The COVID-19 pandemic has had widespread effects on nearly every aspect of life,
including parenting and child development. Understanding how the pandemic has affected
maternal and infant health can aid efforts to support families even after the acute phase of the
pandemic resolves. Parental influence on child development begins before the child is even born,
with research showing that prenatal and early life maternal mental health has impacts on infant
development (Della Vedova, 2014; Tanner Stapleton et al., 2012). Given the strong evidence for
increased prenatal mental health problems during the pandemic (Morris & Saxbe, 2021), it is
essential to consider potential effects on infant development during this time.
Perinatal Stress and Mental Health
Maternal prenatal stress and mental health problems are associated with multiple child
adverse outcomes, surfacing as early as birth and infancy. Various pathways have been posited
for the effects of prenatal stress on fetal development. The most widely discussed mechanism is
increased fetal exposure to the stress hormone cortisol, which is known to have an impact on
multiple facets of fetal development (Beijers et al., 2014; Glover, 2014, 2015). Additional
potential pathways include changes in maternal immune activation, changes to maternal health
behaviors (i.e., sleep, exercise, eating), and genetic and epigenetic transmission (Beijers et al.,
2014). While the exact mechanisms are still up for debate, and the mechanisms are likely
additive, there is clear evidence for the association between maternal prenatal distress and
subsequent offspring outcomes (Bussières et al., 2015; Rice et al., 2010; van den Bergh et al.,
2017).
More specifically, research has shown that perinatal maternal mental health problems are
related to later infant development (Della Vedova, 2014; Tanner Stapleton et al., 2012). Reviews
65
summarize a large body of work showing increased risks for psychological and developmental
problems in children born to mothers with perinatal mood disorders (Hoffman et al., 2017; Stein
et al., 2014; van den Bergh et al., 2017). Specifically, infant temperament, self-regulation, and
socioemotional development have also been shown to be associated with prenatal maternal stress
and mood disorders (Bush et al., 2017; E. P. Davis et al., 2004, 2007; E. Davis & Sandman,
2010; Gerardin et al., 2011; Graignic-Philippe et al., 2014; Huizink et al., 2002; Pacheco &
Figueiredo, 2012; Räikkönen et al., 2015). In a study of perinatal mental health and infant
temperament, researchers found that maternal self-reported prenatal depression was related to
increased difficulty in infant temperament at three months of age (Della Vedova, 2014). Even
after controlling for postpartum mental health, studies exploring prenatal maternal depression
find associations with more difficult infant temperament at two to three months postpartum
(Chong et al., 2016; Davis et al., 2007; Rouse & Goodman, 2014).
While there is strong evidence for an association between prenatal maternal distress and
infant socioemotional development, additional investigation is needed as some findings are
mixed. Some studies have found null results for the association between prenatal distress and
infant development (Baibazarova et al., 2013; Zande & Sebre, 2014), and a few have even found
mixed or positive effects of prenatal stress on child development (B. Lin et al., 2014; Y. Lin et
al., 2017). Additionally, researchers have highlighted that postpartum mental health may drive
this association and that prenatal stress is simply an early indicator of postpartum maternal
mental health and the parenting environment (Dipietro, 2012). Others have found that maternal
prenatal distress is related to problematic infant temperament even after controlling for
postpartum maternal distress, suggesting that maternal prenatal distress may have a direct impact
on infant temperament (Nomura et al., 2019). Thus, there is still room to refine our
66
understanding of the effects of both prenatal and postpartum stress and mood on infant
temperament. Moreover, while these studies do not address causality, there is considerable
evidence for a causal association between prenatal stress and child development (Glover, 2015).
However, because experimental human studies of prenatal stress are unethical, natural
experiments that are occasioned by disasters have provided insight into the causal effects of
prenatal stress and mental health on child development outcomes.
Disaster Studies
Prenatal exposure to natural disasters has been associated with poorer cognitive, motor,
socioemotional, and temperamental outcomes in infants (van den Bergh et al., 2017). More
specifically, studies exploring exposure to the Quebec Ice Storm during pregnancy have found
associations with cognitive and socio-emotional development (King & Laplante, 2005; Laplante
et al., 2016). These authors found that elevated maternal subjective stress, in reaction to the
Quebec Ice Storm, during pregnancy was associated with infant fussiness, dullness, and
attention-seeking temperament characteristics at six months of age (Laplante et al., 2016).
However, findings across the field are still somewhat mixed, and there is debate over the role of
objective versus subjective exposure to stress (King & Laplante, 2005). In addition to findings
for stress during the Quebec Ice Storm, a study of the Queensland Flood found associations
between early gestational exposure to the flood and poorer offspring personal-social abilities
(Simcock et al., 2017). Disaster studies have also highlighted how maternal social support may
buffer the impacts of stressful events. Research from the Iowa flood study found that social
support may be protective against the development of severe anxiety symptoms following
exposure to the traumatic event (Brock et al., 2015). Thus, the role of social support as a
protective factor in mental health, particularly during widespread disasters, is important. While
67
there is preliminary evidence linking stress in response to natural disasters and highlighting the
role of social support, additional studies are needed to assess the impact of in-utero exposure to
maternal stress and mental health on infant temperament, particularly during the most recent
global-scale stressor, the COVID-19 pandemic.
COVID-19 Pandemic
The risks to maternal and infant health during the pandemic may be particularly high, as
both increases in prenatal maternal mental health problems and simultaneous decreases in access
to social support have been noted (Morris & Saxbe, 2021). Initial work during the COVID-19
pandemic provides evidence for the association between maternal distress and infant
temperament. A study from the MOM-COPE cohort recruited in northern Italy, assessing 163
pregnant women, found evidence for a model linking retrospectively reported prenatal stress and
social support with infant temperament through pathways including postpartum anxiety,
postpartum parenting stress, and mother-infant bonding (Provenzi, Grumi, et al., 2021). Another
study using data from the same cohort proposed a potential biological mechanism underlying the
association between prenatal stress and infant temperament during the COVID-19 pandemic
(Provenzi, Mambretti, et al., 2021). They found that retrospectively reported maternal prenatal
stress during the COVID-19 pandemic was associated with an epigenetic marker of early
adversity in infants, methylation of the CpG site of the SLC6A4 gene. In turn, they found that
infants with higher methylation in this gene region showed greater surgency but did not show
differences in negative affectivity or effort control. Counter to this finding, another study found
that mothers with higher postpartum stress rated their infants as having lower surgency and
regulation at three months postpartum, even though they did not find differences in infant
temperament based on maternal SARS-CoV-2 infection (Bianco et al., 2022). The inconsistency
68
in these findings may be due to differences in the timing of stress measurement, which is further
complicated by the retrospective report of maternal stress in the MOM-COPE project. There is
limited research using prospective, longitudinal designs during the COVID-19 pandemic to
assess associations between maternal prenatal and postpartum distress and infant temperament.
Of the extremely limited research using this design, a study of 468 pregnant women in Quebec,
Canada, found that higher maternal prenatal distress significantly contributed to poorer infant
socioemotional development based on the Ages and Stages Questionnaire around two months of
age during the first wave of the COVID-19 pandemic, and further, found that this association
was mediated by postnatal distress (Duguay et al., 2022). While there is initial evidence for
associations between prenatal maternal distress during the COVID-19 pandemic and infant
temperament, more work is needed.
Moreover, multiple studies during the COVID-19 pandemic have shown that loneliness is
a key factor in the development of depression and anxiety during this period (Palgi et al., 2020;
Tso & Park, 2020). Given the body of research linking maternal prenatal stress and mental health
with infant temperament, social disconnection and mental health problems during the pandemic
are of grave concern for mothers and infants. However, there is a paucity of work exploring the
impacts of maternal prenatal and early postpartum social disconnection on infant temperament.
Provenzi and colleagues’ model, showing that prenatal maternal social support during the
pandemic influences infant temperament via maternal bonding (Provenzi, Grumi, et al., 2021),
provides initial evidence for the importance of maternal social connection during the pandemic.
However, more work is needed, particularly in larger samples and in relation to reported changes
in social contact related to the COVID-19 pandemic.
69
To date, no research has assessed the relationship between maternal distress and infant
temperament during the COVID-19 pandemic in comparison with a pre-pandemic control group,
which is essential in disentangling the specific effects of the pandemic. Moreover, many of these
studies were small and did not include many important covariates, such as first-time parenthood
and maternal characteristics like age, education, and racial/ethnic identity. Furthermore, research
is needed to explore the impacts of both prenatal and postpartum maternal distress within the
same cohort, as well as provide additional evidence for associations with infant temperament
given the inconsistent findings in the literature. Finally, no research has explored infant
temperament with respect to changes in social contact specific to the COVID-19 pandemic.
The Current Study
The current study aims to fill these gaps by exploring infant temperament in a sample of
infants born to mothers who were pregnant during the first wave of the COVID-19 pandemic as
compared with a pre-pandemic control group. The following hypotheses were tested:
Aim 1. Infants born during the pandemic will have more negative affectivity, more
surgency, and less effort control at three months postpartum. All subsequent analyses will
be tested with respect to temperament subscales found to be significantly different
between groups in aim 3a.
Aim 2a. Higher levels of 1) prenatal depressive symptoms, 2) postpartum depressive
symptoms, 3) prenatal stress, and 4) postpartum stress will predict more problematic
infant temperament.
Aim 2b. Maternal 1) prenatal depressive symptoms, 2) postpartum depressive symptoms,
3) prenatal stress, and 4) postpartum stress will mediate differences in infant
temperament between pandemic and pre-pandemic groups.
70
Aim 2c. Pandemic group will moderate associations between maternal 1) prenatal
depressive symptoms, 2) postpartum depressive symptoms, 3) prenatal stress, and 4)
postpartum stress and infant temperament such that each maternal mental health measure
will be more strongly associated with more problematic infant temperament during the
pandemic as compared with pre-pandemic samples.
Aim 3a. Greater self-reported decreases in 1) prenatal and 2) postpartum social contact
during the pandemic will predict more problematic infant temperament.
Aim 3b. For associations found to be significant in aim 3.e., concurrent maternal stress
and depressive symptoms will mediate the relationship between maternal social
disconnection and infant temperament.
To our knowledge, this is the first study to explore differences in infant temperament in
infants born during the pandemic as compared with a pre-pandemic control sample. Our study
design also allowed us to consider both prenatal and concurrent maternal stress at three months
postpartum to assess the potential confounding effects of the ongoing COVID-19 pandemic on
parenting.
Methods
Study Procedure
Pre-pandemic Study Procedure
Our pre-pandemic control group included participants from the USC Hormones Across
the Transition to CHildrearing (HATCH) study, which followed pregnant women across the
transition to parenthood beginning in March 2014. Participants came into the lab for a three- to
four-hour prenatal visit between 20-35 weeks gestation. During this visit, participants were asked
to complete questionnaires administered via the Qualtrics platform that took about one and a half
71
hours to complete. Questionnaires included in this battery assessed a range of constructs,
including stress and mental health. When the infant was three months of age, participants were
sent a Qualtrics questionnaire battery to complete remotely that assessed postpartum stress and
mental health, as well as infant temperament. All study procedures were IRB approved.
Pandemic Study Procedure
Pregnant individuals were recruited via social media for the University of Southern
California Coronavirus, Health, Isolation, and Resiliency in Pregnancy (CHIRP) study, which
launched on April 6th, 2020. The week of April 7th represented the peak of "sheltering in place"
behavior in the U.S. (Schaul et al., 2020). Indeed, 97.7% of women participating in the CHIRP
reported that their community had issued an order to restrict large gatherings and close non-
essential businesses (Morris & Saxbe, 2021). Participants provided consent prenatally and
completed remote questionnaires through the Qualtrics platform, which took approximately 20-
30 minutes to complete. We followed up with participants at three-month postpartum and
requested that they complete the 20-40 minute postpartum questionnaire also through the
Qualtrics platform. At both time points, participants were asked to respond to questions assessing
mental health, stress, and social contact and were asked to answer additional questions related to
their infant’s temperament at three months postpartum. Our questionnaire battery was modeled
after the battery used in the HATCH study in anticipation of using the HATCH sample as a pre-
pandemic control group. All study procedures were IRB approved, and data were monitored for
fraudulent responses.
Participants
Pre-pandemic Sample Participants
72
Mothers involved in this study were heterosexual, expecting a single infant (i.e., not
multiples), cohabitating and planning to cohabitate after the birth of their child, and expecting
their first child. They were recruited from a community sample in the greater Los Angeles area
via fliers posted in obstetricians' offices, at community health clinics, and on social media. The
HATCH study was launched in March 2014, and 80 of the 100 participants recruited prenatally
completed the three-month questionnaire. Seven participants were excluded because their three-
month questionnaire was due and completed after February 2020, and one subject was excluded
due to incomplete data for this analysis. The final sample size for control participants in this
study was 72. Participants in the HATCH study were diverse and representative of the greater
Los Angeles area. Of note, participants in this sample were highly educated. Demographic
information is shown in Table 1.
Pandemic Sample Participants
Mothers involved in the CHIRP study were recruited at any time during pregnancy from
across the U.S. and were not restricted based on sexual orientation, living situation, or parity.
Demographic data for the current sample is shown in Table 1. A large proportion of participants
who responded to this survey were White, and the sample was also highly educated. 366
participants (57.5%) of our prenatal sample responded to our three-month postpartum
questionnaire. Additional cases were excluded if data was determined to be fraudulent (36
cases), subjects were living outside the U.S. (11 cases), or women gave birth to twins (six cases).
To avoid potential confounding effects of prenatal stress related to the widespread coverage of
the murder of George Floyd, participants who responded to the prenatal survey on or after May
25, 2020, were excluded (17 cases). Moreover, to assess the impacts of pandemic-related
distress, and not infection with COVID-19 itself, we excluded 23 subjects who reported having a
73
confirmed or suspected case of COVID-19 at any point prior to the three-month postpartum
questionnaire. Of the remaining 273 subjects, nine subjects did not complete the temperament
questionnaire, and one subject did not have complete covariate data. The resulting sample size
for the current analysis was 263. This sample was largely white (81.0%), and similar to the
HATCH sample, the CHIRP was highly educated. Demographic information is displayed in
Table 1.
Measures
Social Connection
Changes to prenatal social contact during the COVID-19 pandemic were assessed by
asking participants, “As compared to before COVID-19, how much total contact (including in-
person, phone, or online) do you have with … ” 1) neighbors/community members, 2)
coworkers, 3) friends, and 4) family. Responses were given on a five-point scale (“1, much less”
to “5, much more”). A social contact score was created by averaging their responses across each
of the four sets of contacts. This question was asked at both the prenatal and 3-month time
points. Reliability was acceptable at each time point, with Cronbach’s alpha of .74 and .73 for
the prenatal and postpartum measures, respectively. Given the COVID-specific nature of this
question, this question was only assessed in the pandemic sample.
Depressive Symptoms
Prenatal and postpartum depression symptoms were assessed using the Beck Depression
Inventory-II (BDI-II; Beck et al., 1996), a 21-item self-report measure that has been
comprehensively validated and widely used to assess mental and somatic complaints related to
depression, including loss of pleasure and changes to sleep and appetite. Respondents rate items
74
on a four-point scale ranging from “0, not at all” to “3, severely.” Scores are summed for a total
score ranging from 0-63, with higher scores indicating worse depressive symptomatology.
Stress
Prenatal and postpartum stress was measured using the 14-item Perceived Stress Scale
(PSS-14; Cohen et al., 1983), a widely used psychological instrument for measuring perceived
stress. This is a 14-item self-report measure assessing the frequency of feelings around coping,
emotion control, and unexpected events. Responses for each question range from “0, never” to
“4, almost always” and are summed for a score ranging from 0-56. Higher scores reflect higher
perceptions of stress.
Infant Temperament
Infant temperament will be measured using the Revised Infant Behavior Questionnaire
(Very Short Form; Putnam et al., 2014). This is a parent-report questionnaire containing 37
items. Parents are asked to rate the frequency of infant behavior on a seven-item scale ranging
from "1, never" to "7, always," or "does not apply." Results are provided in three subscales,
including measures of infant surgency (positive affect, active, approach-oriented temperament),
effortful control, and negative affectivity. Overall, this measure has been shown to have good
reliability and validity (Gartstein & Rothbart, 2003).
Analyses
Analyses were conducted in IBM SPSS version 28 (IBM Corp., 2022). Zero-order
correlations for all study variables are shown in Table 2. Consistent with previous literature and
best practices (Bianco et al., 2022; Brunst et al., 2014; Huizink et al., 2002; Provenzi, Grumi, et
al., 2021; Provenzi, Mambretti, et al., 2021), all analyses controlled for infant age at the
postpartum survey, maternal age, first-time parenthood, maternal education, and identification as
75
Black, Hispanic/Latina, Asian/Pacific Islander, or Multiracial/Other regardless of zero-order
correlations. We were unable to control for American India/Alaska Native in regression and
mediation analyses due to low or no cases in each group. Additionally, we tested associations
between infant temperament and sex for cases in which infant sex was available (60 pre-
pandemic participants, 56 pandemic participants). Across the combined samples, infant sex was
not significantly related to infant negative affectivity [r(114) = .00, p = .992] or surgency [r(114)
= .17, p = .076], but infant sex and effortful control were correlated [r(114) = .20, p = .036].
Additionally, we explored the inclusion of infant birth weight adjusted for gestational age as a
covariate. Infant adjusted birth weight was not associated with any of our infant temperament
measures, and the inclusion of adjusted birth weight adjusted in our models did not affect the
results. Thus, infant birth weight was left out of the final models for parsimony.
Assumptions of linear regression and ANCOVA were acceptable for all models.
However, due to outliers, bootstrapping methods were used. ANCOVA with bootstrapping was
used to assess differences in infant temperament between pandemic and pre-pandemic groups.
When significant differences in infant temperament were found, linear regression with
bootstrapping was used to assess associations between maternal distress variables and infant
temperament, as well as between social disconnection and infant temperament within the
pandemic group. Moderation (model 1) and mediation (model 4) analyses were conducted using
models 1 and 4 of the PROCESS macro (Hayes, 2017). All variables that define products were
mean-centered prior to moderation analyses. Unless otherwise noted, 5000 bootstrap samples
were used for all ANCOVA, regression, mediation, and moderation analyses.
76
Results
Infant Temperament
As shown in Figure 1, at three months postpartum, mothers rated infants born during the
COVID-19 pandemic as having significantly higher negative affectivity than did mothers of
infants born prior to the pandemic (F(1,324) = 18.28, p <.001). The mean negative affectivity
score for infants in the pandemic sample was 4.39 (SE = 0.07, Bootstrap 95% CI 4.25, 4.53), as
compared with 3.68 (SE = 0.14, Bootstrap 95% CI 3.42, 3.95) in the pre-pandemic sample.
These findings held after restricting the sample to first-time parents only. We did not find
differences between pandemic and pre-pandemic groups with respect to infant surgency
[F(1,324) = 0.01, p = .974] or effortful control [F(1,324) = 0.014, p = .904].
Maternal Distress
As shown in Table 3, prenatal and postpartum stress and depressive symptoms
significantly predicted infant negative affectivity across the combined sample of both the pre-
pandemic and pandemic cohorts.
Prenatal depressive symptoms mediated differences in infant negative affectivity between
pandemic and pre-pandemic groups with an indirect effect of 0.07 (95% CI 0.00, 0.16). Contrary
to our expectation, the indirect effect of the model testing the mediation of postpartum
depressive symptoms was non-significant as the confidence intervals included zero (95% CI -
0.02, 0.08). Both prenatal and postpartum maternal stress mediated differences in infant negative
affectivity between pandemic and pre-pandemic groups with indirect effects of 0.13 (95% CI
0.01, 0.27) and 0.06 (95% CI 0.01, 0.13), respectively. Post-hoc analyses showed that prenatal
stress did not significantly mediate the association between pandemic status and infant negative
77
affectivity after controlling for postpartum stress (95% CI -0.06, 0.16), and postpartum stress did
not mediate the association after controlling for prenatal stress 95% CI -0.07, 0.01).
Pandemic group status did not moderate associations between mental health and infant
negative affectivity. The interactions of pandemic by prenatal depressive symptoms [F(1, 302) =
0.41, p = .520], postpartum depressive symptoms [F(1, 319) = 0.82, p = .365], prenatal stress
[F(1, 322) = 1.51, p = .219], and postpartum stress [F(1, 317) = 1.22, p = .270] on infant
negative affectivity were all non-significant.
Social Contact
Table 3 shows the results of the regression analyses testing the associations between
social connection and infant temperament. Consistent with our hypothesis, postpartum social
contact was significantly associated with infant negative affectivity (such that higher postpartum
social contact was associated with more negative affectivity within the pandemic group).
However, counter to our expectations, prenatal social contact was not associated with infant
negative affectivity.
Counter to our hypothesis, neither concurrent maternal depressive symptoms (95% CI -
0.08, .01) nor stress (95% CI -0.08, .00) mediated the relationship between maternal social
contact and infant negative affectivity as both confidence intervals included zero.
Discussion
This is the first study to explore differences in infant temperament in a sample of infants
born during the COVID-19 pandemic as compared with a pre-pandemic sample. We found that
infants born during the COVID-19 pandemic displayed significantly more negative affectivity at
three months postpartum as compared with infants born prior to the COVID-19 pandemic. We
did not find significant differences in infant effortful control or infant surgency between
78
pandemic and pre-pandemic groups. Across the combined sample of both the pandemic and pre-
pandemic cohorts, prenatal and postpartum stress and depressive symptoms significantly
predicted infant negative affectivity, and both prenatal and postpartum maternal stress mediated
the difference in infant negative affectivity between the pandemic and pre-pandemic groups.
This suggests that maternal stress across pregnancy and postpartum is playing a role in the
increases in infant negative affectivity we see during the COVID-19 pandemic. We did not find
that prenatal or postpartum stress mediated the association between pandemic status and negative
affectivity after controlling for the other, suggesting that overall perinatal stress is important, and
neither prenatal nor postnatal stress is the primary driver. Interestingly, prenatal but not
postpartum depressive symptoms mediated differences in infant negative affectivity based on
pandemic group. This suggests that there may be a fetal programming effect of maternal
depressive symptoms rather than a postpartum parenting effect of depressive symptoms driving
increases in infant negative affectivity during the pandemic. This is not to say that postpartum
maternal depressive symptoms are not concerning, as we did find associations between maternal
depressive symptoms and infant negative affectivity, but rather that the increases in negative
affectivity that we see during the pandemic appear to be driven by prenatal maternal depressive
symptoms.
Pandemic status did not moderate the association between maternal depressive symptoms
or stress and infant negative affectivity at either time point. This indicates that maternal mental
health during the pandemic is not differentially impacting infant temperament as compared to
pre-pandemic times, so there is no sensitizing or buffering effect of the pandemic. Instead,
greater infant negative affectivity observed during the pandemic is simply due to increases in
both prenatal and postpartum maternal distress during the COVID-19 pandemic. That is,
79
maternal stress during the pandemic is not qualitatively different; there is simply more distress
during the pandemic. Thus, previously developed interventions aimed at supporting maternal
distress may be effective in supporting maternal and infant mental health during the pandemic.
Finally, we found that mothers’ postpartum, but not prenatal, report of decreased social
contact was significantly associated with infant negative affectivity, and this association was not
explained by maternal stress or depressive symptoms. Our data suggests that decreased maternal
social contact during the pandemic may not be due to the impact on maternal mental health, and
social support may be meaningful for infant temperament independent of the effects of mental
health. For example, social contact helps build familiarity and comfort in parenting through
modeling, support, and shared information from experienced parents. Moreover, it is possible
that maternal social contact is a proxy for infant social interactions, and decreases in infant social
contact during the pandemic may influence temperament. It is also possible that mothers who felt
more isolated were more likely to rate their infants as difficult in part because they had less
contact with other mothers and babies, decreasing the chance to normalize some degree of infant
fussiness.
Overall, these findings are consistent with previous work finding associations between
maternal distress and infant socioemotional development during the COVID-19 pandemic
(Bianco et al., 2022; Duguay et al., 2022; Provenzi, Grumi, et al., 2021). However, there is some
inconsistency in the literature with respect to the association between maternal distress during
the pandemic and specific infant temperament domains (i.e., negative affectivity, surgency, effort
control). Our findings are consistent with research showing that maternal COVID-19 impact
score was related to infant negative emotionality (Bianco et al., 2022). However, other studies
have found relationships between maternal distress and infant surgency, but not infant negative
80
affectivity (Provenzi, Mambretti, et al., 2021). Regardless, it is clear that maternal distress during
the COVID-19 pandemic has implications for infant temperament. Our work furthers this
literature by providing support for the unspoken assumption of previous research that infants are
showing more difficult temperaments during the COVID-19 pandemic, as no other studies have
compared infant temperament in pandemic versus pre-pandemic samples. We also provide
clarity on the question of why we are seeing increases in negative affectivity during the
pandemic, showing that there does not appear to be a differential relationship between maternal
distress and infant negative affectivity during the pandemic, but simply that we are seeing
increases in infant temperament concerns due to across-the-board increases in maternal mental
health problems during the pandemic. Furthermore, this study is the first to explore the
association between maternal social contact and increased infant negative affectivity during the
pandemic, distinct from maternal distress.
Based on our findings, efforts to support maternal and infant mental health in the wake of
the COVID-19 pandemic should focus on maternal prenatal depressive symptoms, both prenatal
and postpartum maternal stress, and maternal postpartum social contact.
Limitations
Our study is limited by a convenience sample recruited online. While our sample is more
diverse than those from previous work (Duguay et al., 2022), our sample is still highly educated
and predominantly White. Given the disproportionate effects of the pandemic on African-
American and Latinx individuals (Evans, 2020; Tai et al., 2020), who were underrepresented in
our sample, the levels of mental health concerns are likely more acute than captured in our study.
Moreover, due to the virtual nature of the survey, as was necessitated with much research during
81
the COVID-19 pandemic, there is the possibility that ineligible participants responded to our
survey. While we carefully monitored our data for fraudulent responses, this possibility remains.
Furthermore, it is essential to acknowledge that infant temperament was measured via
maternal report. Thus, it is possible that maternal mental distress may be influencing her ratings
of infant temperament rather than being associated with actual differences in temperament during
the pandemic. Regardless, maternal perception of infant temperament is an central piece of the
puzzle. Additionally, maternal postpartum depressive symptoms did not explain differences in
infant temperament between groups, providing some reassurance that maternal depressive
symptoms were not explaining her ratings.
Finally, a limitation of our analysis was that we did not have data on infant sex for the
majority of the sample and therefore could not include infant sex as a covariate. However, initial
research on infant temperament during the pandemic did not find differences in temperament by
infant sex (Provenzi, Grumi, et al., 2021), and we did not find differences in infant negative
affectivity based on infant sex, suggesting that our findings related to negative affectivity are
robust regardless of covarying for sex. We also did not find significant associations between
infant sex and surgency but did find a correlation between sex and effortful control. Thus, further
work is warranted, particularly with respect to the difference in effortful control in pandemic
versus pre-pandemic groups after controlling for infant sex.
The pre-pandemic sample was drawn from an ongoing longitudinal study of the transition
to parenthood. Thus, participants in the pandemic and pre-pandemic groups are not precisely
matched on demographics. For example, all participants in the HATCH control group are first-
time parents living in the greater Los Angeles area at the time of recruitment. While we
controlled for first-time parenthood in our analyses, there are inherent differences in our cohorts
82
that must be acknowledged. Despite these limitations, this project is the first to explore infant
temperament during the pandemic as compared with a pre-pandemic control group.
Strengths
The naturalistic design of this study can provide some insight into the causality of
prenatal stress and offspring development. An issue with the fetal programming literature is the
challenge of disentangling environmental versus inherited influences on child development.
Behavioral genetics study designs have shown that when prenatal maternal distress is associated
with offspring behavioral outcomes, the association is likely to be explained, at least in part, by
shared genes (Hannigan et al., 2018; McAdams et al., 2015). Mothers who experience depression
during pregnancy are more likely to possess genes that confer risk for depressive
psychopathology and are more likely to pass along those genes to their offspring than women
who do not experience depression during pregnancy. This confound is not accounted for in the
vast majority of the fetal programming literature, limiting previous findings. Yet, behavioral
genetics studies require extremely large sample sizes and often use retrospective study designs
with large public health databases. Researchers are limited to the measures available in these
existing databases, and it is difficult to explore the association between prenatal distress and
infant development using longitudinal designs with well-validated and precise measures. One
step in addressing this confound is to use "natural experiment" designs to examine upheavals
such as natural disasters and terrorist attacks that may increase stress for pregnant women,
increasing rates of stress and mental health concerns beyond those at high risk for mental health
disorders. By capturing maternal prenatal well-being during a large-scale pandemic, the current
study captures prenatal stress effects during a time when many individuals, not just those at
83
highest risk for mental health problems, are experiencing stress, anxiety symptoms, and
depressive symptoms.
Finally, measuring the postpartum environment is also an essential consideration for
work in this area. Research has suggested that the association between prenatal stress and anxiety
and offspring outcomes may actually be attributable to postnatal maternal anxiety and depression
(O’Connor, Heron, Golding, et al., 2002), as postpartum maternal mental health is a known risk
for adverse child psychopathology and behavioral outcomes (Goodman et al., 2011). However,
prenatal factors may still confer independent risk, with studies showing that prenatal and
postpartum depression represent separate and additive risks for child behavioral and emotional
problems (O’Connor, Heron, & Glover, 2002). Thus, it is important to consider the role of both
the prenatal and postpartum environment when assessing child development outcomes. This
study incorporates consideration of both prenatal and postpartum stress, depressive symptoms,
and social contact, finding that prenatal but not postpartum depressive symptoms, and
postpartum but not prenatal stress, appear to influence infant negative affectivity. Additionally,
post-hoc analyses indicate that both prenatal and postpartum stress appear to be important and
that one timepoint does not seem to stand out above the other as a key predictor.
Future Directions
As one of the first studies exploring infant temperament during COVID-19, further
investigation is necessary. In particular, more work is needed with larger, more diverse, and
more representative samples with more consideration of infant characteristics such as infant sex.
Additionally, future work should explore the associations between maternal distress and infant
temperament, using independent ratings of infant temperament (such as observed infant
behavior) rather than maternal reports. Finally, intervention research should explore the
84
effectiveness of interventions aimed at supporting maternal perinatal distress and postpartum
social connection, as well as interventions for infants high in negative affectivity to promote
better self-regulation and promote parent-infant bonding. Additionally, research suggests that
more negative and reactive infant temperaments predict internalizing and externalizing problems
in later childhood and adolescence (Sanson, 2004; Teerikangas et al., 1998), and thus, these
findings may be an early indicator of potentially increased behavioral problems in the generation
of children born during the pandemic. It will be necessary for future work to continue following
these children and focus on methods to prevent some of the long-term mental health risks
associated with a fussier temperament.
Conclusion
Our findings show a greater prevalence of more difficult infant temperament, specifically
infant negative affectivity, during the pandemic as compared to a pre-pandemic sample. We
found that both maternal distress and social contact during the pandemic influence infant
negative affectivity, and each appear to play a unique role in the increases in infant negative
affectivity that we observed during the COVID-19 pandemic. More specifically, we found stress
across the perinatal period was influential in the differences in infant temperament during the
pandemic, but prenatal and not postpartum maternal depressive symptoms helped to explain
increased problematic temperament during the pandemic. Finally, distress during the pandemic
does not appear to have qualitatively different impacts on infant temperament as compared to
pre-pandemic times. Instead, there is simply more maternal distress during the pandemic, driving
the increases in problematic infant temperament we are seeing. Interventions should be aimed at
reducing maternal perinatal stress, reducing prenatal depressive symptoms, and bolstering
postpartum social contact.
85
References
Baibazarova, E., Van De Beek, C., Cohen-Kettenis, P. T., Buitelaar, J., Shelton, K. H., & Van
Goozen, S. H. M. (2013). Influence of prenatal maternal stress, maternal plasma cortisol and
cortisol in the amniotic fluid on birth outcomes and child temperament at 3 months.
Psychoneuroendocrinology, 38(6), 907–915. https://doi.org/10.1016/j.psyneuen.2012.09.015
Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck depression inventory–II. Psychological
Assessment.
Beijers, R., Buitelaar, J. K., & de Weerth, C. (2014). Mechanisms underlying the effects of prenatal
psychosocial stress on child outcomes: beyond the HPA axis. European Child and Adolescent
Psychiatry, 23(10), 943–956. https://doi.org/10.1007/s00787-014-0566-3
Bianco, C., Sania, A., Kyle, M. H., Beebe, B., Barbosa, J., Bence, M., Coskun, L., Fields, A.,
Firestein, M. R., Goldman, S., Hane, A., Hott, V., Hussain, M., Hyman, S., Lucchini, M., Marsh,
R., Mollicone, I., Myers, M., Ofray, D., … Amso, D. (2022). Pandemic beyond the virus:
maternal COVID-related postnatal stress is associated with infant temperament. Pediatric
Research. https://doi.org/10.1038/S41390-022-02071-2
Brock, R. L., O’hara, M. W., Hart, K. J., Mccabe-Beane, J. E., Williamson, J. A., Brunet, A.,
Laplante, D. P., Yu, C., & King, S. (2015). Peritraumatic distress mediates the effect of severity
of disaster exposure on perinatal depression: The Iowa Flood Study. Journal of Traumatic Stress,
28, 515–522. https://doi.org/10.1002/jts.22056
Brunst, K. J., Bosquet Enlow, M., Kannan, S., Carroll, K. N., Coull, B. A., & Wright, R. J. (2014).
Effects of prenatal social stress and maternal dietary fatty acid ratio on infant temperament: does
race matter? https://doi.org/10.4172/2161-1165.1000167
86
Bush, N. R., Jones-Mason, K., Coccia, M., Caron, Z., Alkon, A., Thomas, M., Coleman-Phox, K.,
Wadhwa, P. D., Laraia, B. A., & Adler, N. E. (2017). Effects of pre-and postnatal maternal stress
on infant temperament and autonomic nervous system reactivity and regulation in a diverse, low-
income population. Development and Psychopathology, 29(5), 1553–1571.
Bussières, E. L., Tarabulsy, G. M., Pearson, J., Tessier, R., Forest, J. C., & Giguère, Y. (2015).
Maternal prenatal stress and infant birth weight and gestational age: A meta-analysis of
prospective studies. Developmental Review, 36, 179–199.
https://doi.org/10.1016/j.dr.2015.04.001
Chong, S., Broekman, B. F., Qiu, A., Aris, I. M., Chan, Y. H., Rifkin‐Graboi, A., Law, E., Chee, C.
Y. I., Chong, Y., & Kwek, K. Y. C. (2016). Anxiety and depression during pregnancy and
temperament in early infancy: findings from a multi‐ethnic, Asian, prospective birth cohort
study. Infant Mental Health Journal, 37(5), 584–598.
Cohen, S., Kamarck, T., & Mermelstein, R. (1994). Perceived stress scale. Measuring Stress: A Guide
for Health and Social Scientists, 10, 1–2.
Davis, E. P., Glynn, L. M., Dunkel-Schetter, C., Hobel, C., Chicz-Demet, A., & Sandman, C. A.
(2007). Prenatal exposure to maternal depression and cortisol influences infant temperament.
Journal of the American Academy of Child and Adolescent Psychiatry, 46(6), 737–746.
https://doi.org/10.1097/chi.0b013e318047b775
Davis, E. P., Snidman, N., Wadhwa, P. D., Glynn, L. M., Dunkel-Schetter, C., & Sandman, C. A.
(2004). Prenatal maternal anxiety and depression predict negative behavioral reactivity in
infancy. Infancy, 6(3), 319–331. https://doi.org/10.1207/s15327078in0603_1
87
Davis, E., & Sandman, C. (2010). The timing of prenatal exposure to maternal cortisol and
psychosocial stress is associated with human infant cognitive development. Child Development,
81(1), 131–148. https://doi.org/10.1111/j.1467-8624.2009.01385.x
Della Vedova, A. M. (2014). Maternal psychological state and infant’s temperament at three months.
Journal of Reproductive and Infant Psychology, 32(5), 520–534.
https://doi.org/10.1080/02646838.2014.947472
Dipietro, J. A. (2012). Maternal stress in pregnancy: Considerations for fetal development. Journal of
Adolescent Health, 51(2 suppl), 3–8. https://doi.org/10.1016/j.jadohealth.2012.04.008
Duguay, G., Garon-Bissonnette, J., Lemieux, R., Dubois-Comtois, K., Mayrand, K., & Berthelot, N.
(2022). Socioemotional development in infants of pregnant women during the COVID-19
pandemic: the role of prenatal and postnatal maternal distress. Child and Adolescent Psychiatry
and Mental Health, 16(1), 28. https://doi.org/10.1186/S13034-022-00458-X
Evans, M. K. (2020). COVID’s color line — Infectious disease, inequity, and racial justice. New
England Journal of Medicine, 383(5), 408–410. https://doi.org/10.1056/NEJMp2019445
Gartstein, M. A., & Rothbart, M. K. (2003). Studying infant temperament via the Revised Infant
Behavior Questionnaire. Infant Behavior and Development, 26(1), 64–86.
https://doi.org/10.1016/S0163-6383(02)00169-8
Gerardin, P., Wendland, J., Bodeau, N., Galin, A., Bialobos, S., Tordjman, S., Mazet, P., Darbois, Y.,
Nizard, J., Dommergues, M., & Cohen, D. (2011). Depression during pregnancy: Is the
developmental impact earlier in boys? A prospective case-control study. Journal of Clinical
Psychiatry, 72(3), 378–387. https://doi.org/10.4088/JCP.09m05724blu
88
Glover, V. (2014). Maternal depression, anxiety and stress during pregnancy and child outcome; what
needs to be done. Best Practice and Research: Clinical Obstetrics and Gynaecology, 28(1), 25–
35. https://doi.org/10.1016/j.bpobgyn.2013.08.017
Glover, V. (2015). Prenatal stress and its effects on the fetus and the child: possible underlying
biological mechanisms. In Advances in Neurobiology (Vol. 10, pp. 269–283). Springer New
York LLC. https://doi.org/10.1007/978-1-4939-1372-5_13
Goodman, S. H., Rouse, M. H., Connell, A. M., Broth, M. R., Hall, C. M., & Heyward, D. (2011).
Maternal depression and child psychopathology: A meta-analytic review. Clinical Child and
Family Psychology Review, 14(1), 1–27. https://doi.org/10.1007/s10567-010-0080-1
Graignic-Philippe, R., Dayan, J., Chokron, S., Jacquet, A. Y., & Tordjman, S. (2014). Effects of
prenatal stress on fetal and child development: A critical literature review. Neuroscience and
Biobehavioral Reviews, 43, 137–162. https://doi.org/10.1016/j.neubiorev.2014.03.022
Hannigan, L. J., Eilertsen, E. M., Gjerde, L. C., Reichborn-Kjennerud, T., Eley, T. C., Rijsdijk, F. v.,
Ystrom, E., & McAdams, T. A. (2018). Maternal prenatal depressive symptoms and risk for
early-life psychopathology in offspring: genetic analyses in the Norwegian Mother and Child
Birth Cohort Study. The Lancet Psychiatry, 5(10), 808–815. https://doi.org/10.1016/S2215-
0366(18)30225-6
Hayes, A. F. (2017). Introduction to mediation, moderation, and conditional process analysis: A
regression-based approach. Guilford publications.
Hoffman, C., Dunn, D. M., & Njoroge, W. F. M. (2017). Impact of postpartum mental illness upon
infant development. Current Psychiatry Reports, 19(12). https://doi.org/10.1007/s11920-017-
0857-8
89
Huizink, A. C., Robeles de Medina, P. G., Mulder, E. J. H., Visser, G. H. A., & Buitelaar, J. A. N. K.
(2002). Psychological measures of prenatal stress as predictors of infant temperament. Journal of
the American Academy of Child & Adolescent Psychiatry, 41(9), 1078–1085.
https://doi.org/https://doi.org/10.1097/00004583-200209000-00008
IBM Corp. (2022). IBM SPSS Statistics for Macintosh (Version 28.0). IBM Corp.
King, S., & Laplante, D. P. (2005). The effects of prenatal maternal stress on children’s cognitive
development: Project Ice Storm. Stress, 8(1), 35–45.
Laplante, D. P., Brunet, A., & King, S. (2016). The effects of maternal stress and illness during
pregnancy on infant temperament: Project Ice Storm. Pediatric Research, 79(1), 107–113.
https://doi.org/10.1038/pr.2015.177
Lin, B., Crnic, K. A., Luecken, L. J., & Gonzales, N. A. (2014). Maternal prenatal stress and infant
regulatory capacity in Mexican Americans. Infant Behavior and Development, 37(4), 571–582.
Lin, Y., Xu, J., Huang, J., Jia, Y., Zhang, J., Yan, C., & Zhang, J. (2017). Effects of prenatal and
postnatal maternal emotional stress on toddlers’ cognitive and temperamental development.
Journal of Affective Disorders, 207, 9–17.
McAdams, T. A., Rijsdijk, F. V., Neiderhiser, J. M., Narusyte, J., Shaw, D. S., Natsuaki, M. N.,
Spotts, E. L., Ganiban, J. M., Reiss, D., Leve, L. D., Lichtenstein, P., & Eley, T. C. (2015). The
relationship between parental depressive symptoms and offspring psychopathology: Evidence
from a children-of-twins study and an adoption study. Psychological Medicine, 45(12), 2583–
2594. https://doi.org/10.1017/S0033291715000501
Morris, A. R., & Saxbe, D. E. (2021). Mental health and prenatal bonding in pregnant women during
the COVID-19 pandemic: Evidence for heightened risk compared with a prepandemic sample.
Clinical Psychological Science. https://doi.org/10.1177/21677026211049430
90
O’Connor, T. G., Heron, J., & Glover, V. (2002). Antenatal anxiety predicts child
behavioral/emotional problems independently of postnatal depression. Journal of the American
Academy of Child and Adolescent Psychiatry, 41(12), 1470–1477.
https://doi.org/10.1097/00004583-200212000-00019
O’Connor, T. G., Heron, J., Golding, J., Beveridge, M., & Glover, V. (2002). Maternal antenatal
anxiety and children’s behavioural/emotional problems at 4 years. British Journal of Psychiatry,
180(JUNE), 502–508. https://doi.org/10.1192/bjp.180.6.502
Pacheco, A., & Figueiredo, B. (2012). Mother’s depression at childbirth does not contribute to the
effects of antenatal depression on neonate’s behavioral development. Infant Behavior and
Development, 35(3), 513–522. https://doi.org/10.1016/j.infbeh.2012.02.001
Palgi, Y., Shrira, A., Ring, L., Bodner, E., Avidor, S., Bergman, Y., Cohen-Fridel, S., Keisari, S., &
Hoffman, Y. (2020). The loneliness pandemic: Loneliness and other concomitants of depression,
anxiety and their comorbidity during the COVID-19 outbreak. Journal of Affective Disorders,
275, 109–111. https://doi.org/10.1016/j.jad.2020.06.036
Provenzi, L., Grumi, S., Altieri, L., Bensi, G., Bertazzoli, E., Biasucci, G., Cavallini, A., Decembrino,
L., Falcone, R., Freddi, A., Gardella, B., Giacchero, R., Giorda, R., Grossi, E., Guerini, P.,
Magnani, M. L., Martelli, P., Motta, M., Nacinovich, R., … Borgatti, R. (2021). Prenatal
maternal stress during the COVID-19 pandemic and infant regulatory capacity at 3 months: A
longitudinal study. Development and Psychopathology, 1–9.
https://doi.org/10.1017/S0954579421000766
Provenzi, L., Mambretti, F., Villa, M., Grumi, S., Citterio, A., Bertazzoli, E., Biasucci, G.,
Decembrino, L., Falcone, R., Gardella, B., Longo, M. R., Nacinovich, R., Pisoni, C., Prefumo,
F., Orcesi, S., Scelsa, B., Giorda, R., & Borgatti, R. (2021). Hidden pandemic: COVID-19-
91
related stress, SLC6A4 methylation, and infants’ temperament at 3 months. Scientific Reports
2021 11:1, 11(1), 1–8. https://doi.org/10.1038/s41598-021-95053-z
Putnam, S. P., Helbig, A. L., Gartstein, M. A., Rothbart, M. K., & Leerkes, E. (2014). Development
and assessment of short and very short forms of the Infant Behavior Questionnaire-Revised.
Journal of Personality Assessment, 96(4), 445–458.
https://doi.org/10.1080/00223891.2013.841171
Räikkönen, K., Pesonen, A. K., O’Reilly, J. R., Tuovinen, S., Lahti, M., Kajantie, E., Villa, P.,
Laivuori, H., Hämäläinen, E., Seckl, J. R., & Reynolds, R. M. (2015). Maternal depressive
symptoms during pregnancy, placental expression of genes regulating glucocorticoid and
serotonin function and infant regulatory behaviors. Psychological Medicine, 45(15), 3217–3226.
https://doi.org/10.1017/S003329171500121X
Rice, F., Harold, G. T., Boivin, J., Van Den Bree, M., Hay, D. F., & Thapar, A. (2010). The links
between prenatal stress and offspring development and psychopathology: Disentangling
environmental and inherited influences. Psychological Medicine, 40(2), 335–342.
https://doi.org/10.1017/S0033291709005911
Rouse, M. H., & Goodman, S. H. (2014). Perinatal depression influences on infant negative
affectivity: Timing, severity, and co-morbid anxiety. Infant Behavior and Development, 37(4),
739–751. https://doi.org/10.1016/j.infbeh.2014.09.001
Sanson, A. (2004). Connections between temperament and social development: a review. Social
Development, 13(1), 144–170.
Schaul, K., Mayes, B. R., & Berkowitz, B. (2020). Where Americans are still staying at home the
most. Washington Post.
92
Simcock, G., Laplante, D. P., Elgbeili, G., Kildea, S., Cobham, V., Stapleton, H., & King, S. (2017).
Infant neurodevelopment is affected by prenatal maternal stress: The QF 2011 Queensland Flood
Study. Infancy, 22(3), 282–302.
Stein, A., Pearson, R. M., Goodman, S. H., Rapa, E., Rahman, A., McCallum, M., Howard, L. M., &
Pariante, C. M. (2014). Effects of perinatal mental disorders on the fetus and child. The Lancet,
384(9956), 1800–1819. https://doi.org/10.1016/S0140-6736(14)61277-0
Tai, D. B. G., Shah, A., Doubeni, C. A., Sia, I. G., & Wieland, M. L. (2020). The disproportionate
impact of COVID-19 on racial and ethnic minorities in the United States. Clinical Infectious
Diseases. https://doi.org/10.1093/cid/ciaa815
Tanner Stapleton, L. R., Dunkel-Schetter, C., Westling, E., Rini, C., Glynn, L. M., Hobel, C. J., &
Sandman, C. A. (2012). Perceived partner support in pregnancy predicts lower maternal and
infant distress. Journal of Family Psychology, 26(3), 453–463. https://doi.org/10.1037/a0028332
Teerikangas, O. M., Aronen, E. T., Martin, R. P., & Huttunen, M. O. (1998). Effects of infant
temperament and early ntervention on the psychiatric symptoms of adolescents. Journal of the
American Academy of Child & Adolescent Psychiatry, 37(10), 1070–1076.
https://doi.org/10.1097/00004583-199810000-00017
Tso, I. F., & Park, S. (2020). Alarming levels of psychiatric symptoms and the role of loneliness
during the COVID-19 epidemic: A case study of Hong Kong. Psychiatry Research, 293, 113423.
van den Bergh, B. R. H., van den Heuvel, M. I., Lahti, M., Braeken, M., de Rooij, S. R., Entringer, S.,
Hoyer, D., Roseboom, T., Räikkönen, K., King, S., & Schwab, M. (2017). Prenatal
developmental origins of behavior and mental health: The influence of maternal stress in
pregnancy. Neuroscience and Biobehavioral Reviews.
https://doi.org/10.1016/j.neubiorev.2017.07.003
93
Zande, D., & Sebre, S. (2014). Longitudinal associations between symptoms of parental perinatal
depression, social support and infant temperament. Baltic Journal of Psychology, 15(1), 2.
94
Table 3.1
Demographics.
Pre-pandemic Pandemic
Demographics / Characteristics N Mean SD N Mean SD
Days of Fetal Exposure to Pandemic 72 0.00 0.00 263 129.17 58.72
Infant Age at Postpartum Survey (Days) 72 99.71 13.29 263 101.17 12.14
Maternal Age (years) 72 30.68 4.12 263 32.54 4.21
Infant Temperament
Negative Affectivity 72 3.69 0.98 263 4.38 1.13
Effort Control 72 5.73 0.78 263 5.65 0.70
Surgency 72 4.90 1.02 263 4.80 0.98
Maternal Distress Variables
Prenatal Depressive Symptoms 72 9.72 5.60 243 14.38 8.78
Postpartum Depressive Symptoms 72 9.85 7.00 260 11.65 8.53
Prenatal Stress 72 20.74 6.39 263 28.37 7.91
Postpartum Stress 72 20.69 7.67 258 24.29 8.81
Maternal Prenatal Social Contact Score - - - 256 1.82 0.82
Maternal Postpartum Social Contact Score - - - 259 1.76 0.73
N % N %
First Time Parents 72 100 140 53.2
Trimester at Prenatal Survey
First 0 0.0 18 6.8
Second 30 41.7 129 49.0
Third 42 58.3 113 43.0
Did not disclose 0 0.0 3 1.1
Race / Ethnicity
White 32 44.4 213 81.0
Black 5 6.9 17 6.5
Hispanic / Latinx 17 23.6 19 7.2
American Indian / Alaska Native 1 1.4 0 0.0
Asian / Pacific Islander 13 18.1 11 4.2
Multiracial / Other 4 5.6 3 1.1
Education
Did Not Complete High School 0 0.0 1 0.4
High School Degree / GED 0 0.0 15 5.7
Some College 7 9.7 12 4.6
Associate Degree 3 4.2 12 4.6
Bachelor’s Degree 27 37.5 74 28.1
Master’s Degree 29 40.3 82 31.2
Professional / Doctoral Degree 6 8.3 67 25.5
95
Table 3.2
Zero-Order Correlations.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1. Pandemic -
2. Negative Affectivity .25** -
3. Effort Control -.05 .04 -
4. Surgency -.04 .25** .49** -
5. Prenatal Depressive
Symptoms
.23** .10 -.07 -.03 -
6. Postpartum
Depressive Symptoms
.09 .14* -.10 -.04 .58** -
7. Prenatal Stress .38** .17** -.05 -.05 .65** .38** -
8. Postpartum Stress .17** .19** -.23** -.11* .55** .74** .56** -
9. Prenatal Social
Contact
- .08 .03 .12 -.17** -.11 -.17** -.15* -
1. Postpartum Social
Contact
- -.25** -.04 -.10 -.07 -.09 -.12 -.12 .30** -
11. Fetal Exposure to
Pandemic (Days)
.72** .24** .03 -.03 .14* .03 .19** .08 .05 -.04 -
12. Infant Age at
Postpartum Survey
.05 .02 .02 .07 .04 .02 .09 .07 -.07 .03 -.06 -
13. Maternal Age .18** .18** .04 .08 -.15** -.06 -.07 -.01 -.02
-
.197**
.08 .04 -
14. First Time Parent .40** .06 -.02 -.06 .14* .05 .20** .10 -.09 -.04 .19** .15** .23** -
15. Highest Education .05 .20** -.07 -.06 -.23** -.07 -.06 .05 .10 -.11 .09 -.13* .35** -.09 -
16. Underrepresented
Race/Ethnicity
-.34** -.02 .13* .11* -.11* -.09 -.17** -.09 .03 .01 -.17** .02 -.19** -.17** -.09
17. Black -.01 .12* .09 .10 .00 .01 -.07 -.03 .12 .02 .08 .09 -.04 .00 -.09
18. Hispanic/Latina -.22** -.15** .10 .11 -.08 -.13* -.07 -.12* -.13* -.02 -.15** -.02 -.21** -.08 -.15**
19. American Indian/
Alaska Native
-.11 -.01 .06 .07 .01 -.04 -.01 -.01 - - -.08 .08 -.03 -.04 -.10
20. Asian/Pacific
Islander
-.22** .01 .02 .00 -.12* -.02 -.15** .00 .140* .03 -.14* -.07 -.02 -.16** .12*
21. Multiracial/Other -.13* .03 -.02 -.07 .05 .02 .02 .05 -.09 -.03 -.06 .04 -.02 -.03 .00
Note:
*
p < 0.05;
**
p < 0.01;
***
p < 0.001
96
95
Table 3.3
Bootstrapped regression analyses for prediction of negative affectivity based on mental health variables
across the full sample and based on social contact within the pandemic sample.
Model Number of
Bootstrap
Samples
B SE p (95%) CI
Full Sample
Prenatal Depressive
Symptoms
n = 315
4993 0.02 .01 .006 0.01, 0.04
Postpartum Depressive
Symptoms
n = 332
4999 0.02 .01 .009 0.01, 0.04
Prenatal Stress
n = 335
4996 0.03 .01 .002 0.01, 0.04
Postpartum Stress
n = 330
4994 0.02 .01 .002 0.01, 0.04
Pandemic
Group
Prenatal Social Contact
n = 256
4783 0.05 .09 .569 -0.14, 0.22
Postpartum Social
Contact
n = 259
4783 -0.36 .10 <.001 -0.56, -0.17
Note. Each line represents an individual model controlling for infant age at the postpartum survey,
maternal age, first-time parenthood, maternal education, and identification as Black, Hispanic/Latina,
Asian/Pacific Islander, or Multiracial/Other. We were unable to control for American Indian/Alaska
Native in bootstrapped regression analyses due to low case counts, and the number of bootstrap samples
varied due to low cases of participants in self-identifying as Multiracial or Other Race.
97
95
Figure 3.1
Estimated Marginal Means for Negative Affectivity in Pandemic and Pre-pandemic Groups.
Note. Estimated marginal means control for covariates at the following values: baby’s age at three-month
survey = 100.86, maternal age (years) = 32.14, first-time parent = 1.37, highest educations = 4.46, Black
= .07, Hispanic = .11, Asian / Pacific islander = .07, Multiracial / other = .02, American Indian / Alaska
Native = .00
98
95
General Discussion
The COVID-19 pandemic has had widespread impacts across the globe, and maternal
perinatal wellbeing and infant development are not exempt. This dissertation work highlights the
effects of the COVID-19 pandemic on maternal distress and social contact and highlights how
these components may be impacting birth and temperament outcomes.
In Study One, we found that women pregnant during the COVID-19 pandemic reported
significantly higher levels of depressive symptoms, anxiety symptoms, and stress, as well as
weaker prenatal bonding with their babies as compared with a pre-pandemic comparison group.
We found associations between maternal distress and perceived impact on social connection,
with heightened levels of stress, anxiety symptoms, and depressive symptoms in those who
perceived more negative influences on their social relationships. However, we did not find
associations between maternal distress and self-reported decreases in social contact during the
pandemic. In fact, pandemic-related reductions in social contact were associated with stronger
prenatal bonding with infants. Thus, mothers’ perceptions of negative social impacts may be
more strongly associated with their distress, whereas self-reported changes in social contact
outside the household appeared to support the maternal-fetal bond. This highlights that there may
be both positive and negative impacts of the COVID-19 pandemic on the perinatal experience.
Given that prenatal mental health problems are associated with a wide array of negative birth and
developmental outcomes for offspring (Bush et al., 2017; E. Davis & Sandman, 2010; Elysia P
Davis et al., 2007; Elysia Poggi Davis et al., 2004; Gerardin et al., 2011; Pacheco & Figueiredo,
2012; Räikkönen et al., 2015), this evidence for heightened distress in pregnant women during
the pandemic is of concern.
99
95
Increases in maternal mental health problems and decreases in social contact during the
pandemic affect not only mothers, but also infants. In Study Two, we found that within the
pandemic sample, greater self-reported decreases in social contact were related to lower infant
birth weight. This finding appeared to be driven by increased depressive symptoms among
expectant mothers such that those with greater decreases in social contact experienced more
depressive symptoms, which in turn predicted lower birth weight. With this finding, we further
the literature on the impacts of perinatal social support, providing support for a relationship
between maternal social contact and birth weight, and extending the literature to explore the
association during COVID-19, a period when social contact has been particularly limited.
In Study Three, we followed participants beyond the birth of their child and into the
postpartum period. We found that mothers who were pregnant during the pandemic reported
higher levels of negative affectivity in their infants at three months postpartum, as compared
with a pre-pandemic comparison group. Our analyses suggest that maternal distress and social
contact appear to play a role in this difference. Both maternal prenatal and postpartum stress
helped to explain higher levels of infant negative affectivity during the COVID-19 pandemic,
and mothers’ prenatal but not postpartum depressive symptoms were also associated with infant
negative affectivity. We did not find that pandemic status moderated our findings, suggesting
that the strength and direction of the relationship between maternal distress and infant negative
affectivity remained consistent across the two samples, and our finding that levels of infant
negative affectivity were higher in our pandemic sample is explained by the increased rates of
maternal distress that we found. This work makes a substantial contribution to the literature as it
is the first to explore differences in infant temperament during the pandemic as compared with a
100
95
pre-pandemic comparison group, establishing a foundation for research on infant socioemotional
development during the COVID-19 pandemic.
Taken together, our findings highlight that pregnant women reported significantly greater
mental health problems during the first wave of the COVID-19 pandemic than within our pre-
pandemic sample. Moreover, these mental health concerns, along with decreases in maternal
social contact, are associated with infant health and development during the pandemic. Our
findings point to a substantial need for maternal and infant support during this time. Further work
should explore the effectiveness of interventions aimed at strengthening prenatal social support
and reducing maternal distress to improve maternal and child well-being, and continued research
and monitoring will be needed to assess the lasting impacts of the pandemic over the years and
decades to come.
101
95
References
Bush, N. R., Jones-Mason, K., Coccia, M., Caron, Z., Alkon, A., Thomas, M., Coleman-Phox, K.,
Wadhwa, P. D., Laraia, B. A., & Adler, N. E. (2017). Effects of pre-and postnatal maternal stress
on infant temperament and autonomic nervous system reactivity and regulation in a diverse, low-
income population. Development and Psychopathology, 29(5), 1553–1571.
Davis, E. P., Glynn, L. M., Dunkel-Schetter, C., Hobel, C., Chicz-Demet, A., & Sandman, C. A.
(2007). Prenatal exposure to maternal depression and cortisol influences infant temperament.
Journal of the American Academy of Child and Adolescent Psychiatry, 46(6), 737–746.
https://doi.org/10.1097/chi.0b013e318047b775
Davis, E. P., Snidman, N., Wadhwa, P. D., Glynn, L. M., Dunkel-Schetter, C., & Sandman, C. A.
(2004). Prenatal maternal anxiety and depression predict negative behavioral reactivity in
infancy. Infancy, 6(3), 319–331. https://doi.org/10.1207/s15327078in0603_1
Davis, E., & Sandman, C. (2010). The timing of prenatal exposure to maternal cortisol and
psychosocial stress is associated with human infant cognitive development. Child Development,
81(1), 131–148. https://doi.org/10.1111/j.1467-8624.2009.01385.x
Gerardin, P., Wendland, J., Bodeau, N., Galin, A., Bialobos, S., Tordjman, S., Mazet, P., Darbois, Y.,
Nizard, J., Dommergues, M., & Cohen, D. (2011). Depression during pregnancy: Is the
developmental impact earlier in boys? A prospective case-control study. Journal of Clinical
Psychiatry, 72(3), 378–387. https://doi.org/10.4088/JCP.09m05724blu
Pacheco, A., & Figueiredo, B. (2012). Mother’s depression at childbirth does not contribute to the
effects of antenatal depression on neonate’s behavioral development. Infant Behavior and
Development, 35(3), 513–522. https://doi.org/10.1016/j.infbeh.2012.02.001
102
95
Räikkönen, K., Pesonen, A. K., O’Reilly, J. R., Tuovinen, S., Lahti, M., Kajantie, E., Villa, P.,
Laivuori, H., Hämäläinen, E., Seckl, J. R., & Reynolds, R. M. (2015). Maternal depressive
symptoms during pregnancy, placental expression of genes regulating glucocorticoid and
serotonin function and infant regulatory behaviors. Psychological Medicine, 45(15), 3217–3226.
https://doi.org/10.1017/S003329171500121X
Abstract (if available)
Abstract
Study 1
We compared 572 pregnant women (319 first-time mothers) surveyed in spring 2020, during the first wave of COVID-19 lockdowns in the United States, with 99 pregnant women (all first-time mothers) surveyed before the pandemic (2014– 2020). Compared with the pre-pandemic sample, women assessed during the pandemic showed elevated depression, anxiety, and stress and weaker prenatal bonding to their infants. These findings remained significant when restricting the pandemic sample to first-time mothers only and held after controlling for race/ethnicity, education, and pregnancy stage. Average levels of depression and anxiety within the pandemic group exceeded clinically significant thresholds, and women who estimated that the pandemic had more negatively affected their social relationships reported higher distress. However, pandemic-related changes to social contact outside the household were inconsistently associated with mental health and with some positive outcomes (fewer depressive symptoms, stronger prenatal bonding). Given that prenatal stress may compromise maternal and child well-being, the pandemic may have long-term implications for population health.
Study 2
Social support and mental health during pregnancy have been associated with birth outcomes such as infant birth weight. The COVID-19 pandemic has had drastic impacts both on social connectedness and mental health, with evidence that pregnant women reported elevated prenatal depression, anxiety symptoms, and stress during the height of pandemic lockdowns. To date, no work has explored whether maternal social contact and mental health predict infant birth weight during the COVID-19 pandemic. A sample of 262 pregnant U.S. women completed an online questionnaire assessing social contact, depressive symptoms, anxiety symptoms, stress, and partner relationship satisfaction during the first wave of the COVID-19 pandemic. At three months postpartum, they reported on birth weight and gestational age. All analyses controlled for maternal age, education, race/ethnicity, and first-time parenthood. We found that maternal self-reported decreases in social contact during the pandemic were significantly associated with lower infant birth weight. This association was moderated by maternal prenatal depressive symptoms but not by prenatal anxiety symptoms or stress. Partner relationship quality did not appear to buffer the association between prenatal support and infant birth weight. Decreased social contact during the COVID-19 pandemic has implications for maternal and infant health. Prenatal maternal social contact appears to influence birth weight via impacts on maternal depressive symptoms. Interventions aimed at bolstering social support and decreasing depressive symptoms in perinatal populations are essential during and after the COVID-19 pandemic, as the social restructuring occasioned by the pandemic may lead to lasting changes in social behavior.
Study 3
COVID-19 pandemic lockdowns have been associated with heightened mental health risks in pregnant women and new parents. Given that maternal perinatal distress is a risk factor for poorer infant socioemotional development, exploration of the potential effects of maternal distress on infant temperament is warranted. We compared two samples: 263 U.S. women who were pregnant during the COVID-19 pandemic and 72 U.S. women who were pregnant prior to the pandemic. Women in each sample completed questionnaire measures assessing prenatal and postpartum depressive symptoms via the Beck Depression Inventory-II, prenatal and postpartum stress using the Perceived Stress Scale 14, and infant temperament at three months postpartum using the Very Short Form of the Revised Infant Behavior Questionnaire. The pandemic sample also answered questions regarding changes to social contact due to the pandemic. ANCOVA, linear regression, mediation, and moderation analyses were conducted to explore relationships between maternal mental health, social contact, and infant temperament variables. Analyses controlled for baby’s age at three months, maternal age, maternal education, self-reported race/ethnicity, and first-time parenthood. At three months postpartum, mothers rated infants born during the COVID-19 pandemic as having significantly higher negative affectivity than did mothers of infants born prior to the pandemic (F(1,324) = 18.28, p <.001). We did not find differences in infant surgency or effort control. Maternal prenatal and postpartum stress and depressive symptoms predicted infant temperament, and prenatal stress [0.13 (95% CI 0.01, 0.27)], postpartum stress [0.06 (95% CI 0.01, 0.13)], and prenatal depressive symptoms [0.07 (95% CI 0.00, 0.16)] mediated differences in infant negative affectivity between pandemic and pre-pandemic samples. Pandemic group status did not moderate associations between prenatal depressive symptoms and infant negative affectivity. Finally, mothers’ reports of decreased postpartum social contact were significantly associated with more infant negative affectivity. We found that mothers reported more negative affectivity among infants born during the COVID-19 pandemic as compared with infants born prior to the pandemic. Increased maternal distress during the pandemic, specifically prenatal depressive symptoms and prenatal and postpartum stress, appeared to explain these differences. We did not find that maternal distress during the pandemic differentially impacted infant temperament as compared with pre-pandemic; instead, these increases were due to increased levels of maternal mental health problems. Furthermore, postpartum maternal social contact during the pandemic was associated with infant negative affectivity, and this association was not explained by maternal distress.
Linked assets
University of Southern California Dissertations and Theses
Conceptually similar
PDF
Prenatal predictors of parental sensitivity in first-time mothers and fathers
PDF
Supporting a high value maternity system of care: prioritizing resilience of and relationships with mothers to improve maternal and child health
PDF
The old ball and linkage: couples’ prenatal conflict behavior, cortisol linkage, and postpartum depression risk
PDF
Bridging the divide in perinatal mental health
PDF
Inhibitory control in first-time fathers: Neural correlates and associations with paternal mental health
PDF
The impact of childhood trauma on substance use and mental health during the SARS-CoV-2 pandemic among young adults
PDF
Couple conflict during pregnancy: Do early family adversity and oxytocin play a role?
PDF
Fathers' cross-sectional and longitudinal white matter microstructure organization during the transition to parenthood
PDF
Maternal mental health matters: Creating FQHC+ to meet the complex needs of perinatal women of color
PDF
Relationships and meaning: examining the roles of personal meaning and meaning-making processes in couples dealing with important life events
PDF
Examining the associations of respiratory problems with psychological functioning and the moderating role of engagement in pleasurable activities during late adolescence
PDF
Neural and behavioral correlates of fear processing in first-time fathers
PDF
Association of maternal and environmental factors with infant feeding behaviors in a birth cohort study
PDF
The impact of the COVID-19 pandemic on K–12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals
PDF
Effect of biomass fuel exposure on infant respiratory health outcomes in Bangladesh
PDF
Neighborhood context and adolescent mental health: development and mechanisms
PDF
The good and the bad of pandemic-era public policy
PDF
The impact of the COVID-19 pandemic on K–12 public school districts in southern California: responses of superintendents, assistant superintendents, and principals
PDF
Incarceration trajectories of mothers in state and federal prisons and their relation to the mother’s mental health problems and child’s risk of incarceration
PDF
Impacts of caregiving on wellbeing among older adults and their spousal caregivers in the United States
Asset Metadata
Creator
Morris, Alyssa Rae (author)
Core Title
Pregnancy in the time of COVID-19: effects on perinatal mental health, birth, and infant development
Contributor
Electronically uploaded by the author
(provenance)
School
College of Letters, Arts and Sciences
Degree
Doctor of Philosophy
Degree Program
Psychology
Degree Conferral Date
2022-08
Publication Date
07/26/2022
Defense Date
05/19/2022
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
birth outcomes,COVID-19,infant development,maternal mental health,OAI-PMH Harvest,pandemic,perinatal
Format
application/pdf
(imt)
Language
English
Advisor
Saxbe, Darby (
committee chair
), Beam, Christopher (
committee member
), Manis, Frank (
committee member
), Margolin, Gayla (
committee member
), West, Amy (
committee member
)
Creator Email
alyssarm@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC111375217
Unique identifier
UC111375217
Legacy Identifier
etd-MorrisAlys-10993
Document Type
Dissertation
Format
application/pdf (imt)
Rights
Morris, Alyssa Rae
Type
texts
Source
20220728-usctheses-batch-962
(batch),
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Repository Email
cisadmin@lib.usc.edu
Tags
birth outcomes
COVID-19
infant development
maternal mental health
pandemic
perinatal