Clínica y Salud (2023) 34(2) 71-78

Clínica y Salud
h t t p s : / / j o u r n a l s. c o p m a d r i d. o r g / c l y s a

Perinatal Mental Health during the COVID-19 Pandemic: A Longitudinal Study

Covadonga Chavesa, Ioana Mezeia, Carlos Marchenab, and Almudena Duquec
Complutense University of Madrid, Spain; bUniversidad Francisco de Vitoria, Madrid, Spain; cPontifical University of Salamanca, Spain
a

ARTICLE INFO A B S T R A C T

Article history: Few studies have shown the psychological impact of the COVID-19 pandemic on new mothers’ health, but the long-term
Received 25 November 2022 consequences of the crisis are yet unknown. This study aimed at evaluating the changes experienced in perinatal mental
Accepted 22 May 2023 health 6 months after the start of the COVID-19 pandemic in Spain. Women (n = 176, average age = 33.80) were recruited
during the pandemic. Participants completed the Edinburgh Postnatal Depression Scale, the Satisfaction With Life Scale and
Positive, and the Negative Affect Schedule. Results showed a decrease in depressive symptoms, t(174) = 2.58, p = .01, d = 0.02,
Keywords:
whereas anxiety symptoms remained high, t(174) = 1.31, p = .19. In terms of psychological well-being, the results showed a
Perinatal mental health
decrease in life satisfaction, t(175) = 2.58, p = .011, d = 0.16, and negative affect, t(175) = 3.15, p = .002, d = 0.26, and an increase
Well-being
Depression in positive affect, t(175) = -4.45, p < .001, d = 0.35. This study is expected to shed light on the design of future interventions
Anxiety aimed at the prevention of symptoms and to enhance life satisfaction during the perinatal stage.
Pandemic

La salud mental perinatal durante la pandemia de la COVID-19: un estudio

longitudinal

R E S U M E N
Palabras clave:
Algunos estudios han mostrado el impacto psicológico de la pandemia de COVID-19 en la salud mental perinatal, pero
Salud mental perinatal
Bienestar aún se desconocen las consecuencias a largo plazo de esta crisis sanitaria. El presente estudio tuvo como objetivo evaluar
Depresión los cambios en la salud mental perinatal tras 6 meses del inicio de la pandemia de la COVID-19 en España. Se reclutaron
Ansiedad mujeres en etapa perinatal (n = 176, edad promedio = 33.80) durante la pandemia. Las participantes cumplimentaron la
Pandemia Escala de Depresión Postparto de Edimburgo, una escala de satisfacción con la vida y otra de afecto positivo y negativo. Los
resultados mostraron una disminución de los síntomas depresivos a los 6 meses, t(174) = 2.58, p = .01, d = 0.02, mientras que
los síntomas de ansiedad se mantuvieron elevados, t(174) = 1.31, p = .19. En cuanto al bienestar psicológico, los resultados
mostraron una disminución en la satisfacción con la vida, t(175) = 2.58, p = .01, d = 0.16, y en el afecto negativo, t(175) = 3.15,
p = .002, d = 0.26, y un aumento en el afecto positivo, t(175) = -4,45, p < .001, d = 0.35. Se espera que este estudio arroje luz
sobre el diseño de futuras intervenciones dirigidas a la prevención de síntomas y a la mejora de la satisfacción con la vida
durante la etapa perinatal.

Among the general population, mental health problems tend to 45%) (Viveiros & Darling, 2018). Other common symptoms during this
be more common among women than men (Guimaraes et al., 2019). period include excessive worry, uncertainty, and stress.
Furthermore, certain stages in the life cycle of women can facilitate Although women in the perinatal stage generally receive
the appearance of psychological problems, particularly the perinatal regular care and attention from healthcare professionals,
stage (Dunkel-Schetter, 2011). The perinatal stage encompasses the psychological problems during this stage remain underdiagnosed
process of pregnancy and the year following birth (Yu et al., 2021). A and undertreated in comparison to other stages in women’s lives
period is characterised by a multitude of changes: physical, mental, (Bina & Glasser, 2019). The lack of time, the associated stigma,
social, cultural and established gender roles (Hoekzema et al., 2020). or the lack of knowledge about perinatal depression and its
Although the experience of maternity is usually associated with consequences prevent these women from seeking help (Grissette
positive emotions, the perinatal stage may be extremely stressful et al., 2018). Also, there are several institutional barriers that
(Geller, 2004). The most common symptomologies among pregnant can restrict access to health services, such as lack of human
women or new mothers are depression (10%-20%) and anxiety (25%- resources or inadequate training, lack of time for consultations,

Cite this article as: Chaves, C., Mezei, I., Marchena, C., & Duque, A. (2023). Perinatal mental health during the COVID-19 pandemic: A longitudinal study. Clínica y Salud, 34(2), 71-78.
https://doi.org/10.5093/clysa2023a18

Correspondence: cchavesv@ucm.es (C. Chaves).

ISSN:1130-5274/© 2023 Colegio Oficial de la Psicología de Madrid. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
72 C. Chaves et al. / Clínica y Salud (2023) 32(2) 71-78

or simply lack of recognition of the problem by the health system with greater life satisfaction during the first wave of the pandemic
(Prevatt & Desmasaris, 2018). Thus, identifying early indicators of (Chaves et al., 2022).
perinatal depression is a crucial public health issue (NICE, 2014). Psychological distress experienced during the public health
Furthermore, beyond merely identifying psychological symptoms, emergency may be related to the various measures imposed to bring
promoting maternal well-being has become a key issue in perinatal the pandemic under control. Firstly, restrictions on mobility and
mental health (NICE, 2014). In this line, the WHO (2019) has called social relations made it difficult to establish a normal routine and
for action to ensure a positive maternal experience that satisfies the social support was significantly diminished (Caparrós-González et al.,
expectations, personal beliefs, and sociocultural circumstances of 2020). Secondly, misinformation about the real risks of infection led
women. This proposal would imply knowing and assessing not only to the imposition of procedures and protocols which were potentially
psychological symptoms, but also well-being and life satisfaction harmful to women’s mental health, such as restrictions on hospital
during this stage. visits or support during childbirth (Matvienko-Skikar et al., 2020).
Recent studies have found that the risk of transmission of COVID-19
Psychological Consequences of COVID-19 from an infected mother to their baby through breastfeeding is low
and the WHO highly recommends skin-to-skin contact between
The global pandemic of SARS-CoV-2 (COVID-19) beginning in mothers and newborns to establish an affective connection
late 2019 has brought dramatic changes to ordinary life. Although (Matvienko-Sikar et al., 2020). However, despite the evidence, the
COVID-19 is a physical illness, the mental health consequences protocols and organisation of neonatal units have been significantly
can be very significant (Parrish, 2020) and there is no doubt the modified, possibly impacting the psychological well-being of mothers
changes wrought by the pandemic caused a great deal of anxiety and and babies.
insecurity among the general public (Usher et al., 2020). The public health crisis caused by COVID-19 has posed a serious
In Spain, the psychological consequences of the pandemic have challenge to perinatal health. There are some Spanish studies
been evident. A study conducted during the first wave of COVID found examining the psychological impact of the pandemic during the
that 22.1% of people surveyed experienced symptoms of depression perinatal period (e.g., Awad-Sirhan et al., 2022; Caparrós-González et
and 19.6% symptoms of anxiety (Valiente et al., 2020). Within these al., 2020; Chaves et al., 2022; Motrico et al., 2022; Puertas-González
percentages it was observed that women rather than men and the et al., 2021), but their long-term consequences are yet unknown.
young rather than the elderly experienced greater psychological Hence, it is necessary to conduct longitudinal studies which can shed
distress (Valiente et al., 2020). This study also found high levels of light on the evolution of symptoms of depression and anxiety and
well-being during the pandemic. This underscores the fact that perinatal well-being during the pandemic.
distress and well-being are relatively independent dimensions and The aim of the present study is to evaluate the longitudinal
should be evaluated separately (Keyes, 2007). changes experienced in perinatal mental health 6 months after
Ongoing safety measures, such as social distancing and the onset of the COVID-19 pandemic in Spain. The specific
intermittent confinement, had a negative impact on mental health in objectives are: 1) to analyse the changes in psychological distress
general (Chaves de Lima et al., 2020). These measures increased the (i.e., symptoms of depression and anxiety) during the perinatal
likelihood of symptoms of psychological distress, such as substance stage after 6 months of pandemic; 2) to evaluate the changes in
abuse, depression and anxiety, intrafamily and/or domestic violence, psychological well-being (life satisfaction and affective balance); 3)
insomnia, loneliness, and suicide (Chaves de Lima et al., 2020; Parrish, to identify the variables regarding the physical health of the baby
2020). Furthermore, the absence of clear information and constant and mother which may influence these changes; and 4) to explore
uncertainty gave rise to feelings of panic, confusion, discrimination, the changes after 6 months depending on the perinatal situation
and anger (Usher et al., 2020). (i.e., women who remained in the same perinatal stage vs. women
Thus, symptomologies must be evaluated over time in order who have passed from the pregnancy stage in the first wave to the
to understand the long-term impact on psychological well-being postpartum stage in the second wave).
and to identify risk and protection factors among the general
population. Wang et al. (2020) conducted a longitudinal study in Method
China during the first wave (end of January 2020) and the second
wave (end of February 2020) of the pandemic. The study found Participants
that rates of anxiety and depression remained stable. The results
also showed that symptoms of post-traumatic stress, while slightly The sample consisted of 176 women (> 18), who were pregnant
lower, continued to be significant. or who had a baby (postnatal period up to a maximum of 6 months)
at the moment of the initial evaluation at the start of the first
Perinatal Mental Health during COVID-19 confinement period for COVID-19 in Spain (April, 2020; for details,
see Chaves et al., 2022)1. In the first wave, 59.1% of the women were
The experience of stress may increase certain mental health pregnant (average months of pregnancy = 6.9, SD = 1.59) and the
problems during the perinatal stage (WHO, 2020) and it is highly 40.9% were in the postnatal period (average months from birth = 2.2,
probable that the pandemic has had an impact on the perinatal SD = 1.55). In the second wave, 1.7% of the women were pregnant
mental health (Motrico et al., 2022). High rates of anxiety and (average month of pregnancy = 7.5, SD = .9) and 98.3% were in the
depression have been found in women in the perinatal stage in postnatal period (average months from birth = 6.56, SD = 3.36).
various countries and cultures (e.g., United Kingdom, China, Canada, The mean age of participants was 33.80 years of age (SD = 3.89). The
Australia, India) (Caparrós-González et al., 2020). In Spain, high majority of participants were university graduates (79.4%), followed
levels of perinatal mental distress have also been identified. A study by those with vocational training (14.3%), secondary education
by Chaves et al. (2022) of 724 women in the perinatal stage found (5.1%), and primary education (1.1%). Regarding civil status, 92.6%
high levels of symptoms of depression and anxiety (58.7% and 51.2% of participants were married or lived with their partner, 6.9% were
respectively). Despite these high rates of psychological distress, the single, and only 0.6% were separated or divorced. As for employment,
levels of well-being were also high. Factors such as being married, 41.7% were on maternity leave, followed by 39.4% who were working,
being a health worker, the perception of their own or their baby’s some 12% were unemployed, 6.3% were working domestically, and
good health, healthy eating, and sleeping habits were all associated 0.6% were students.
 Perinatal Mental Health during COVID-19 73

Measures snowball sampling. The initial evaluation was made during the first
confinement in Spain (April, 2020) and the results have already
Sociodemographic Information been published (Chaves et al., 2022). The second evaluation was
made in October 2020, a period when the restrictions imposed
The participants provided information on their age, civil status, for COVID-19 were looser and more selective (i.e., according to
education and current employment situation, and perinatal stage (i.e., incidence). This second wave only included participants of the
prenatal/postnatal). first study who agreed to participate in the follow-up study. In
both waves participants provided their informed consent prior to
Information regarding their Health and the Health of the Baby completing an online form. The same assessment protocol was
completed at time 1 and time 2. Participation was voluntary and
Women answered one question regarding their health (i.e., “My participants did not receive any reward. This study was approved
physical health is…/My physical health in the last 6 months has by the University Ethics Committee (reference 2019/20-033) and
been…”) and three questions regarding the health of their baby: 1) “The was conducted in compliance with the Declaration of Helsinki.
health of the baby (or foetus) is/The health of the baby (or foetus) in the
last 6 months has been…”; 2) “The baby’s feeding is/The baby’s feeding Data Analysis
during the last 6 months has been…”; 3) “The sleep of the baby is/The
sleep of the baby during the last 6 months has been…”. The last two In order to analyse the changes to psychological well-being and
items (i.e., feeding and sleep) were presented only to women who had distress after 6 months of pandemic, a series of Students’ t tests
given birth. These four items were answered using a Likert-type scale were conducted for repeated measurements (i.e., time 1 vs. time
from 1 (poor) to 5 (excellent). 2). Also, differences between pregnant women and women during
postpartum in both waves were also analysed using Students’ t.
Information on the Pandemic A chi-square independence test was conducted to analyse the
difference in prevalence of symptoms in both waves using the cut-
Two questions were included on worries associated with COVID offs indicated above for the EPDS.
(i.e., “Have you been worried about the possibility your baby/foetus will To identify the possible variables related to the changes a series of
catch COVID-19? and “Did you worry hospitals would be overwhelmed bivariate correlations were made between the variables on the baby’s
because of COVID at the time of giving birth?”). These two questions and mother’s health at T1 and residual scores between T1 and T2 of
were answered on a 6-point Likert-type scale ranging from 0 (very the variables for the symptoms and well-being. Residualised scores
slightly or not at all) and 5 (extremely). were obtained by removing from the T2 score the portion that can
be linearly predicted by the T1 score (Castro-Schilo & Grimm, 2018).
Finally, to analyse the influence of the perinatal situation on the
Edinburgh Postnatal Depression Scale (EPDS; García-Esteve et
symptomologies and well-being, the sample was divided into two
al., 2003).
groups: 1) women who remained in the same perinatal stage (i.e.,
pregnant or in the postpartum stage for both waves) and 2) women
The Edinburgh Postnatal Depression Scale (EPDS) is a self-reporting
who had changed their perinatal stage between the first and second
questionnaire consisting of 10 questions designed to measure the
wave (from pregnancy to postpartum). To analyse the main effects
symptoms of depression during the perinatal stage. The questionnaire
of time and group interaction, a series of mixed 2 x 2 ANOVA tests
has a Likert-type scale with a range of 4 points, with answers from 0
were conducted. All the statistical tests were parametric, since the
(never) to 3 (very often). The reliability obtained in this study was α
sample size allowed assuming normality in the distribution (Pardo
= .87. The optimum cut-off score on EPDS is 11 or more (Terren et al.,
et al., 2009).
2003). Moreover, the cut-off score on the anxiety subscale (i.e., items 3,
The data obtained in the study was analysed using the Statistical
4 and 5) is six or more (Matthey, 2008).
Package for the Social Sciences 25.0 (SPSS) for Windows.

Satisfaction with Life Scale (SWLS; Vázquez et al., 2013)

Results
This is a questionnaire consisting of 5 questions to evaluate the
Analysis of Changes in Psychological Distress and Well-being
level of life satisfaction using a global score of the responses. The
questionnaire uses a Likert-type scale with a range of 7 points, with
Table 1 provides the descriptive statistics for waves 1 and 2.
answers from 1 (strongly disagree) to 7 (strongly agree). The reliability
Regarding psychological distress, a statistically significant decrease
obtained in this study was α = .84.
in the prevalence of symptoms of depression, t(174) = 2.58, p = .01, d =
0.02, was found over the 6-month period. Differences were also found
Positive and Negative Affect Schedule (PANAS; López-Gómez et in the proportion of women who reported symptoms of perinatal
al., 2015) depression (EPDS ≥ 11) in October compared to April, c2(1)= 16.21,
p < .001, phi = .30. The prevalence of depression in the second wave
This is a self-reporting questionnaire consisting of 20 items, 10 of (October) was 54.3%, compared to 60% in the first wave (April). Of this
which refer to the positive affect subscale and 10 to the negative affect percentage, 14.3% were new cases (n = 25). Some 20% of participants
subscale. The questionnaire uses a Likert-type scale of 5 points, from (n = 35) stopped experiencing symptoms of depression in the
1 (very slightly or not at all) and 5 (extremely). The reliability for this second wave while 40% (n = 70) continued to experience depressive
study was α = .88 and α = .89, for the positive and negative subscales symptoms from the first wave and 25.7% (n = 44) remained without
respectively. any symptoms.
Symptoms of anxiety remained stable over the 6 month period
Procedure without any statistically significant differences, t(174) = 1.31, p = .19.
The prevalence of anxiety in the second wave (October) was 53.4%,
The study was conducted using the Qualtrics platform (https:// similar to the 54,6% in the first wave (April). Of this percentage,
www.qualiatrics.com) and distributed through social media using 17.7% were new cases (n = 31). Some 18.9% of participants (n = 33)
74 C. Chaves et al. / Clínica y Salud (2023) 32(2) 71-78

stopped experiencing anxiety in the second wave while 35.4% (n = SWLS were women in postpartum phase showed higher levels of
62) continued to experience symptoms of anxiety since the first wave satisfaction with life in the first wave (Table 2).
and 28% (n = 49) had no symptoms.
Effect of the Physical Health of Mother and Baby on Changes in
Table 1. Descriptive Statistics and analysis of the Differences between Waves Symptoms and Psychological Well-being
1 and 2
T1 T2 A series of bivariate correlations were performed to explore the
M SD M SD t p d effect of the physical health of the mother and baby at time 1 on chan-
EPDS 12.54 5.32 11.46 5.70 2.58 .01 0.20 ges in symptomology and psychological well-being (Table 3). The re-
EPDS Anxiety 7.60 2.29 7.34 2.69 1.31 .19 0.10 sults show that the quality of the baby’s sleep is associated with lower
SWLS 26.14 5.68 25.22 6.15 2.58 .01 0.16 levels of depression (r = -16, p =.03) and negative emotions (r = -20, p
PANAS Positive 28.73 6.96 31.16 7.08 -4.39 < .001 0.35 = .01), and an increase in positive emotions (r = 15, p = .04). The baby’s
PANAS Negative 23.42 7.13 21.53 8.41 3.16 .002 0.26 health is also associated with an increase in positive emotions of the
Note. EPDS = Edinburgh Postnatal Depression Scale; SWLS = Satisfaction With Life mother (r = .17, p =.02). Finally, the mother’s health is associated with a
Scale; PANAS = Positive and Negative Affect Schedule. reduction in depression levels (r = -.22, p = .003) and negative emotions
(r = -.25, p =.001), and increased positive emotions (r = .20, p =.007).

In relation to symptoms of anxiety, it should be noted that 47.5%

of participants reported being worried about the possibility of their Effect of the Change in Perinatal Stage on Psychological Well-
baby/foetus becoming infected with COVID-19. Furthermore, 61% being and Distress
reported being worried about hospitals being overwhelmed at the
time of giving birth. To analyse the influence of the perinatal stage on symptomologies
Regarding psychological well-being, statistically significant and well-being, the sample was divided into two groups: 1) women
differences were found in life satisfaction, t(175) = 2.58, p = .011, d who remained in the same perinatal stage (i.e., pregnant or in the
= 0.16, with lower levels after 6 months. Statistically significant postpartum stage for both waves) and 2) women who changed
differences were also observed in the two subscales of affective perinatal stage between the first and second wave (from pregnancy to
balance, with an increase in positive affect, t(175) = -4.45, p < .001, postpartum). First, the differences between the two groups in the first
d = 0.35, and a decrease in negative affect, t(175) = 3.15, p = .002, d = evaluation (April) were analysed. No significant initial differences were
0.26, after 6 months. found between the groups for any of the analysed variables: depression
Differences between the pregnant women and women during (t = -4.53, p = .651), anxiety (t = .087, p = .931), positive emotions
postpartum in both waves were also tested. No significant (t = 1.353, p = .178), negative emotions (t =1.842, p = .067), and life
differences were found in any of the variables included, except for satisfaction (t = .371, p = .711).

Table 2. Descriptive Statistics and Analysis of the Differences between Pregnant Women and Women during Postpartum in Both Waves
Time 1 Time 2
Pregnant Postpartum Pregnant Postpartum
t (p) R2xy t (p) R2xy
M SD M SD M SD M SD
EPDS 12.65 4.99 12.38 5.80 0.32 (.74) .00 13.33 5.03 11.43 5.71 0.57 (.56) .00
EPDS Anxiety 7.64 2.14 7.54 2.51 0.29 (.77) .00 9.66 2.51 7.30 2.68 1.50 (.13) .01
SWLS 25.39 5.56 27.21 5.70 -2.10 (.03) .01 26.66 3.51 25.19 6.18 0.41 (.68) .00
PANAS Positive 28.01 7.36 29.76 6.23 -1.65 (.10) .02 5.85 3.38 31.14 7.11 0.29 (.77) .00
PANAS Negative 23.53 6.95 23.25 7.41 0.26 (.79) .00 24.33 8.96 21.47 8.41 0.58 (.56) .00

Table 3. Bivariate Correlations between the Physical Health of Mother/Baby at Time 1 and Changes over Time
Residualised Residualised Residualised
Residualised EPDS
SWLS PANAS Positive PANAS Negative
Baby’s sleep (n = 56) -.16* .11 .15* -.20**
Baby’s feeding (n = 56) -.12 .07 .10 -.07
Baby’s health (n = 176) -.11 .10 .17* -.12
Mother’s health (n = 176) -.22** .12 .20** -.25**

Note. Residualised scores were obtained by removing from the T2 score that portion that can be linearly predicted by the T1 score.
* p < . 05, **p < .01.

Table 4. Descriptive Statistics and ANOVA of the Repeated Measures for Variables in Psychological Well-being and Distress in Both Groups
Group 1 Group 2 Principal effect Principal effect
Interaction effect
T1 T2 T1 T2 (Group) (Time)
M SD M SD M SD M SD F (p) h 2
F(p) h
2
F (p) h2
EPDS 12.33 5.36 13.13 5.82 12.72 5.28 10.68 5.45 2.01 (.15) .01 2.08 (.15) .01 10.79 (.001) .06
EPDS Anxiety 7.64 2.19 7.89 2.62 7.61 2.33 7.09 2.69 1.71 (.19) .01 0.41 (.52) .002 3.49 (.02) .02
SWLS 26.37 5.93 24.86 6.26 26.03 5.59 25.40 6.13 0.01 (.92) .00 7.96 (.005) .04 1.35 (.25) .01
PANAS Positive 29.66 6.24 29.62 7.23 28.16 7.23 31.92 6.92 0.22 (.63) .00 3.57 (.10) .06 10.96 (.001) .06
PANAS Negative 23.17 7.64 23.33 8.72 23.65 6.81 20.76 8.12 1.02 (.31) .00 5.09 (.20) .03 5.47 (.02) .03
Note. Group 1 = remaining in the same perinatal stage (n = 59); group 2 = change in perinatal stage (n = 117); T1 = first wave; T2 = second wave.
 Perinatal Mental Health during COVID-19 75

EPDS EPDS Anxiety

14 8
12 7.8
10 7.6
8 7.4
6 7.2
4 7
2 6.8
0 6.6
T1 T2 T1 T2
G1 G2 G1 G2

SWLS PANAS Positive

26.5 33
32
26
31
25.5 30
25 29
28
24.5
27
24 26
T1 T2 T1 T2
G1 G2 G1 G2

PANAS Negative
24
23.5
23
22.5
22
21.5
21
20.5
20
19
T1 T2
G1 G2

Figure 1. Interaction effect (time-group) on symptomatology and psychological well-being.

Note. Group 1 = remaining in the same perinatal stage (n = 59); group 2 = change in perinatal stage (n = 117); T1= first wave; T2 = second wave.

Table 4 shows descriptive statistics and the results of the ANOVA and the lifting of many restrictions may explain the decrease in
test of the repeated measures for psychological well-being and depressive symptoms (Ramírez-Ortiz et al., 2020). A study on the
distress variables according to the perinatal stage. The results show types of psychological responses to situations of pandemic found
significant interactions between group and time for depression, that 55.3% of people showed resilience in the face of traumatic
anxiety, and positive and negative emotions. The interaction effects events, a more common response than any other (Valiente et al.,
can be observed in Figure 1. The group experiencing a change in 2020). This may explain the high percentage of mothers who stopped
perinatal stage (from pregnancy to postpartum) showed lower experiencing perinatal depression six months after the first wave. It
levels of depression, anxiety, and negative emotions and higher is important to note that 54.3% of participants showed symptoms of
levels of positive emotions in the second wave (October). This perinatal depression in October, of whom 40% were women whose
interaction was not observed in life satisfaction, that showed a symptoms of depression persisted until April. These high rates of
significant decline for both groups from the first wave (April). perinatal depression coincide with the findings of a study conducted
in Poland, which showed an increase in rates of perinatal depression
Discussion compared to before the pandemic (Chrzan-D tko et al., 2020). These
results underscore the importance of conducting psychological
The aim of this study was to evaluate the changes in perinatal evaluation of women during the perinatal stage.
mental health over the course of 6 months from the onset of the Also of note is that 14% of women without symptoms of depression
COVID-19 pandemic in Spain. Regarding the first specific objective in the initial evaluation reported these symptoms six months later.
(to analyse the changes in psychological distress), it was found that These results show the existence of different patterns of response
symptoms of depression decreased 6 months from the start of the to the pandemic, with some women responding with a delayed
pandemic, where some 20% of participants stopped experiencing depression. It would be interesting to further study the factors
perinatal depression. The results show that the high rates of symptoms associated with these different patterns of response.
of depression at the onset of the pandemic may have been a normal With regard to symptoms of anxiety, it was found that rates
reaction to the stress generated by a public health crisis which was remained stable over the six month period. The findings on levels of
unprecedented for most of the population (Fernández-Theoduloz et psychological distress are in line with the results of a longitudinal
al., 2022). Furthermore, the end of the strict confinement in Spain study on the psychological impact of COVID-19 among the general
76 C. Chaves et al. / Clínica y Salud (2023) 32(2) 71-78

population in Spain which showed a slight decrease in symptoms of of depression and negative emotions was associated with the baby’s
depression and stable levels of anxiety 4 months from the start of better quality of sleep and better physical health of the mother while
the pandemic (González-Sanguino et al., 2021). The authors indicated the increase in positive emotions was associated with the baby’s
that, although the symptoms of depression began to decrease when better sleep and better perceived health of the baby and mother.
the confinement was lifted, concerns about contagion and health These proved to be important factors in explaining symptoms of
persisted over time. Additionally, it was also found that a higher depression in the first wave (Chaves et al, 2022). Sleep disturbances
percentage of women were worried about the possibility of their baby and perceived physical health are variables traditionally associated
catching COVID-19 (47.5%) or that hospitals would be overwhelmed with depression during the perinatal stage (Ross et al., 2005).
at the time of giving birth (61%). These figures reveal the high degree As for the fourth specific objective (i.e., to explore the changes
of uncertainty among women due to the pandemic. The SARS-CoV-2 after 6 months depending on the perinatal situation), it was found
pandemic also caused changes in the protocols and organisation of that women who changed their perinatal stage (from pregnancy to
neonatal units, such as the reduction of hospital stays and restrictions postpartum) had lower levels of depression, anxiety, and negative
on accompaniment during childbirth (Arnáez et al., 2020). These emotions and higher levels of positive emotions six months after the
changes can accentuate the uncertainty and anxiety of mothers, as start of the pandemic as compared to women who remained in the
was found in research into previous public health crises. Research on same perinatal stage. This may indicate that symptoms of depression
the SARS outbreak of 2003 shows that pregnant women were very tend to decrease after childbirth with a simultaneous increase
worried about the risk of infection, transmitting the virus to the in positive emotions. Despite the fact the pandemic and the new
foetus or catching SARS during childbirth or when at the hospital. situation of being a mother are potentially stressful (Geller, 2004), the
Two thirds of women were afraid to go to the hospital and one third birth of the baby may result in a relief of symptoms and the general
adopted strategies to reduce their risk of infection (for example, self- improvement of well-being among the participants. Additionally,
confinement) (Lee et al., 2007). It would be interesting to further no significant differences were found in terms of life satisfaction
research the psychological consequences of circumstances such as according to the perinatal situation – both groups showed a significant
self-confinement, living with an infected person, limited access to decrease compared to the first wave (April). These results reaffirm
healthcare during pregnancy, and/or worry about overwhelmed that the different components that make up well-being can function
hospital services. relatively independently from each other (Veenhoven, 2009).
Regarding the second specific objective of the study (i.e., to In conclusion, this study represents an advance in the
evaluate the changes in psychological well-being of women in understanding of perinatal mental health both in general and
the perinatal stage), it was found that life satisfaction decreased in situations of crisis such as that caused by COVID-19. A better
significantly over the 6-month period. These findings are in line understanding of psychological distress and well-being can help
with those of the previous study (Contra el Estigma, 2020), which prevent the appearance of mental health problems in the event of
observed a decrease in psychological well-being 4 months from the subsequent waves of the pandemic (Thombs et al, 2020).
onset of the pandemic. Life satisfaction is a global self-evaluation of This study presents certain limitations. Firstly, due to the
a person’s life and reflects, in part, their perception of their quality characteristics of the research (i.e., online survey, probabilistic
of life (Veenhoven, 2009). Given the changes to normal life which snowball sampling), it is possible that the most vulnerable families
took place during these six months (i.e., numerous restrictions on did not participate in the study and the results only reflect the view
mobility, interpersonal distancing, uncertainty, changes in work, of those families in better circumstances. Thus, it is necessary to
etc.), a decrease in life satisfaction could be expected, as seen during carry out further studies which include all socioeconomic levels
previous times of social or economic crisis in Spain (Bartoll et al., of the population. Secondly, there are some factors that were not
2014). examined in the current study but may have also contributed to
It was found, however, that levels of positive affect increased the decrease in symptoms over time, such as the recovery of social
and negative affect decreased in comparison to the first wave. Note support or the economic activity after the lifting of lock-down, or
that PANAS is a measurement which is highly sensitive to changes the change in perinatal status (from pregnant to postpartum). In
in hedonic tone (Watson et al., 1988). These results may confirm the the future, it is important to consider this last factor since previous
concept of hedonic adaptation (Lyubomirsky, 2011), defined as the research has shown that there are variations during the perinatal
capacity for people to adapt to positive or negative circumstances in period in terms of symptoms of depression and anxiety (Teixeira et
life. Thus, after a brief period of adaptation, people return to their al., 2009). Furthermore, a longer time frame is necessary to follow-
baseline state of well-being even after suffering severely negative up the changes of this pandemic. Thirdly, using a more robust
events (Godoy-Izquierdo et al., 2008). measure of anxiety would help draw stronger conclusions regarding
The drop in life satisfaction and the improvement of affective this dimension.
balance after six months of pandemic shows that well-being is a Despite these limitations, this work contributes to a better
complex and multidimensional construct (Ryan & Deci, 2001). Life understanding of perinatal mental health during the COVID-19
satisfaction is often considered the cognitive component of well- pandemic and may serve as the basis for future research. Some
being while affect is the emotional aspect (Vázquez et al., 2009). The contributions can be highlighted. First, this is the first longitudinal
emotional component refers to pleasant or unpleasant experiences, study on the consequences of COVID-19 on perinatal mental health
moods or states measured in a specific time. However, life satisfaction in Spain. It provides information on the mental health of a relatively
refers to the degree to which an individual subjectively perceives large sample of pregnant and postpartum women at different times
that his/her aspirations are attained or satisfied (Diener et al., 2003), of the COVID-19 pandemic. Second, this is also the first study on
considering quality of life, environment, and real living conditions. COVID-19 on perinatal mental health in Spain that incorporates
This study shows that the different components of mental health measures of both symptoms and well-being. Research on the
evolved differently during the pandemic and thus it is important to architecture of mental health has consistently found that well-
evaluate them independently. being and symptoms can be considered as two dimensions that are
With regards to the third specific objective (i.e., to identify the relatively independent of each other (Watson, 2016). Although most
variables which may influence these changes), it was found that of the extant research on perinatal mental health has focused on the
the quality of sleep and physical health of the baby and mother are study of negative symptoms, the results of this study support the
important factors in the improvement of symptoms and the well- need to evaluate these dimensions separately. A model of human
being of mothers during the pandemic. The decrease in symptoms functioning which considers both positive and negative aspects
 Perinatal Mental Health during COVID-19 77

offers a more complex perspective on human nature (Keyes, 2007). It www.contraelestigma.com/resource/estudio-covid-resultados-

is expected that this study may lay the foundations for the design of finales/
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Conflict of Interest González-Sanguino, C., Ausín, B., Castellanos, M. A., Saiz, J., & Muñoz,
M. (2021). Mental health consequences of the Covid-19 outbreak
in Spain. A longitudinal study of the alarm situation and return
The authors of this article declare no conflict of interest. to the new normality. Progress in Neuro-Psychopharmacology &
Biological Psychiatry, 107, Article 110219. https://doi.org/10.1016/j.
pnpbp.2020.110219
Note Grissette, B. G., Spratling, R., & Aycock, D. M. (2018). Barriers to help-seeking
behavior among women with postpartum depression. Journal of
1
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assessment protocol. Six months later, 176 women (24.3% of those Sousa, G. S., & Alburquerque Perrelli, J. G. (2019). Enfermedad mental en
who completed the first wave) responded to the second wave. No mujeres embarazadas. Enfermería Global, 18(1), 499-534. https://doi.
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and those who did not participate in the second wave, nor in the M., Lucco, F., Martínez-García, M., Desco, M., Ballesteros, A., Crone, E. A.,
sociodemographic variables (i.e., age, civil status, education, and Vilarroya, O., & Carmona, S. (2020). Becoming a mother entails anatomical
changes in the ventral striatum of the human brain that facilitate its
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