Introduction

This paper reviews recent literature about the impact of the COVID-19 pandemic on the mental well-being of pregnant and puerperant (i.e., perinatal) women. When the novel coronavirus (COVID-19) outbreak in 2019 developed into a pandemic, major lifestyle, healthcare, economic, and social structure changes followed around the world. Fewer personal interactions caused feelings of isolation and loneliness. It became impossible to control or predict the future. In Japan, it has taken time to adapt to the new way of life, after the COVID-19 pandemic challenged and necessitated the reconstruction of core beliefs related to selfconfidence and trust in others. Such disruption of core beliefs has been linked to depression and anxiety [1]. Conversely, resilient individuals are less likely to develop mental health disorders [1]. We identify factors that improve resilience and propose a support system that would promote the well-being of perinatal women.

The Effect of the COVID-19 Pandemic on the Mental Health of Perinatal Women

In 2020, the COVID-19 pandemic led to social distancing measures, such as lockdowns, across the globe. Large-scale surveys on mental health were conducted during this period while the pandemic continued unabated. These surveys revealed a relationship between the pandemic and the mental health of perinatal women.

A survey that compared mental health in China before and after the pandemic found an increase in both depression and anxiety among pregnant women since the start of the pandemic [2]. In an online survey with perinatal women in 64 countries, 43% of the women had Post Traumatic Stress Disorder (PTSD), 31% reported having anxiety and/or depression, and 53% experienced loneliness [3]. Another survey, conducted in the United States, found that women with self-reported histories of mental health diagnoses were more likely to have depression, generalized anxiety disorder, and PTSD during the pandemic” [4]. Pregnant women were unable to participate in prenatal classes and talk with other mothers. The lack of social interaction caused or worsened depression, anxiety, loneliness, and repetitive negative thinking or emotions, leading to suicide in some cases [5]. Similarly, 20% of pregnant women who participated in a survey in the United States indicated that they had thoughts of self-harm [6].

Factors Negatively Affecting the Mental Health of Perinatal Women during the COVID-19 Pandemic

In a survey in the United States, two-thirds of pregnant women indicated that the spread of COVID-19 caused them to feel stressed about going to the hospital [7]. Furthermore, many women who canceled or reduced their appointments at healthcare institutions were experiencing depression [6]. Sources of stress in the United Kingdom included “uncertainty surrounding perinatal care, exposure risk for both mother and baby, inconsistent messaging from information sources and lack of support networks,” as well as lack of trust in healthcare personnel [8,9].

The COVID-19 Pandemic and the Mental Health of Mothers in Japan

In a recent study on the prevalence of postpartum depression since the beginning of the pandemic in Japan, the rate of depression among pregnant women was found to be 17%. Although this figure is higher than previous reports [10], there was no difference between the prevalence of depression before compared with after the beginning of the COVID-19 pandemic [11]. However, the prevalence of postpartum depression was higher in regions with many new COVID-19 infections, compared to other regions [12]. Furthermore, 24.8% of working pregnant women experienced maternity harassment (i.e., pregnancy discrimination) from supervisors and/or colleagues, and these women had a higher chance of developing depression than other workers [13]. Working from home in accordance with mandatory measures to prevent the spread of COVID-19 did not affect the prevalence of maternity harassment.

The declaration of a state of emergency in response to the COVID-19 pandemic restricted travel between prefectures in Japan, making it impossible for many pregnant women to Satogaeri-bunben (i.e., return to their hometowns to give birth). Consequently, the rate of women who were able to receive postpartum support declined to 52% from 84% before the pandemic, and many couples took care of their babies on their own [14]. The possibility of postpartum depression during the COVID-19 pandemic was significantly lower among puerperal women who had social support than those who did not [15]. Pregnant women have experienced severe psychosocial stress during the COVID-19 pandemic, especially due to loneliness [16], and 56% of mothers experienced anxiety or hardship following childbirth [17].

The COVID-19 pandemic disrupted the conventional childbirth culture of Japan, requiring mothers and their partners to construct postpartum life in new ways. This disruption of core beliefs has likely been a cause of anxiety.

Factors Promoting Resilience in Mothers during the COVID-19 Pandemic

The literature published so far has also examined factors that promote maternal resilience. Due to lockdown, 93% of pregnant women were unable to attend antenatal classes and were unable to talk with other pregnant women. For this reason, they used ICT to obtain information about pregnancy and parenting, with relationships with partners being particularly important, followed by support from acquaintances, such as conversations with friends, which was effective in reducing anxiety [5]. Exercising more than 7 hours per week also lowered the risk of postpartum depression, and exercising had an effect on stabilizing the mental health of mothers due to the pandemic [2]. The use of virtual communication platforms, self-care behavior (e.g., sufficient sleep, physical activity, healthy meals, etc.), and partner emotional support promote resilience in mothers. The use of Information and Communication Technology (ICT) and support from partners also have marked positive effects on mental health [8].

In order for perinatal women to gain resilience, it is important to increase opportunities for them to receive support from close family members and professionals, and to support them in maintaining the life they have led so far.

The Role of Midwives during the COVID-19 Pandemic

The COVID-19 pandemic has increased the likelihood of perinatal women developing mental health disorders. Before the COVID-19 pandemic, the rate of postpartum depression in Japan was 9.0% [18], with plans to decrease this further, to prevent child abuse by mothers who have postpartum depression. Furthermore, the rate of postpartum depression in men is 11.7%, and it is associated with domestic violence and paternal bonding disorder [19].

In 2015, the Japanese government implemented the Healthy Parent and Child 21 Policy. One of the aims of the policy was to provide all pregnant women with the opportunity to learn about postpartum depression [20]. During the COVID-19 pandemic in 2020, however, only 34% of pregnant women were able to attend parenting classes organized by municipal governments, as planned, while this rate was 78% before the pandemic. Therefore, it is necessary to re-activate the support system that is available during pregnancy.

In 2020, the number of suicides in Japan increased by 4.5% over the previous year. In particular, 1,698 working women committed suicide. A major factor resulting in female suicides could be stress associated with living in confined spaces with other family members, as many of the women who committed suicide did not live alone. This suggests the importance of adjusting family relationships in dealing with the COVID-19 pandemic.

To promote the mental well-being of perinatal women, midwives must restore and resume the support that was provided before the pandemic as soon as possible. Although utilization of online resources has increased in Japan since the beginning of the COVID-19 pandemic [21], not every pregnant or puerperant woman is able to utilize ICT. Since online dissemination of information has proven to be effective, we suggest providing accurate information about COVID-19 through social media while expediting the reopening of face-to-face parenting classes with appropriate measures in place to prevent infection. These classes should offer support for building new family relationships while providing pregnant women and their partners with education that will improve resilience [22].

Conclusion

Many of the surveys on COVID-19 and the mental health of perinatal women are conducted online. This could create a sampling bias, as participants would include only women who utilize online resources, who have sufficient knowledge about digital technology, and access to websites and other online resources. Perinatal women who have posttraumatic stress, and anxiety, or depression were twice as likely to seek information from various sources (e.g., social media, news, conversations with others) at least five times a day [5].

Putting the likely sampling biases aside, the COVID-19 pandemic has probably had a significant impact on the mental health of perinatal women. It is very likely that the lockdowns and other mandatory measures to control the spread of the disease increased the sense of isolation among perinatal women, worsening their depression or anxiety.

The number of people infected by COVID-19 in Japan is small compared to other countries. Still, for the past year, prenatal support could not be provided due to the pandemic. The situation in Japan has stabilized somewhat. However, it is necessary to reestablish support for women during pregnancy and thereafter, in preparation for the next pandemic.

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