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Pandemic stressors taking a toll on pregnant patients’ mental health

Kaiser Permanente analysis finds more depression, anxiety among Black and Hispanic individuals


Pregnant patients surveyed by Kaiser Permanente researchers early in the COVID-19 pandemic reported more severe mental health symptoms when they were distressed about changes in prenatal care, childcare challenges, and food insecurity. The results were reported in the International Journal of Public Health.

Lyndsay Avalos, PhD, MPH, research scientist with the Division of Research.

“The COVID-19 pandemic may be having severe mental health repercussions for pregnant individuals,” said lead author Lyndsay Avalos, PhD, MPH, a research scientist with the Kaiser Permanente Division of Research. “The known short- and long-term consequences associated with prenatal psychological distress highlight the need for extra focus on support services for pregnant individuals and monitoring of those with depression or anxiety symptoms and their children.”

The stress may have been experienced more by certain groups. A second, separate study by the research team, using similar data, found disparities in how Black and Hispanic pregnant individuals experienced pandemic stressors compared with white patients. That study was published in Frontiers in Psychiatry.

Both studies analyzed results of an online survey about the experience of being pregnant during the pandemic filled out by patients of Kaiser Permanente Northern California.

The International Journal of Public Health study looked at 6,628 surveys completed early in the pandemic, between June 22 and Sept. 30, 2020. More than one third of respondents reported being depressed (25% mild, 8% moderate, 3% severe). Similar rates of anxiety were reported (22% mild, 8% moderate, 5% severe). Depression and anxiety were more likely among survey respondents who had COVID-19 during pregnancy, employment that exposed them to the coronavirus, experienced changes in their job status, or were distressed about changes in prenatal care, childcare challenges, and food insecurity.

The study, covering a period before COVID-19 testing was common, found 2% of the pregnant individuals had a coronavirus infection during pregnancy and 4% said a household member tested positive. Changes in the jobs and economic conditions during the early pandemic shut-down period were reflected in the survey responses: 23% lost their job, 23% said a partner lost their job, 26% reported childcare challenges, and 19% reported food insecurity.

“These findings clearly indicate the negative impact the pandemic has had on many pregnant patients and the importance of studying this topic,” said senior author Lisa Croen, PhD, a research scientist at the Division of Research. “This is why we launched this survey, which we expect will continue to produce important insights from our pregnant patients.”

Black, Hispanic patients hit harder

The Frontiers of Psychiatry study included nearly 11,000 pregnant patients who filled out the survey between June 2020 and April 2021. The same Division of Research team examined survey results looking for disparities in prenatal mental health during the pandemic by race and ethnicity. The study found Black pregnant patients were 85% more likely and Hispanic pregnant patients were 17% more likely to report depression than white patients. Black participants were 71% more likely to report anxiety during pregnancy compared with white participants.

Sylvia Badon, PhD, staff scientist, Division of Research.

Black and Hispanic survey respondents were more likely than white respondents to experience pandemic-related stressors such as job loss, a partner’s job loss, food insecurity, and distress over changes to prenatal care. Twenty-six percent of Black patients reported job loss, compared with 20% of white patients.

Food insecurity was reported by 31% of Black patients, 24% of Hispanic patients, and 9% of white patients. A further analysis found that Hispanic individuals’ greater food insecurity contributed to their higher rates of depression and anxiety compared with white patients.

The study found disparities in distress about changes in prenatal care delivery: 34% of Black patients reported it, as did 31% of Hispanic patients, compared with 24% of white patients. The further analysis found that worry about prenatal care changes contributed to higher rates of depression and anxiety among Black and Hispanic patients.

“Our findings highlight the importance of understanding and addressing social and economic contributors to mental health inequities during pregnancy as we work to eliminate these inequities,” said study senior author Sylvia Badon, PhD, staff scientist at the Division of Research.

Racial/ethnic differences in pandemic stressors in pregnancy.

As health care systems evaluate how care delivery will take place post-pandemic, they should be working with Black and Hispanic communities, Avalos said. “Health care systems must identify ways to address stressful aspects of changes in prenatal care and food insecurity to help reduce these mental health disparities and address the overall well-being of pregnant women,” she said.


Pandemic prenatal care adapts

Among the stressors cited often by survey respondents was change to prenatal care. This was similar to findings of other surveys of pregnant patients around the U.S. and Canada.

It is understandable that some survey respondents were concerned about changes in prenatal care given the uncertainty surrounding the early pandemic period, said Mara Greenberg, MD, a maternal-fetal medicine specialist with The Permanente Medical Group, who was a co-author on the International Journal of Public Health study. Kaiser Permanente Northern California had to shift some prenatal care to phone and video visits and consolidated in-person visits to avoid multiple trips to the clinic.

“We took great care identifying the prenatal care services that had to be in-person and those that could be virtual,” Greenberg said. “Internal panels of obstetric experts were convened to confirm that changes in care delivery maintained the level of excellence that our patients deserve and that they were getting prior to the pandemic, such as a detailed prenatal intake with first trimester labs and ultrasound in person.”

The studies were funded by Kaiser Permanente Northern California Community Health grants and the National Institutes of Health.

Additional co-authors on the International Journal of Public Health study were Badon, Nerissa Nance, Kelly Young-Wolff, PhD, MPH, Jennifer Ames, MS, PhD, Yeyi Zhu, PhD, Monique M. Hedderson, PhD, Assiamira Ferrara, MD, PhD, and Ousseny Zerbo, PhD, all of the Division of Research.

The same group, along with Croen, were co-authors on the Frontiers of Psychiatry study.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit or follow us @KPDOR.




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