COVID-19 Public Health Restrictions and New Mothers’ Mental Health: A Qualitative Scoping Review

Abstract

Public health restrictions to protect physical health during the COVID-19 pandemic had unintended effects on mental health, which may have disproportionately affected some potentially vulnerable groups. This scoping review of qualitative research provides a narrative synthesis of new mothers’ perspectives on their mental health during COVID-19 pandemic restrictions through pregnancy to the postpartum period. Database searches in PubMed, CINAHL, and PsycINFO sought primary research studies published until February 2023, which focused on new mothers’ self-perceived mental health during the pandemic (N = 55). Our synthesis found that new mothers’ mental health was impacted by general public health restrictions resulting in isolation from family and friends, a lack of community support, and impacts on the immediate family. However, public health restrictions specific to maternal and infant healthcare were most often found to negatively impact maternal mental health, namely, hospital policies prohibiting the presence of birthing partners and in-person care for their infants. This review of qualitative research adds depth to previous reviews that have solely examined the quantitative associations between COVID-19 public health restrictions and new mothers’ mental health. Here, our review demonstrates the array of adverse impacts of COVID-19 public health restrictions on new mothers’ mental health throughout pregnancy into the postpartum period, as reported by new mothers. These findings may be beneficial for policy makers in future public health emergency planning when evaluating the impacts and unintended consequences of public health restrictions on new mothers.

Introduction

The COVID-19 pandemic threatened mental and physical health and the capacity of healthcare systems around the world. In an attempt to slow the spread of the virus, numerous strategies were applied, including a range of public health measures. Mandated interventions such as the use of personal protective equipment, physical distancing, mass population testing, movement restrictions, and lockdowns were implemented (Asongu et al., 2021). While such public health measures may have helped reduce COVID-19 case counts and alleviate pressure on healthcare systems in the short term, they may have also resulted in harm by contributing to mental health concerns and creating a loss of social support networks (Haug et al., 2020; Pfefferbaum & North, 2020). Some measures, especially those that affect engagement with the healthcare system, have been shown to disproportionately affect vulnerable groups (Blundell et al., 2020). For example, many Western countries mandated reductions in visiting hours for individuals staying in hospitals. Indeed, a systematic review on the impact of visiting hour reductions showed that patients who stayed in hospital while this measure was implemented reported reductions in both physical and mental health due to a lack of social support (Hugelius et al., 2021). Likewise, new mothers ¹ —arguably one of society’s most vulnerable groups—have reported mental health difficulties attributed to COVID-19-related public health measures (Kotlar et al., 2021).

Challenges for New Mothers

While the transition to motherhood is expected to be one of joy in many societies, there are various issues that new mothers face—even during non-pandemic times—that can contribute to poor emotional and mental health (McLeish et al., 2021). Hormonal changes related to pregnancy, childbirth, and lactation can negatively impact one’s mood and sleep habits (Montgomery-Downs et al., 2013; Trifu et al., 2019). These changes have the potential to negatively impact family time and maternal–infant bonding. In addition, breastfeeding challenges, including low self-efficacy, can result in depressive symptoms and stress (Yuen et al., 2022). The stress related to the pressures of work–life balance, loss of autonomy, and changing societal roles, potentially leading to a lack of bonding with one’s child, can also have negative effects on maternal well-being (McNamara et al., 2019). Across many settings (particularly in low- and middle-income countries), new mothers experience consistent challenges securing adequate maternal and infant healthcare (Mohseni et al., 2023; Vizheh et al., 2023). Unfortunately, the COVID-19 pandemic created additional stressors and challenges for both mental health and securing adequate care among new mothers during pregnancy, childbirth, and postpartum (Kotlar et al., 2021).

COVID-19 Pandemic Challenges for New Mothers

The onset of the COVID-19 pandemic and related public health measures exacerbated challenges for new mothers globally. The pandemic changed the way new mothers cope with sometimes unexpected symptoms or stressors associated with pregnancy, the experience of childbirth, and the beginning of a new life. Widespread deaths caused by COVID-19, adjusting to changing public health measures, and social distancing contributed to increased levels of prenatal stress (Kotlar et al., 2021). Pregnant women are also at a heightened risk of infection with COVID-19, not only to themselves but also to their fetuses, which may contribute to prenatal stress (Muralidar et al., 2020). Furthermore, like many others, pregnant women have faced a wide range of pandemic-related stressors such as the restriction of movement, financial difficulties, remote work, social isolation, and more (Garcia-Silva et al., 2021). Coping with such challenges can further develop into long-term chronic stress, especially in countries that have faced longer periods of restrictions. This heightened maternal stress can negatively impact fetal development while also affecting the long-term health of the mother (McLeish & Redshaw, 2017).

Summary of Previous Literature

Since the onset of the COVID-19 pandemic, several reviews have examined the relationship between this public health crisis, lack of social support, and the mental health of pregnant individuals and new mothers. A scoping review conducted by Kotlar and colleagues (2021) examined the impact of the pandemic on pregnant individuals. Similarly, another scoping review by Campos-Garzón et al. (2021) solely included pregnant people as their population of interest for examining the psychological impacts of the pandemic. Notably, one retrospective analysis following new mothers found that participants experienced feelings of loss due to the COVID-19 pandemic, partially contributing to an increase in perinatal mental distress (Larotonda & Mason, 2022). Several systematic reviews and meta-analyses have also been published within this field (Bedaso et al., 2021; Demissie & Bitew, 2021; Yan et al., 2020). However, these reviews have focused mostly on quantitative measures of clinically diagnosed mental illnesses (e.g., anxiety and depression) in new mothers or have only included literature published prior to the pandemic (Bedaso et al., 2021; Demissie & Bitew, 2021; Yan et al., 2020). As such, there is a knowledge gap pertaining to new mothers’ experiences during the pandemic with regard to associated public health measures and their self-perceived mental health.

Objectives

To address this gap, our scoping review was conducted to summarize pandemic-related challenges from the perspectives of new mothers. Our approach allows for reflection on the impacts of such public health restrictions and may aid in informing public health policy for future pandemics and/or other public health emergencies.

Methods

This scoping review followed the methodological framework established by Arksey and O’Malley (2005) with suggested recommendations by Levac and colleagues (2010), including clearly defining the rationale of the review, justifying any limitations, and creating the data charting form collaboratively. As this review summarizes previously published research only, ethical approval was not required.

Research Question

This scoping review is guided by the following research question: “What are the subjective experiences and perceptions of new mothers regarding the impact of COVID-19 pandemic public health restrictions on their mental health?” The findings of this review are presented in a narrative synthesis to identify common and divergent stressors identified by new mothers and their impacts on mental well-being, that were attributed to COVID-19-related public health restrictions.

Identifying Relevant Studies

A literature search was conducted in February 2023 in three databases: PubMed, CINAHL, and PsycINFO. Search strategies included a combination of the following concepts: new mother, mental health, and COVID-19 (see Appendix A). A supplementary literature search with the key words “new mothers,” “COVID-19,” and “mental health” was also conducted in Google Scholar in February 2023 to capture any studies that were missed.

Study Selection

Inclusion and Exclusion Criteria

Articles were included in this scoping review if they were primary research studies published in English that were conducted during the pandemic (i.e., data collection for the study occurred on or after March 11, 2020) and that focused on new mothers’ mental health. A focus on mental health rather than mental illness (two related yet distinct terms; Westerhof & Keyes, 2010) was chosen to provide a broader view on the health of new mothers. However, self-reports of mental distress and mental health did not exclude participants with mental illness. Indeed, the occurrence of negative emotional experiences among new mothers under the societal conditions of the pandemic may have predisposed this group to deepening mental health struggles and subsequent diagnoses of mental illness (Kotlar et al., 2021; McLeish et al., 2021).

Both qualitative and mixed-methods studies were included. Quantitative studies were included only if the study directly captured participants’ perceptions through responses to open-ended questions. We included new mothers if they were first-time mothers and/or had given birth and were up to 6 months postpartum during a study’s data collection period, inclusive of all gender identities. A 6-month cut-off was used as this is the upper limit of the delayed postpartum timeframe for physical and hormonal recovery (Moura et al., 2016; Romano et al., 2010). Focus was on studies with participants in the postpartum stage as they can share insights on their full experience of new motherhood from pregnancy through to the postpartum period.

Study Screening

Screening was performed with Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia (available at https://www.covidence.org/). Before screening, pilot testing was conducted to ensure that all reviewers understood and applied the inclusion and exclusion criteria. Overall agreements of 90% and 97% were achieved for title/abstract and full-text screening, respectively. Screening was done in duplicate and independently at the title, abstract, and full-text screening steps. In the cases where conflicts arose, disagreements were resolved through discussion between the two reviewers, or consensus was achieved through the inclusion of a third reviewer.

Data Charting

Data extraction was recorded within a shared Microsoft Excel (2021) spreadsheet. Relevant data and emerging themes from the articles were identified by the reviewers during a pilot exercise using 5% of the included studies. Extraction was then performed independently by one reviewer for each of the remaining included articles, with a second reviewer verifying the extracted items. The charted information included bibliographic data, study design, population of interest, context of the public health restrictions, and themes surrounding mental health impacts of the public health measures.

Collating, Summarizing, and Reporting the Results

Charted findings were reported within a narrative synthesis to address the overarching research question. The number of included studies was provided, followed by a thematic synthesis of the emerging themes from the qualitative findings of the included studies. The latter involved coding the included articles (non-hierarchical coding), developing descriptive themes based on similarities between the codes, and finally generating analytic themes that go beyond what the primary study authors present (the analytic themes are reported in the Results section; see also Appendix B Table 1; Braun & Clarke, 2006; Thomas & Harden, 2008).

Results

Through database searching in PubMed, CINAHL, and PsycINFO (February 2023), 1148 articles were identified. An additional four records were found through supplementary literature searching, for a total of 1152 identified articles. After the removal of duplicates, 908 articles remained. A total of 708 articles were excluded during title and abstract screening, leaving 200 for full-text review. After assessing the full text of those articles, 145 additional articles were excluded. A total of 55 studies were included for qualitative synthesis in this scoping review (see Figure 1).

Figure 1.

PRISMA flow diagram of study selection, adapted from Page et al. (2021). For more information, visit: https://www.prisma-statement.org/.

Of these included articles (see Appendix B), 29 were qualitative studies that used either (semi-structured) interviews (n = 23, with two studies also using focus groups), qualitative surveys (n = 2), analysis of participant comments in online parenting groups (n = 2), or a narrative analysis (n = 2). Twelve studies were mixed methods, some of which included semi-structured interviews in their qualitative portions (n = 4) or surveys with open-ended questions (n = 8). There were also quantitative cross-sectional studies that included open-ended survey questions, but the authors of those studies did not identify their study design as being mixed methods (n = 10). Finally, four case studies were also included.

A variety of analytic methodologies were used (other than in the four case reports), including thematic analysis (n = 28), content analysis (n = 8), descriptive analysis (n = 3), or another analytic framework (e.g., interpretative phenomenological analysis and feminist poststructuralist discourse analysis; n = 8), although the analytic strategy was unclear in some studies (n = 4). The studies took place in North America (n = 22), Europe (n = 16), Asia (n = 5), Oceania (n = 6), Africa (n = 2), and internationally (n = 2). Two studies (Barlow & Sepulveda, 2020; Jacob et al., 2022) did not report their settings; however, both sets of authors were affiliated with institutions in the United States. In many of the studies that reported socio-demographic characteristics, the majority of participants were White (n = 19/30), well-educated (n = 20/23), and married or living with their partner (n = 30/33). The reported ages of the participants in the included studies ranged from 18 to 52 years old.

The studies reported a variety of public health restrictions that were in place due to the COVID-19 pandemic, including lockdowns, curfews, physical/social distancing, working/learning from home, the closure of non-essential business, reduction of in-person healthcare appointments, and restrictions for hospital visitation. Two pairs of studies provided analyses using the same sample populations: in one pair, two studies by Jackson et al. examined themes of healthcare and social support (2021a) and psychological experiences (2021b) of new mothers during the pandemic; in the second pair, Joy et al. (2020) addressed the interplay of blessings and curses in mental health of new mothers, while Ollivier et al. (2021) analyzed the same population in terms of mental health and socialization of new mothers.

Qualitative thematic synthesis of the findings from the included studies resulted in two overarching themes: (1) how general public health restrictions (such as lockdowns and social distancing) impacted the mental health of new mothers and (2) how maternal healthcare restrictions (such as virtual appointments or restricted visitation from family members) impacted the mental health of new mothers. Both themes pointed to poor self-perceived mental health among new mothers related to COVID-19 restrictions.

General Public Health Restriction Impacts on Mental Health

Within the first overarching theme of new mothers’ perceived impacts of general COVID-19 public health restrictions on their mental health, three sub-themes emerged: (1) isolation from family and friends, (2) a lack of community support, and (3) impacts on their immediate family.

Isolation From Family and Friends

Numerous studies (n = 41) described that the mental health of new mothers was influenced by a general sense of isolation from family and friends. In most study settings, lockdowns included restrictions on gathering sizes, which impacted the mental health of new mothers. Participants in a study by Gray and Barnett (2021) noted that social isolation related to COVID-19 public health restrictions impacted their ability to both visit other families and have family members come to their home to visit their new infant. One new mother described the sadness that was felt from needing to impose barriers against family visits:

It was so heart-breaking because they were on the other side of the glass. And [my mother-in-law], this is her first grandchild and she’s propped up against the glass like tears streaming down her eyes, because obviously the first thing you want to do is hold them … it was awful to watch them have to stay outside. (p. 9)

Other studies included new mothers describing tension and sadness that stemmed from not permitting visitors to their home during the postpartum period (Ashby et al., 2022; Chivers et al., 2020; Green et al., 2022; Jackson et al., 2021a; Kolker et al., 2021; Shuman et al., 2022; Vermeulen et al., 2022). Public health restrictions that prevented engagement with friends and family (e.g., stay-at-home orders and capacity limits) were also described as exacerbating mental health concerns. Kolker et al. (2021), for example, demonstrated this idea when a participant shared:

We talked on the phone ... [but] it cannot be compared with the physical presence of your family members when you’re eating together, laughing, and sharing thoughts ... It felt distant. (p. 5)

New mothers further explained that the inability to go to a restaurant or visit another home meant that they had lost a social life they needed to stay positive in the postpartum stage (Anderson et al., 2022; Brown & Shenker, 2021; Gray & Barnett, 2021; Green et al., 2022; Jackson et al., 2021b; Jones et al., 2022; Kinser et al., 2022; Kolker et al., 2021; Kumari et al., 2021; Saleh et al., 2022). One participant in Green et al.’s (2022) study described this worry and the impact on their mental health:

I worry that the lack of social interactions due to the quarantine will negatively impact my mental health because my social supports have been critical for my psychological well-being. (p. 7)

In other cases, the lack of visitors during lockdown was described as a stressor because it influenced the support new mothers could receive, exacerbating feelings of isolation (Cohen & Botz, 2022; Farley et al., 2022; Goyal, Beck, et al., 2022; Jones et al., 2022; Kumar et al., 2020; Saleh et al., 2022; Schaming & Wendland, 2023; Shuman et al., 2022; Stirling Cameron et al., 2021; Tavares et al., 2021; Vermeulen et al., 2022; Wilson et al., 2022). One new mother included in a study by Goyal, Beck, et al. (2022) described her feelings:

It was really hard having no family or friends to help when I needed it. I felt alone and cried a lot … We would have had help from family but couldn’t because of COVID. (p. 81)

Interestingly, studies described that the mental health of new mothers was significantly influenced by the inability to host cultural events during the postpartum stage. Research by Aydın (2021), for example, included one new mother who indicated to interviewers:

Imagine, we could not even practice our customs when the baby was born .... My parents wanted people to come and see the baby and practice our birth rituals because my baby is the first grandchild in the family .... Not being able to accept visits though I wished [I could] and having arguments with them upset me. (p. 47)

This was further supported by other studies that found that pregnant and new mothers reported sadness that COVID-19 gathering restrictions impacted the ability to host baby showers and other culturally significant gatherings (Ashby et al., 2022; Aydın, 2021; Chivers et al., 2020; Goyal, Han, et al., 2022; Kinser et al., 2021; Walsh et al., 2022).

General loneliness stemming from public health restrictions during the pandemic was also described. Even beyond the loss of social connections, new mothers described a feeling of being unable to experience the world with their babies (Ashby et al., 2022; Goyal, Beck, et al., 2022). Feelings of loneliness were described in relation to the lack of ability to visit certain birthing centers or engage with healthcare providers in person due to public health restrictions (Farewell et al., 2020; Goyal, Beck, et al., 2022; Goyal, Han, et al., 2022; Green et al., 2022; Jackson et al., 2021a; Joy et al., 2020; Kinser et al., 2022).

Lack of Community Support

Across multiple studies (Anderson et al., 2022; Ashby et al., 2022; Farewell et al., 2020; Jackson et al., 2021b; Kinser et al., 2021), mothers expressed that a lack of access to childcare services as a result of COVID-19 closures impacted their mental health. Some of the reported mental health struggles included feeling overwhelmed with managing childcare (Kinser et al., 2021), experiencing additional stress due to childcare burden (Anderson et al., 2022), as well as feelings of increased anxiety and guilt when struggling to manage childcare responsibilities (Jackson et al., 2021b). However, in contrast, two studies included participants who reported positive perspectives. One mother mentioned that she was thankful to not have access to childcare as it helped her learn how to provide care in challenging times (Kinser et al., 2021). A participant in Anderson et al.’s (2022) study also described her positive outlook on a lack of childcare services:

I am absolutely loving (although I hate to admit it!) having this extra time with my baby. I desperately wanted to avoid daycare ... I’m absolutely thrilled that I get to observe all his milestones firsthand. (p. 334)

Further to a lack of access to childcare, some studies reported a lack of support in managing one’s other children after childbirth (Davis et al., 2021; Goyal, Beck, et al., 2022; Stirling Cameron et al., 2021; Vermeulen et al., 2022; Walsh et al., 2022). Davis et al. (2021) explained that mothers with other young children to care for experienced increased distress. Davis et al. (2022) noted the increased stress of assisting older children with virtual schoolwork. Some mothers reported exhaustion from the difficulties that they experienced when taking care of their other children with no school or daycare support (Stirling Cameron et al., 2021). One mother included in a study by Goyal, Beck, et al. (2022) expressed the concern of being unable to attend to both of their children’s needs:

We were expecting my toddler to be in daycare three days a week, but since that wasn’t the case, my husband and I have had less time to focus attention on our newborn than we had hoped. Instead, we’ve been dividing attention trying to attend to our two-year old’s emotional needs during all this upheaval and isolation. (p. 81)

Some mothers also reported not having the expected peer support and help with daily caretaking tasks during the postpartum period (Barbosa-Leiker et al., 2021; Brown & Shenker, 2021; Green et al., 2022; Kinser et al., 2022; Lara et al., 2023; Saleh et al., 2022; Vazquez-Vazquez et al., 2021). Work by Farewell et al. (2020) included concerns arising from a lack of moral support from others due to public health restrictions. Similarly, a participant in Shuman et al.’s (2022) investigation reported similar concerns:

Lack of support due to COVID-19 has definitely made me feel more stressed and the adjustment to new motherhood more difficult than if I was able to have friends and family around and able to help more. (p. 105)

The lack of access to parenting support groups represented another gap in community support. Some mothers reported issues when accessing information and support during the postpartum period due to the restrictions and changing messaging during the pandemic (Ollivier et al., 2021). The concerns that arose from being unable to attend or access support groups included a lack of socialization leading to mental health concerns (Brown & Shenker, 2021; Kinser et al., 2022; Lara et al., 2023; Ollivier et al., 2021; Schaming & Wendland, 2023; Walsh et al., 2022) and an inability to ask questions of other mothers (Goyal, Beck, et al., 2022). One participant even expressed that she believes new mothers have been marginalized by the governmental response to the COVID-19 pandemic due to the lack of support:

I do feel like we’ve been let down, to be honest. I do feel like we’ve been let down. That and new mums, ‘cause even from a safeguarding perspective, it’s just not fair, that [lack of] support. I don’t really understand why it’s not [sigh] yeah, why it’s not been prioritised to this extent. (Jackson et al., 2021b, p. 9)

Kinser et al. (2021) further highlighted the importance in finding new support structures for new mothers to access mental health resources. New mothers mentioned that working from home allowed for more time to prioritize self-care in new ways like connecting with other new mothers over Zoom (Farewell et al., 2020) or Facebook (Lara et al., 2023). Conversely, some mothers mentioned the inability to engage in their usual coping mechanisms due to COVID-19 restrictions (Davis et al., 2022; Walsh et al., 2022). For example, the interviews conducted by Shuman and colleagues (2022) included a participant who indicated this concern:

I have not had my usual outlets to turn to when I get stressed, such as going to the gym, out to dinner with friends or my husband, or going shopping. (p. 105)

Impacts on Immediate Family

The impacts of public health restrictions on the immediate family were discussed in each study. They demonstrated both positive and negative impacts depending on the circumstances and socioeconomic status of new mothers and their families. Several studies described positive impacts that new mothers experienced by having their partner home for extended periods of time due to working remotely (Brown & Shenker, 2021; Davis et al., 2021; Farewell et al., 2020; Goyal, Beck, et al., 2022; Goyal, Han, et al., 2022; Jackson et al., 2021a; Joy et al., 2020; Kolker et al., 2021; Sakalidis et al., 2021; Wilson et al., 2022). A participant in Farewell and colleagues’ (2020) study shared their positive outlook on having their partner at home for extended periods of time due to stay-at-home orders:

Definitely the partner support has been really helpful. And I think that has made this whole change in our life a lot easier for us in that my husband and I get along really well and have been really supportive of each other. (p. 4)

Partners not only provided support, but some studies found that they provided relief to new mothers as well (Jackson et al., 2021a, 2021b; Joy et al., 2020; Rodriguez-Gallego et al., 2022; Vermeulen et al., 2022). Whether it was taking care of the new baby, entertaining other children, or completing household chores, many mothers found this beneficial as it allowed them to have some time for self-care, one-on-one bonding with their newborn, or much-needed rest. This resulted in improved mental health outcomes for new mothers as stated by a participant in Jackson and colleagues’ (2021a) study:

My husband’s working from home every day or was, which is great because it means that he can cuddle [baby] for 10 minutes and I can go off and do something for my sanity round the house, even if it’s just hoovering a room. (p. 7)

Public health measures not only improved some relationships between partners but also relationships with other immediate family members. New mothers throughout many studies (n = 19) mentioned that due to restrictions and stay home orders, there was increased family bonding time (Aydin, 2021; Bolgeo et al., 2022; Davis et al., 2021; Draganović et al., 2021; Farewell et al., 2020; Farley et al., 2022; Goyal, Beck, et al., 2022; Goyal, Han, et al., 2022; Jackson et al., 2021a, 2021b; Kinser et al., 2021; Kinser et al., 2022; Kumari et al., 2021; Rodrigues-Gallego et al., 2022; Sakalidis et al., 2021; Saleh et al., 2022; Thomson et al., 2022; Vazquez-Vazquez et al., 2021; Vermeulen et al., 2022). Additionally, participants in Davis and colleagues’ (2021) and Ashby and colleagues’ (2022) study reported benefits from a slower pace of life and having sufficient time required to adjust with a newborn without the stress of external visits. Goyal, Han, and colleagues (2022) noticed that mothers were grateful to have their own time and that distancing restrictions enhanced maternal emotional well-being through a sense of renewed independence by being able to say no to family visits. Participants also commented on the positive impacts of having extended amounts of time to bond with the newborn, which may not occur during non-pandemic times (Anderson et al., 2022; Brown & Shenker, 2021; Goyal, Beck, et al., 2022; Gray & Barnett, 2021; Joy et al., 2020; Rodrigues-Gallego et al., 2022; Wolfe-Sherrie et al., 2022). Research by Goyal, Beck, and colleagues (2022), for example, included one new mother who articulated these benefits:

While the prolonged isolation postpartum was emotionally difficult, I also realize that my husband and I had the chance to bond with our baby in a way that we likely never would have been able to under normal circumstances. In that way, this was all a blessing in disguise. (p. 82)

Though several studies mentioned the positive impacts of having one’s partner home for extended periods of time, some studies mentioned the negative impacts of constantly having their partner around, including increased arguing (Anderson et al., 2022; Aydın, 2021; Jones et al., 2022; Joy et al., 2020; Tavares et al., 2021). A participant in a study by Joy and colleagues (2020) reported:

Although having my husband home allowed him to spend more time with the kids, it increased stress between us [and] we argued more. (p. 215)

In contrast, one mother reported feeling isolated and alone since her husband was an essential worker and working a minimum of 40 hours a week (Goyal, Beck, et al., 2022). Some mothers mentioned the loss of external support such as childcare services resulting in poor mental health, which led to a strain on their relationship (Anderson et al., 2022; Aydın, 2021). Others mentioned financial strains from the loss of employment for their partner, thus increasing relationship strain (Atuhaire et al., 2021; Aydın, 2021; Farley et al., 2022; Goyal, Beck, et al., 2022; Green et al., 2022; Ryan & Barber, 2022; Walsh et al., 2022; Wolfe-Sherrie et al., 2022). Working mothers noted a variety of stressors related to working from home (Lara et al., 2023), job loss (Ashby et al., 2022; Davis et al., 2022), or having to return to work early due to their spouse’s job loss (Farley et al., 2022; Jones et al., 2022). Those in lower wage occupations spoke of the need to ration food due to closure of food pantries (Davis et al., 2022).

Impacts of Public Health Restrictions Specific to Maternal Healthcare

Within the second overarching theme of new mothers’ perceived mental health impacts of restrictions specific to maternal healthcare, four sub-themes emerged based on chronologic impacts during (1) pregnancy, (2) birth planning, (3) birth, and (4) the postpartum period.

Impacts on New Mothers’ Mental Health During Pregnancy

Several studies (n = 8) noted heightened feelings of anxiety and stress for pregnant women in obtaining prenatal healthcare because of changes implemented to follow COVID-19 public health restrictions (Abu Sabbah et al., 2022; Barlow & Sepulveda, 2020; Chivers et al., 2020; Davis et al., 2021; Farewell et al., 2020; Goyal, Han, et al., 2022; Kolker et al., 2021; Kumari et al., 2021). Restrictions involved limitations of visitors, cancellation of appointments for check-ups and testing, and a shift to virtual visits. Participants in one study reported a sense of frustration because the messaging and guidance regarding prenatal visits was inconsistent (Farewell et al., 2020). Moreover, prenatal doctors’ visits were often moved to virtual visits or cancelled altogether, with new mothers reporting worry and frustration caused by those changes (Abu Sabbah et al., 2022; Goyal, Han, et al., 2022; Kumari et al., 2021). One participant in a study by Abu Sabbah et al. (2022) expressed anxiety and anger at her missed care:

During the lockdown, I could not do the prenatal follow-up. All clinics were closed. I missed the seventh, eighth, and ninth months’ visits. I was anxious; I wanted to be reassured about my baby’s health . . . I was shocked when I learned about his feet problem . . . I was furious when the nurse told me that. (p. 7)

Restrictions affecting laboratory testing and ultrasound appointments were reported in several studies (Abu Sabbah et al., 2022; Barlow & Sepulveda, 2020; Davis et al., 2021; Kumari et al., 2021; Vermeulen et al., 2022). This resulted in increased stress and uncertainty. One participant reported:

I have anemia and have taken the iron supplement for one month. Because of corona lockdown, I was unable to check my hemoglobin. It was difficult to do laboratory tests such as haemoglobin and urinary analysis before my caesarean section, neither was I able to do the follow-up visits in the last weeks before the operation. (Abu Sabbah et al., 2022, p. 6)

In a few studies (n = 7), participants expressed grief at the loss of bonding with their partner or spouse who was excluded from attending prenatal visits or ultrasound scans (Chivers et al., 2020; Davis et al., 2021; Farewell et al., 2020; Goyal, Han, et al., 2022; Jones et al., 2022; Kolker et al., 2021; Vermeulen et al., 2022). Some mothers reported that this increased their feelings of isolation.

Impacts on New Mothers’ Mental Health From Changes in Birthing Plans

In many of the included studies (n = 12), new mothers expressed feelings of disappointment, worry, fear, and anxiety about having to change their birthing plans due to public health restrictions (Abu Sabbah et al., 2022; Anderson et al., 2022; Davis et al., 2021; Gray & Barnett, 2021; Jackson et al., 2021a; Kolker et al., 2021; Lara et al., 2023; Saleh et al., 2022; Shuman et al., 2022; Sullivan et al., 2022; Vazquez-Vazquez et al., 2021; Wilson et al., 2022). Some of these changes included stopping non-hospitalized births, leaving mothers disappointed. One of the interviewed mothers in Gray and Barnett’s (2021) study shared her experience:

So, I was hoping for a sort of like natural birth, birth pool things like that, that they had in the midwife centre of the hospital. But they said that was all closed due to staffing restraints. So, it meant that we went to the sort of delivery suite, which was also in the same hospital so that was where we had to go instead which was not what we had hoped for. (p. 9)

In a study conducted in Mexico, participants who could afford private hospitals chose to pay in order to have their partner accompany them and to avoid public clinics, stating “Public clinics [are] where women are most at risk, since people go there for everything” (Lara et al., 2023, p. 8). Another shared concern across these studies was the worry of not being permitted to have a support person, such as a partner, a doula, or family members, during birth. One participant shared, “to [give birth] alone is terrifying” (Davis et al., 2021, p. 11).

To address these worries, some mothers changed their birthing plans to avoid impacts of public health restrictions. In Shuman et al. (2022), some participants mentioned choosing an out-of-hospital birth to avoid restrictions or to reduce the risk of exposure to COVID-19. Jackson et al. (2021a) reported the experience of a mother who asked for a delay in labor induction in hopes that a natural labor would start and allow a home birth to avoid being at the hospital. A participant in Abu Sabbah et al. (2022) opted for a caesarean section instead of vaginal birth for fear that the pandemic would worsen resulting in the closure of hospitals. For those who were planning to birth their child in the hospital setting, concerns were raised about having to wear personal protective equipment, such as a face mask during labor (Anderson et al., 2022; Saleh et al., 2022; Shuman et al., 2022). In the open-ended questions from Anderson et al.’s (2022) survey, a respondent shared:

I worry about having to wear a mask during labor. I have had a hard time breathing in them from time to time and I worry I will panic. (p. 333)

Impacts of Negative Birth Experiences on New Mothers’ Mental Health

With respect to the actual birthing experience, many of the fears that were discussed in relation to the birthing plans occurred. Many participants in the included studies reported that hospital restrictions either did not allow for any external parties to be present with them during labor or that the mother-to-be could only have one person and had to choose between a friend, family (such as their partner or a parent), and maternal supports (such as a doula). This restricted ability to have support during labor left mothers feeling isolated and lonely (Abu Sabbah et al., 2022; Anderson et al., 2022; Ashby et al., 2022; Aydın, 2021; Baran et al., 2021; Barlow & Sepulveda, 2020; Bolgeo et al., 2022; Davis et al., 2021; Draganović et al., 2021; Garfield et al., 2021; Gray & Barnett, 2021; Kinser et al., 2021; Ryan & Barber, 2022; Saleh et al., 2022; Schaming & Wendland, 2023; Shuman et al., 2022; Stirling Cameron et al., 2021). Saleh and colleagues (2022) included a quote from a mother who shared her concerns:

I genuinely feel like I needed my mom at the time . . . they did give me the option of telling my mom to go rather than my spouse, but how am I going to let my spouse miss the birth of his first child? (p. 63)

Similarly, a mother in a case study (Barlow & Sepulveda, 2020) shared that she was distressed that her husband could not be with her during labor, and the breathing techniques that she had learned were prohibited to lessen the spread of COVID-19. In a different study, a mother shared that having to wear a face mask during labor was emotionally distressing because her newborn would not be able to see her whole face the first time she held him (Shuman et al., 2022).

Impacts on New Mothers’ Mental Health in the Postpartum Period

Across the studies, there were numerous reports of distress caused by lack of healthcare supports for new mothers, for their babies, and for breastfeeding and subsequent mental health concerns in the postpartum period. While in the hospital immediately postpartum, some new mothers reported feeling very alone as their companion was not allowed to stay after the birth (Abu Sabbah et al., 2022; Baran et al., 2021; Jacob et al., 2022; Jones et al., 2022; Keith, 2022; Rice & Williams, 2021; Schaming & Wendland, 2023; Walsh et al., 2022). One new mother reported feeling abandoned and forgotten about:

[My partner] had to leave 4 hours after [I gave birth]. It was terrifying. I’d never had a baby before, and I had the whole night and then the whole next day to take care of a newborn by myself after having a hard labor and delivery. I was there alone, I was on pain medication. It was not set up to help women at all. It was more helpful for the staff than it was for the parent. I felt—not by [my partner], but by our health care system during this time ...—abandoned and forgotten about. (Rice & Williams, 2021, p. E559)

Those with children in the neonatal intensive care unit reported difficulties in communication with the healthcare team as parents were not allowed to visit (Garfield et al., 2021). One participant reported that restrictions prevented her and her husband from visiting their 8-day old baby after a 6-hour surgery, reporting gratitude that staff “turned a blind eye” to allow them to be together (Jackson et al., 2021a, p. 6).

A common sentiment expressed was the feeling of a lack of postnatal care (Baran et al., 2021; Jackson et al., 2021a; Kinser et al., 2022; Kolker et al., 2021; Rice & Williams, 2021; Ryan & Barber, 2022). New mothers reported feelings of uncertainty regarding their health and the health of their baby (Barlow & Sepulveda, 2020; Kolker et al., 2021; Kumar et al., 2020; Larotonda & Mason, 2022; Walsh et al., 2022; Wolfe-Sherrie et al., 2022). In Kolker et al.’s (2021) study, a participant expressed concern about her baby’s hearing test being cancelled. Some mothers were confused by the lack of face-to-face consultations and sought their own solutions on the internet (Jackson et al., 2021a; Ollivier et al., 2021). Another study reported being given online pages to read when postnatal appointments were cancelled:

When they cancelled everything, it took weeks for them to do anything online and then it was pages of reading, there’s no videos, no nothing, and then you have all these questions, and you try to call to find out some answers and no one can give you any answers and there was no one to talk to. (Davis et al., 2021, p. 11)

When virtual visits (telephone or video) were conducted, participants noted issues with connectivity, poor picture quality limiting proper assessment, as well as difficulties getting mom and baby into the same frame to be seen by a lactation consultant (Kolker et al., 2021; Nagendrappa et al., 2021). Participants in a study by Stirling Cameron et al. (2021) were new Canadians recently admitted as refugees from Syria; they reported on the challenges of English/Arabic interpretation for telephone visits with their doctors.

Studies that reported on breastfeeding challenges found that a lack of in-person visits increased challenges (Atchan et al., 2022; Barbosa-Leiker et al., 2021; Brown & Shenker, 2021; Cohen & Botz, 2022; Davis et al., 2021; Goyal, Beck, et al., 2022; Gray & Barnett, 2021; Jackson et al., 2021b; Jacob et al., 2022; Morniroli et al., 2021; Nagendrappa et al., 2021; Ollivier et al., 2021; Rice & Williams, 2021; Rodrigues-Gallego et al., 2022; Sakalidis et al., 2021; Schaming & Wendland, 2023; Shuman et al., 2022; Walsh et al., 2022). Some reported that new mothers abandoned breastfeeding due to the lack of support and public health restrictions (Jackson et al., 2021b; Rice & Williams, 2021). One study reported a participant who decided not to start breastfeeding due to concerns over lack of support (Morniroli et al., 2021). Those who persevered noted significant difficulties:

Due to having no support since my baby was 2 weeks old, I’ve had to adapt our feeding to allow for her possible tongue tie. I cannot even get a diagnosis due to [the] current situation. Its [sic] been a hard slog and I’ve been in immense pain. (Brown & Shenker, 2021, p. 9)

Finally, several study participants reported challenges seeking mental health services in the postpartum period (Barbosa-Leiker et al., 2021; Davis et al., 2021; Goyal, Beck, et al., 2022; Gray & Barnett, 2021; Kinser et al., 2022; Lara et al., 2023; Ryan & Barber, 2022; Thomson et al., 2022). One study participant voiced her frustrations trying to find mental health support when they recognized their need for it:

It’s not until you’re in that deep, dark place that you need that help and someone can tell you, whereas if I’d known about it before, I might not have gotten to that point. (Davis et al., 2021, p. 10)

Discussion

This qualitative scoping review builds on previous research highlighting the nuanced experiences of new mothers amidst COVID-19–related public health measures, revealing predominantly challenging effects on their self-perceived mental health. A systemic review by Yan et al. (2020) early in the pandemic found that the prevalence rate of postpartum depression was higher during the COVID-19 pandemic compared to before its emergence. A scoping review by Kotlar et al. (2021) reported similar findings and expanded on the fact that public health restrictions could be a significant influence on the mental health of new mothers. These reviews coincide with the findings of the present study to lend evidence toward the suggestion that public health restrictions adversely influenced the mental health of new mothers during the COVID-19 pandemic. However, the aforementioned reviews of quantitative research may lack sufficient elaboration on the specific impacts of public health restrictions on the self-perceived mental health of new mothers. The qualitative findings included in this review expand on the depth of public health restriction impacts that have largely negatively influenced new mothers’ mental health during the pandemic. Specifically, the new mothers captured within the studies included reported mental health impacts related to general health restrictions, including the lack of social and community support as well as impacts on the immediate family. Additionally, mental health distress also emerged specifically from the effects of pandemic restrictions on maternal healthcare. These findings, combined with existing quantitative knowledge, provide a clearer picture of the impacts of public health restrictions on new mothers’ mental health as well as a stronger evidence base for future maternal health policy and planning for the provision of essential services to perinatal women in other public health emergencies.

Public health restrictions that reduced opportunities to connect with family and friends as well as access tangible support appeared to be particularly detrimental for new mothers’ mental health and had further impacts on immediate family dynamics. Social support, which could include participation in cultural events and traditions, has been found to be protective against mental health distress, including during the COVID-19 pandemic (Schug et al., 2021). The participants included in our review expressed anxiety and sadness over the inability to gather with friends and family. Some individuals specifically reported that they were unable to organize or attend traditional events associated with pregnancy or childbirth. Previous research on maternal mental health has found that having a high degree of perceived social support may reduce the risk of developing postpartum depression, even during times of overarching global stress like the COVID-19 pandemic (Terada et al., 2021). The results of this review add to the evidence that public health restrictions related to social gatherings, while potentially valuable to reduce viral caseload in the general population, could have negative impacts on mental health during pregnancy through to the postpartum.

Further to the impacts of general restrictions, however, were new mothers’ perspectives on the impacts of pandemic restrictions to maternal care, which may be of particular value for future planning of the provision of essential maternal services in subsequent pandemics. For example, birthing partners were universally restricted during COVID-19 in the included studies of this review. Participants described that policies prohibiting birthing partners caused maternal stress and anxiety. Separation from, or the lack of, a birthing partner during birth has previously been linked to stress even prior to the COVID-19 pandemic (Dunning et al., 2016). This distress, coupled with the increased stress of a pandemic, may exacerbate an already stress-inducing experience and could perhaps have downstream effects on the birthing process as well as maternal and infant health. Indeed, similar stress and anxiety were reported while speaking about barriers to accessing in-person care for the infant. Virtual care increased during the COVID-19 pandemic to remove access barriers and reduce caseload (Bhatia et al., 2021); however, the present review found that new mothers often desired increased in-person visits to healthcare providers during the pandemic. Additionally, new mothers with lower socioeconomic status often do not have access to virtual resources for care. Previous research has found that new mothers may benefit more from in-person healthcare visits, especially when virtual care could result in missed milestones of infant healthcare (Kolker et al., 2021). Thus, the findings of this review add to the broader question regarding the need for balance in reducing COVID-19 (or other viral) case transmission while ensuring sufficient and context-dependent healthcare (Lalor et al., 2021).

Limitations

Like most research, this review has some limitations. Its qualitative findings should be examined with the consideration that the experience of each participant is likely unique and not easily generalizable to the experiences of all new mothers. Future reviews may benefit from specifically identifying research that represents broader socio-demographic diversity, including new mothers who are racialized, have a low income, or are less educated, as well as those with differing gender identities and sexual orientations, and whose experiences may be missed in the currently published literature.

This review also has limitations regarding the operationalization of mental health; the search strategy did not include clinically diagnosed mental illnesses. However, self-reported mental health may be a more accurate representation of mental states during a public health emergency when access to healthcare and mental illness diagnoses were limited. Thus, self-reported mental state was prioritized instead of clinical diagnoses of mental illness in the search phase of this study. This approach provided a wider view that captured new mothers at risk of mental illness. Furthermore, participants with clinically diagnosed mental illness were not excluded; several studies focused on those with diagnosed depression or anxiety (Anderson et al., 2022; Goyal, Beck, et al., 2022; Green et al., 2022; Nagendrappa et al., 2021; Ryan & Barber, 2022).

Conclusion

This scoping review identifies a range of studies that qualitatively describe the impacts of COVID-19 public health restrictions on new mothers’ self-perceived mental health. Overall, we found that COVID-19 restrictions overwhelmingly had adverse effects on maternal mental health. General restrictions reduced access to family and friends, coinciding with isolation, decreased amounts of community support, leaving new mothers feeling overwhelmed, anxious, and distressed, as well as increased stress within families. In some studies, new mothers reported positive impacts on their mental health, such as increased support gained from their partners working from home and being thankful that external childcare supports were shut down in order to have more bonding time with their child. However, these latter findings were rare compared to the negative impacts and were dependent on the specific socioeconomic status and circumstances of those new mothers and their families. In contrast, public health restrictions limiting access to maternal healthcare from pregnancy through the postpartum period had exclusively detrimental impacts on new mothers’ mental health, such as increasing worry, fear, anxiety, and stress.

The findings of this review fill a knowledge gap by providing depth and understanding to new mothers’ experiences and thus build on previously published reviews that focused on quantitative measures of new mothers’ mental health during the COVID-19 pandemic. This review demonstrates the array of adverse impacts of COVID-19 public health restrictions on mental health throughout pregnancy into the postpartum period, as reported by new mothers. In the likely case of future pandemic and/or other public health emergency planning, our review may be beneficial for policy makers when evaluating the impacts and unintended consequences of public health restrictions on vulnerable populations, including new mothers. Such evaluations may prove vital for proposing alternatives that reduce negative consequences for mental health.

Supplemental Material

Supplemental Material - COVID-19 Public Health Restrictions and New Mothers’ Mental Health: A Qualitative Scoping Review

Supplemental Material for COVID-19 Public Health Restrictions and New Mothers’ Mental Health: A Qualitative Scoping Review by Ammanie Abdul-Fatah, Michelle Bezanson, Sebastian Lopez Steven, Emily Tippins, Sarah Jones, Heather MacDonald, and Renate Ysseldyk in Qualitative Health Research