To be soft again: A phenomenological study of uncertainty and resilience in childbearing during the COVID-19 pandemic

Abstract

Background:

During the COVID-19 pandemic, uncertainty was exacerbated in experiences of pregnancy and childbirth as people navigated through uncharted territory. Building resilience may be one effective way to cope. However, for those who carry a heavier burden in upholding others, a societal expectation of “toughness” and the ability to endure may lead to an appearance of resilience, while on the inside, well-being may be compromised.

Objectives:

This study is part of a larger phenomenological study that explored the broad research question: What is the lived experience of childbearing during the COVID-19 pandemic? Specific themes of uncertainty and resilience are reported with the aim to provide a deeper exploration of the role they play in childbearing persons’ lives.

Design:

This study utilized an interpretive phenomenological design, which allowed for an in-depth exploration of participants’ experiences and the implicit meanings of those experiences.

Methods:

Participants who were either currently or recently pregnant and had given birth since the pandemic began were recruited from a larger U.S. national survey. Twenty-two U.S. ethnically, racially, and geographically diverse women were interviewed via Zoom in English or Spanish.

Results:

The text revealed rich narratives of uncertainty during the unfolding of the pandemic vis-à-vis direct experiences of contracting COVID-19, concerns regarding vaccination, and the effects of public health restrictions impacting pregnancy, birth, and postpartum experiences. Participants also shared how courage and humility contributed to their overall resilience, and how resilience may be masked in others.

Conclusion:

When considering the complexity of women’s lives in contemporary society along with the demands of motherhood to facilitate a deeply felt resilience resulting in well-being, interventions must be multi-pronged to lessen the pressures to be a superwoman and/or supermom and change the norm on a societal level for childbearing persons to have the option to be soft again.

Background

During the COVID-19 pandemic, uncertainty prevailed and was exacerbated in experiences of pregnancy and childbirth as birthing people navigated through an overabundance of uncharted territory.^{1 –14} Myriad studies on pregnancy and birth during the COVID-19 pandemic demonstrated consistent findings related to experiences of uncertainty, decision fatigue, and isolation in pregnancy, birth, and postpartum resulting in a range of mental health strains including fear, worry, anxiety, and depression; however, many of the studies also described various coping mechanisms often leading to a sense of acceptance and resilience to ongoing challenges.^{1 –14}

Unfolding research on the risks of COVID-19 in pregnancy and its potential impact on the fetus and newborn validated pregnant persons’ concerns.^{15 –21} Coping with uncertainty is an ongoing challenge for both patients and their healthcare providers who attempt to help their patients navigate through the unknown. ²² Theories of uncertainty have been developed to help facilitate an understanding of the phenomenon^{23 –25}, and these have led to the development of interventions to help patients manage the uncertainties of their health-related events. ²⁶ In situations that challenge one’s ability to cope with unfolding uncertainties, perhaps those that are enduring, or particularly traumatic, building resilience may be one effective way to tolerate life’s curveballs.

Research on resilience in general^27,28 as well as in the context of COVID-19^1,4,10,11 portrays resilience from a positive lens. It has been used synonymously with “grit” not too unlike the American “bootstrap concept.” ²⁹ However, for women, and in particular, those who carry a heavier burden in upholding others, a societal expectation of “toughness” and the ability to endure, may lead to an appearance of resilience on the outside, while on the inside their needs may remain unmet, which may be a detriment to their mental health and well-being.^{30 –32}

Despite the range of research on childbearing during the COVID-19 pandemic, to date, no studies have reported in detail on the specific nuances of uncertainty and, more importantly, on the complexity of resilience as a coping tool in pregnant and newly postpartum persons. The analysis presented here is part of a larger study that explored the broad research question: What is the lived experience of childbearing during the COVID-19 pandemic? The specific themes of uncertainty and resilience are reported in this article. Focusing on these two main themes affords a deeper exploration of the role they play in childbearing persons’ lives, allowing for a more thorough analysis and interpretation. Other themes that surfaced in the larger study will be reported elsewhere. There is much to be gained from understanding these heightened and nuanced experiences of uncertainty and resilience that occurred in a vastly diverse U.S. sample during the COVID-19 pandemic. This understanding may help clinicians provide more empathic and sensitive care for their maternal patients, and advocate for the needed support to improve well-being in pandemic times, as well as in childbearing in general.

Methods

Study design

This study utilized an interpretive phenomenological design introduced by Martin Heidegger ³³ who stressed that the ontological existence of the sociocultural and historical backdrop of humans is integral to “Being” and cannot be stripped away from experience. Narrative text, the data of qualitative research captures this rich context of people’s lives as well as what is important to the person as a “self-interpretive being” who experiences the phenomenon in question, and the task of the researcher is to seek those sometimes “hidden” meanings that subjects ascribe to experiences. ³³ Applying a qualitative lens to phenomena affords the ability to achieve a deeper empathic understanding. Interpretive phenomenology was appropriate for the research question as it allowed for an in-depth exploration of participants’ experiences and their implicit meanings of those experiences. Interpretive phenomenology aims to “uncover and disclose,” whereas general qualitative research aims to describe “who, what, and where.” ³⁴

The essence of phenomenology is to unveil what is taken for granted in everyday lived experiences and to make explicit the intentionality (i.e. the meaning behind) conscious actions and words of participants. ³⁵ Benner and Wrubel discuss Heidegger’s concept of personhood and describe the existential motivations of humans as caring beings, and what shows up for individuals portrays what they care about. ³⁶ Discovering this meaning in the narratives of participants facilitates a deeper understanding of phenomena that may inform practice and attend to the needs and concerns of patients.

The positionality of the researcher is essential in interpretive phenomenology as it provides the backdrop upon which empathic understanding is built to arrive at a new horizon of understanding. ³⁷ The first author, M.N. is a non-practicing certified nurse midwife, mother, grandmother of twins who were toddlers during the pandemic, and professor of nursing and public health who has conducted extensive phenomenological research that explicates the value of empathy in research and practice. The second author, A.R. is a mother (who gave birth during the pandemic), and an epidemiologist whose research has focused on investigations of vaccine uptake and hesitancy in maternal and child populations, and in the general population.

Sample recruitment

Participants who were either currently pregnant or recently pregnant and had given birth since the pandemic began (i.e. March 2020) were recruited from a larger U.S. national survey conducted between May and August, 2021 examining COVID-19 experiences, health behaviors, physical/mental well-being, attitudes toward vaccination, and vaccination uptake in pregnant and postpartum persons.^38,39 As part of the national survey, respondents were invited to additionally participate in a one-on-one interview. A sample of willing participants (those who answered “yes” to “would you be willing to be interviewed?”) was then selected judiciously to obtain geographic, ethnic, and racial representation to increase the transferability of findings based on a varied population sample. Participants were then contacted via email (in English or Spanish, per stated preferred language) to inquire if they were still interested in participating in an interview. Those who confirmed their interest were contacted again, either by M.N. for English speakers or a Spanish-speaking research assistant for Spanish speakers, to schedule the virtual interview.

Data collection

Interviews were conducted and recorded via the virtual platform, Zoom, in English or Spanish, based on the participant’s preference, and lasted between 50 and 90 min. A dialogical style of interviewing based on the Socratic method ⁴⁰ was used with full attention paid to the responses of the participants, which leads the researcher in a conversation style to inquire further into what is being shared. Since this study was part of a larger cross-sectional survey, additional questions were used as prompts to complement the survey questions, such as explicit concerns regarding SARS-CoV-2 infection, social support, COVID-19 vaccine intention and uptake, and overall health-related quality of life. (Please see Supplemental Appendix for interview guide.) The dialogical interview style allows an opportunity to glean rich narratives for the analysis. In a sense, the interpretation of data begins during this process. ⁴⁰ First author, M.N., conducted most of the English interviews, and the native Spanish-speaking research assistant interviewed all Spanish-speaking participants, as well as a few English speakers. Audio recordings were transcribed by professional transcriptionists in English and Spanish, and the same research assistant translated all Spanish transcripts into English. A $35 compensation was either mailed or sent electronically per participant preference.

Consistency between interviewers was guided by the interview prompts but only used to ensure key information was solicited as needed without preventing the conversation style of Socratic interviewing methods. ⁴⁰ Furthermore, the first author, M.N., worked closely with the research assistant, training them on Socratic methods and conducting random checks on translations to assure accuracy. (M.N. has proficient Spanish language skills but is not a native Spanish speaker.)

Saturation, a complex concept of rigor considered in general qualitative study designs, varies according to the design and includes theoretical, thematic, and data saturation, and may be applied at varying stages of the research process. ⁴¹ However, saturation is not an aim of interpretive phenomenology, which is mainly concerned with rich personal narratives. In fact, it is believed to be unattainable in phenomenology and thus was not a focus in this study. ⁴² van Manen et al. purport that “. . .in phenomenological inquiry, you open up a question, which becomes bottomless—so it does not make sense to say that you caught all the meaning or meaningfulness of a human phenomenon.” ⁴² , ^p5

Pseudonyms were used to ensure confidentiality and all transcripts and recordings were stored on a locked computer. A detailed consent form was emailed to participants prior to the interview explaining the purpose of the study and potential risks and benefits from participation. Participants had the opportunity to ask questions and discuss details from the consent form prior to the start of the interview. Participants verbalized understanding that agreeing to be interviewed was agreeing to participate in the study. The procedures were reviewed by the University of San Francisco Institutional Review Board, and a waiver of signed consent was approved.

Data analysis

The following was performed by the first author, M.N. transcripts were imported into NVivo (QSR International, Version 1.6.2) for organization and analysis. Each subject’s narrative was read through in its entirety, and initial reflections were jotted in a memo. This was followed by a slower reading of each text, focusing more on salient points and surfacing meanings. Additional memos were created to record descriptions of the salient points with close examination of any possible implicit meanings hidden beneath the surface. ³³ After completing this step, texts were read again with the aim to consider commonalities surfacing from the data, and coded as such to initiate a thematic analysis. ⁴³ During this process, participant quotes were selected to support the thematic threads. ⁴³ This process provided a prolonged engagement and dwelling with the text (a feature of interpretive phenomenology), which afforded thick descriptions of the phenomenon under investigation and provided a significant opportunity to explore the implicit meanings. ⁴³ Second author, A.R. reviewed transcripts and analyses and provided insightful input. The consolidated criteria for reporting qualitative research checklist was used to report findings. ⁴⁴

Ethics approval

Full approval of the study, including the method of consent, was obtained by the University of San Francisco Institutional Review Board (ID #1542). A detailed consent form was emailed to participants prior to the interview explaining the purpose of the study and potential risks and benefits from participation. Participants had the opportunity to ask questions and discuss details from the consent form prior to the start of the interview. Participants verbalized understanding that agreeing to be interviewed was agreeing to participate in the study. All participants also provided electronic consent before completing the original quantitative national survey, from which the sample for this qualitative study was drawn. The procedures were reviewed by the University of San Francisco Institutional Review Board, and a waiver of signed consent was approved.

Results

Sample

Twenty-two (n = 22) cis-women were interviewed between August and December 2021 and included Spanish-speaking Latinx (n = 8), White European American (n = 7), African American (n = 4), and Asian (n = 3) participants. Two were recent immigrants from South America and India, respectively. Participants lived across the U.S, representing the Northeast, Southeast, South, Midwest, and West. Occupations varied and included lawyer, educator, food vendor, volunteer, lab scientist, nurse, medical secretary, business owner, and unemployed outside the home. At the time of the interview, they were either pregnant, postpartum, or post-pregnancy loss. Most pregnancies were planned or achieved with fertility treatments, with a few unplanned. For some, it was their first pregnancy/child, and for others, subsequent. A few reported chronic health conditions that impacted their pregnancies, with some having complications during pregnancy, such as gestational diabetes, preeclampsia, bleeding, preterm labor, or birth. Although multiple themes surfaced in the larger qualitative study, the focus of this report is exclusively on the analysis of uncertainty and resilience presented below.

Uncertainty

Uncertainty was a profoundly salient theme emerging from the narratives of participants reporting on their lived experience of COVID-19 while pregnant, with some also sharing experiences of birthing and early postpartum. The text revealed rich narratives of uncertainty during the unfolding of the pandemic and is provided here under thematic headings of uncertainty in COVID infection, uncertainty in vaccination, and uncertainty in birth.

Uncertainty in COVID-19 infection

Five of the participants had contracted COVID-19 at some point in time. Three had COVID-19 before pregnancy and one during pregnancy. Sarah, an African American woman, had COVID-19 in between pregnancies (losing the first one at 6 weeks gestation) and experienced severe long-haul symptoms that resulted in hospitalization before getting pregnant again. The lingering symptoms greatly affected her subsequent pregnancy physically and mentally.

. . .If COVID wasn’t happening, I feel like I would be able to breathe during my pregnancy a lot more—like just take a deep breath and be more relaxed about my pregnancy, but because COVID is happening, I feel like COVID has just—it’s a trauma, and it has impacted my brain in such a way that causes me to be very hypervigilant.

Sarah relayed after that it was “just the not knowing” that worried her the most. The relationship between uncertainty and anxiety is clearly portrayed as she struggles with finding a way to cope with all that remains unknown. Her hypervigilance implies a certain doom looming around the corner.

Rami, another African American woman, discovered she was 10 weeks pregnant around the same time she became infected with COVID-19.

. . .It [COVID infection] was before, like, all of our family and stuff found out. And it’s before the end of the dreaded first trimester, so it was very nerve wracking. Very discouraging, at times. There were some complications in the beginning, especially with some bleeding. It was very difficult to find his heartbeat. And so, I was very hesitant to even tell my husband that I was pregnant at the time because I had contracted COVID.

Early pregnancy symptoms mixed with severe COVID-19 caused exacerbated fear and concern, not only for herself but also for her fetus. Added to this physical and emotional strain, Rami spared her husband the news that she was pregnant in an effort to protect him from added worry about the pregnancy, causing her to manage all of these emotions alone. The residual effect of having been infected early in the pregnancy weighed on her: “So, overall, it was just, it was extremely nerve-wracking. And then not knowing if I was going to get over the illness, and then what other effects it might cause later on in my pregnancy.” The fear of COVID-19 was not over once the infection was cleared, as the uncertainty of its effect on the pregnancy lingered into the future.

Veronica, a Spanish-speaking woman, spoke of having COVID-19 before she was pregnant, but focused more on her concern for her two other children at that time. She shared: “It was terrible. My symptoms were severe. I had all the symptoms you can think of, and every time I coughed, I would bleed. And this caused a lot of panic. I had a fear that I would leave my kids behind, like orphans.” Veronica experienced a life-threatening illness, but her main concern was her “potentially” orphaned children, a palpable fear and uncertainty.

These direct experiences of COVID-19 introduce the fear of the unknown, the prevailing uncertainty that many faced during the pandemic, with the focus not on self, but on those who were dependent on them—those in utero and those already born.

Uncertainty in vaccination

COVID-19 vaccination experience surfaced during the interviews either spontaneously or after direct inquiry, with vast uncertainty prevalent in vaccination decisions. Sarah highlighted these concerns. She shared: “When we lost our first pregnancy, I remember thinking, did my getting the vaccine really ruin my chances of getting pregnant, or did having COVID-19 and then having all these long-hauler issues affect me getting pregnant.” Many who lose a pregnancy ruminate on the possible causes, even though miscarriages are common and often have no known etiology. But in light of an infectious pandemic where decisions are needing to be made fast around a pretty “new” intervention such as a vaccine, it naturally becomes a profound point of fear and uncertainty.

Meghan received a COVID-19 vaccine early in her pregnancy and experienced a spontaneous abortion at 16 weeks of gestation. She shared her turmoil of this loss: “Then, of course, I’m stressed out. I go into my bedroom. I close the door. I’m crying to my husband. He’s like, ‘Meghan [the vaccine] did not cause the miscarriage. It’s not possible.’ I was like, ‘I don’t believe you.’” Meghan’s story was further complicated in that her parents were against the vaccine and placed guilt upon her for the loss. She ultimately felt more assured of her decision and confronted her father, but he was not convinced. He responded with:

Well, I just don’t believe that because you did get in the first trimester, and you just don’t do things like that. You are going to hate yourself for the rest of your life, and you’re going to wonder about this forever.

The pure fear of “what if she caused the demise of her fetus” penetrated any logical and rational understanding and evidence to the contrary. This painful, nuanced situation demonstrates a complexity of uncertainty greatly complicated by a novel pandemic.

Isamar shared similar concerns and was torn between the risks of the vaccine and the risks of infection. She shared: “Honestly, I felt like it would affect my baby’s development, I worried something could go wrong with the vaccine. . .I was afraid of both the virus and what the vaccine could cause.” Isamar, like Sarah and Meghan, demonstrates the anguish of making a wrong decision about vaccinating.

Barb, a native Spanish speaker, received her first dose before she was pregnant, and right when she got her second dose, she found out she was pregnant. Her main concern was getting through the genetic testing, praying that the tests would not show any fetal effect from the vaccine, especially because she received the vaccine so early in her pregnancy.

I would tell myself, “Oh, no, my God.” I lived in great fear during this time. I would tell myself, “I don’t know if the vaccine has affected the baby in some way and genetically, I am not going to find out until that week.”

This anticipation consumed her for much of her early pregnancy as she continued: “Honestly, I spent the first 3 months not wanting to move or even go outside to get sunlight. I was stressed. First, the growth of the baby, how its development would progress with me getting the vaccine.” Barb’s fear of the unknown lingered for months and would not abate until her tests came back negative. The sharing of her inner voice provides insight into the reality of her rumination and expressed worries.

Confronting the unknown, doubting decisions, and contemplating the potential of actions versus non-actions weighed heavily on the participants above as they spoke of the uncertainty around the COVID-19 vaccine.

Uncertainty in birth

During the peak of the pandemic, the risks of transmission in the hospital caused a cascade of preventive measures, such as separating the mother and infant at birth, to limiting who was able to attend the birth and visit during the immediate postpartum period. Looking forward in time, uncertainty around the birth and being in the hospital was expressed by many. Jenn shared her worry about her husband not being able to attend the delivery. “So, we were really stressed about him not being able to be there, you know, for me, and also. . .him missing our child’s birth, for her entrance to the world. . .”

Barb shared similar concerns but for a slightly different reason. She also feared being alone at the birth, but as a Spanish speaker, she was more worried about not being able to communicate effectively without her husband due to her English unproficiency. The varying and ever-changing policies in place at hospitals regarding who could be in attendance for the birth ultimately caused much angst leading up to the birth. Sarah was worried about being cared for by someone who wasn’t vaccinated. She stated: “I went to the hospital in July, and I literally remember looking at my nurse, the care assistant, I was just like, “You guys vaccinated? Because if you’re not vaccinated, get out of my room.” The juxtaposition between giving birth in a safe environment and the fear of contracting a virus from a nurse added to the undue stress of giving birth during a pandemic.

Uncertainty is temporal in nature and revealed through experiences of looking back in time at pregnancy loss, and forward in time as potential effects on self and fetal well-being, or future birth situations including who will be there to support them, and what exposures and threats to their family’s health might they encounter in a hospital during a pandemic. The general uncertainties of pregnancy and birth in the best of times were exacerbated during the COVID-19 pandemic. The participants were left without answers, living day to day with fears and anxiety of the unknown.

Resilience: A complex coping

Despite the hardships that participants shared evolving around the vast uncertainty being played out in myriad ways, their resilience was palpable. Ways that this resilience manifested include surrendering to what little they had control over, including all the “what if” possibilities, and reflecting on perspective and the need to evaluate their experiences in a greater context of others’ experiences, such as not being the sole victim of the pandemic, or surviving when others didn’t. These methods of coping allowed many to achieve a sense of tolerance of the uncertainty they endured, which led to an overall resilience to the hardship. However, the complexity of resilience was revealed through contradictory and even surprising statements shared by some of the participants.

Karen relayed what worked for her when she was confronted with worry and uncertainty:

“Well yes, I was afraid that things would not turn out well but I tried to be as calm as possible.” Karen makes a concerted effort to counter her worry but it is clear in her statement that she was attempting to “hold” both of those contradicting emotions—fear and calm, simultaneously. The awareness of her worry did not preclude her ability to find some peace.

Jenn took a different path but attempted the same outcome. She shared how she and her husband coped with the unfolding pandemic: “So, that’s one thing that the two of us just say back and forth to each other, like, ‘This sucks, it’s awful, and we’re still here.’” Eliciting perspective, albeit in the basic form of survival, allowed Jenn to come to terms with her challenges. In light of the underlying awareness that mortality was more real than ever during this pandemic, she was able to find a sense of humility and gratitude that helped her develop resilience.

Knowing that one was not a victim alone in the fight against COVID-19 also brought respite to some. Meghan highlights this: “You know what’s funny? Everyone is doing this. Everyone’s got a story to tell. That’s what is the saddest part, but also just makes it so much more bearable.” There is irony and a tinge of guilt implied in Meghan’s statement. The fact that she can accept her burden more knowing that others are also suffering demonstrates the power of a shared human experience, even when it is traumatic. In a way, this is the opposite of Jenn’s path to peace. For her, it was finding gratitude in “not sharing” the same fate as others; whereas for Meghan, the shared experience is what gave her comfort. Resilience was built on a foundation of humility and strength as demonstrated in the exemplars above, and it is viewed as a positive, powerful force to cope with uncertainty and hardships.

Jenn also brought to life a different perspective on resilience. She shared at the end: “I’ve been called resilient a lot this year. And I’m also just like, I just want to be able to be soft again and not feel this hard shell of, ‘I just have to get us through the next piece of whatever’s going on.’” There is a deep sadness beneath this statement and a longing for a more peaceful and easier time in her life. She endured extreme hardship during her pregnancy, birth, and postpartum above and beyond the average person, including a fractured pelvis and sprained knee at different times during her first 6 months of postpartum. The pandemic exacerbated her hardship in myriad ways. Her longing for something other than what she equates with resilience may imply that she is attempting to live up to an expectation that she must be strong, bearing a “hard” shell, as if it is another burden on top of her already existing burdens. There is a clear resistance to, and perhaps even a resentment of, the external pressure to be resilient, where inside, she has a deep unmet need—to be “soft again.”

Although not many addressed this sentiment as strongly as Jenn, others demonstrated an internalized pressure to uphold an outside appearance of strength. Yadira, a Spanish-speaking woman shared: “If I say I have depression, people might think, ‘She’s lazy, she doesn’t want to do anything.’ And that’s why I felt a lot of support in those therapy groups.” Yadira found respite in a support group that would allow her to be herself and express her depression without fear of judgment. This articulated “imagined” comment by others may reflect an internalized self-judgment of her mental state that is construed as being lazy or possibly weak or needy. It is apparent that she attempts to hide these states of hers until she is in a safe place, such as what is afforded to her in a separate therapeutic setting. This dichotomy of concealing something inside was also apparent in Rami’s story, shared earlier, of getting infected with COVID-19 during the first few weeks of her pregnancy and keeping it a secret from her husband. It was clear she was protecting him while carrying the fear alone on the inside.

Resilience to the uncertainties of childbearing during the COVID-19 pandemic was built upon the various ways the participants coped with the challenges. Some found respite in appreciation for being spared what others may have lost, including life itself; some found it in community with others, knowing that everyone was enduring equally; and some found ways to hold both the fear and peace simultaneously, resulting in an accepting calm. The alternative to resilience may have been too frightful and too risky thought, considering those (newborns, other children) fully dependent on them. And yet, resilience may be just another demand upon the myriad others. This demand was most clear in Jenn’s desire to let go of the hard shell that others admired in her, but it was also apparent in Yadira’s need to suppress her depression, or Rami’s need to initially hide her pregnancy. These women displayed an exterior appearance that concealed a different internal reality.

Discussion

The results above depict the experiences of an ethnically, racially, and geographically diverse U.S. sample of cis-women who were pregnant at some point during the COVID-19 pandemic up until December 2021. Rich narratives of the participants’ experiences afforded a deeper understanding of childbearing during a very precarious time. Moreover, this study provides an understanding of the exacerbated uncertainty that led to fear, worry, and anxiety in childbearing persons during the COVID-19 pandemic, and also reveals the numerous ways in which the participants coped with the challenges. The findings support previous research on experiences of uncertainty in pregnant and birthing persons during the COVID-19 pandemic^{1 –14} as well as in pregnancy in general.^25,26,45,46 Schmuke’s ⁴⁶ review of uncertainty in high-risk pregnancies was not so unlike the experiences of the participants in the current study, even though only a few had high-risk pregnancies. This highlights the similarity of experiences between a low-risk pregnancy during an unprecedented pandemic and a high-risk pregnancy in a non-pandemic time.

Pregnancy and birth, even when low risk, come with some level of uncertainty, which varies greatly, as does coping with it.^25,45,46 Borrelli ⁴⁶ conducted a grounded theory study with 14 first-time mothers with low-risk pregnancies and found uncertainty in the unknown territory of labor and birth and waiting for the unknown. They also revealed how the women employed coping mechanisms to manage the uncertainties that they referred to as going with flow. In another examination of a diverse sample of low-risk pregnancies, Handley reported that women who were Black, younger, unmarried, lived in rural areas, and with lower income and education scored higher in uncertainty. ²⁵

Effects of pandemic restrictions during hospitalization and the birth process also contributed to the uncertainty for the participants in this current study, and changes have been suggested to mitigate the adverse effects. ² However, the focus of this discussion is to consider methods to facilitate an adaptation to, and tolerance of, uncertainty, which can be applied to any pregnancy and childbirth experience, and to alert clinicians regarding the complex presentation of resilience. To address uncertainty in medical situations, Han purported that certain “dimensions of tolerance” that included humility, flexibility, and courage could aid in the transcendence of uncertainty. ²² Humility is seen as enabling transcendence vertically, as in rising above, which was captured in this study when Karen reported her concerted effort to “remain [as] calm as possible” amidst the intensity of the situation. Flexibility is considered more of a horizontal transcendence, moving across diverse and conflicting responses. Meghan’s ability to examine her challenges in solidarity with others demonstrated flexibility, which carried her to a place of acceptance. Han described courage as a forward moving transcendence, being able to meet one’s fears and worries and move from the known present to the unknown future. Courage permeated all participants in this study, as caretakers of their own lives and the life within, in decisions to vaccinate or not, and moving forward regardless of the unknown direction it would take them, helped bring them to a place of surrender, tolerance, and resilience.

Even though the participants in the current study employed methods to facilitate tolerance to uncertainty, which often led to resilience to the challenges, some experienced a need to conceal their inner reality, which may have appeared to portray an outward-appearing resilience. Sehgal referred to endurance as “grit” which they purported can lead to a resiliency that can be protective. ²⁹ However, it may also lead to unreasonable expectations for some. In Woods-Giscombe’s examination of the superwoman role often examined in African American women, they described the general concept of the “strong” woman who can endure monumental stress. ³⁰ They posited that this legacy of strength, when confronted with adversity—also seen as synonymous with resilience, may be contributing to current health disparities in African American women. ³⁰ The participants in their focus group shared that often pressure existed to be “strong” and thus an external face was one of resilience; yet internally they struggled with insufferable stress that manifested in myriad mental and physical health conditions. ³⁰ Beauboeuf-Lafontant cautioned that, particularly those in the mid of childrearing, caring for others placed them in a position of selflessness, powerlessness, and self-silencing, leading to increased risks of depression and psychological distress. ⁴⁷ Woods-Giscombe listed various contributing factors to this phenomenon, particularly common in unsupported traditional households, as: feeling obliged to help others and finding difficulty in asserting boundaries to multiple roles and responsibilities; resisting being vulnerable or dependent; feeling obliged to suppress emotions; and often postponing self-care—all of which may be construed as resilient, yet may also result in devastating effects. ³⁰

The concepts of supermom ³¹ and intensive mothering ³² have also been explored as modern-day social phenomena that impact many. Impossibly high standards for mothering add extra pressure on constant decisions that are laden with potential failure. ³¹ Forbes et al. cite Hays (1996), who coined the term, intensive mothering, which reflects cultural norms that must be met to reach the status of a good mother and includes placing the needs of children and family above one’s own. ³² These standards may add the pressure of holding it together while internally they may be drained and depressed, lacking the resources to provide adequate self-care. Participants in this study also portrayed this characteristic; they were carrying the bulk of the physical and emotional burden of pregnancy during a pandemic, along with protecting their spouses and children simultaneously.

When considering the complexity of women’s lives in contemporary society along with the demands and pressures of motherhood, on top of the severe disruptions created by a global pandemic, to facilitate a genuine resilience resulting in a sense of balance, well-being, agency, and a valuable quality of life, interventions must be multi-pronged. Healthcare practitioners can develop programs aimed to teach stress reduction and coping on an intrapersonal or individual level as part of holistic prenatal care. Brown, a popular advocate for women’s empowerment and critic of the “superwoman” syndrome, has suggested the importance of developing a daily mindfulness and self-compassion practice as a key component of developing resilience. ⁴⁸ On an interpersonal level, practitioners must be alerted to the possibility of a masked resilience presented in their patients and utilize proper screening techniques to unveil the need for support. ⁴⁹ Galathe spoke of the potential harm in masking resilience and shared:

And as we continue to pretend and pretend and act like things are okay, what’s going to happen is that being in this constant state of survival will lead to burnout. And burnout is just the tip of the iceberg on a very slippery slope that can be detrimental to your mental and physical health. . .Let’s not glorify struggles and call them “resilience” and “grit.” ⁴⁹

In addition to tuning in to the possibility of masked resilience presenting in their clients/patients, providers can advocate for holistic, comprehensive care to support childbearing persons, and in particular those of color or marginalized, that fully supports pregnant and birthing persons into the postpartum period. Programs that aim toward building community can help break the isolation so common, especially in early postpartum, and specifically during a pandemic, virtual communities can be of assistance.

On a societal level, the social norm to be a “superwoman” or “supermom” can be challenged to encourage women to express their vulnerabilities and needs. Currently, there is a movement that is advocating for “The Soft Black Woman” as a pushback to the strong Black woman phenomenon and includes a focus on self-care and self-love. ⁵⁰ These tactics can be appropriate for childbearing persons of all races and ethnicities to combat the high standards placed upon the main caregiver, which would lead to a more genuine resilience to the challenges of childbearing and childrearing in pandemic and non-pandemic times.

Limitations

The results in this study are limited due to the nature of qualitative research. However, the aim of interpretive phenomenology is not to present final conclusive evidence or causative relationships, but it affords a glimpse into what is possible for some and may be transferred to similar others. Interviews were only conducted once with each participant, which limited further exploration of the themes that emerged. Nonetheless, the study results provide a solid foundation, and hopefully a curiosity, for further exploration of masking resilience, along with effective ways to navigate uncertainty and support childbearing persons through potential challenges and hardships.

Conclusion

During the COVID-19 pandemic, birthing persons were challenged by numerous uncertainties, leading to undue stress and worries about the well-being of their selves and their unborn fetuses and newborns. This study portrayed nuanced experiences of this uncertainty as the participants shared their stories of pregnancy, birth, and postpartum during the height of the pandemic, and included methods employed by the women to gain a sense of peace and resilience to the hardships. Uncertainty is inevitable in matters of human health and illness, as well as in pregnancy and birth. Concerted effort, courage, and skills are needed to develop tolerance to these inevitable uncertainties. The narratives provided in this study, although specific to the COVID-19 pandemic, can be considered in light of other challenging situations—including a potential future pandemic, or when considering pregnancies laden with concerns of well-being for mother and fetus. Building inner strength and effective coping mechanisms along with a supportive community may lead to a more deeply felt resilience for childbearing persons both during and “in between” deadly pandemics. Attending to, and caring for, the needs of birthing persons and new mothers, particularly those marginalized, and adopting a more supportive, self-care approach may counter the unreasonable expectations to carry concealed burdens and vulnerabilities. These compassionate tactics may have the power to eventually lessen the pressure to be a superwoman or supermom, and eventually change the norm on a societal level for childbearing persons to be soft again.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251344733 – Supplemental material for To be soft again: A phenomenological study of uncertainty and resilience in childbearing during the COVID-19 pandemic

Supplemental material, sj-docx-1-whe-10.1177_17455057251344733 for To be soft again: A phenomenological study of uncertainty and resilience in childbearing during the COVID-19 pandemic by Marcianna Nosek and Annette Regan in Women’s Health

Supplemental Material

sj-pdf-2-whe-10.1177_17455057251344733 – Supplemental material for To be soft again: A phenomenological study of uncertainty and resilience in childbearing during the COVID-19 pandemic

Supplemental material, sj-pdf-2-whe-10.1177_17455057251344733 for To be soft again: A phenomenological study of uncertainty and resilience in childbearing during the COVID-19 pandemic by Marcianna Nosek and Annette Regan in Women’s Health