Perspectives in Infant Mental Health - The Voices of COVID-19
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Vol. 28 No. 3 | Fall 2020
Perspectives in Infant Mental Health
The Voices of COVID-19 Professional Publication of the World Association for Infant Mental Health
Contents
From Desk of the President of WAIMH,
C. Paul..............................................................................................................1
WAIMH Executive Director Corner,
K. Puura...........................................................................................................3
The Voices of COVID-19 Perspectives in Infant Mental
Health Special Issue: From the Editors,
M. Foley, H. Brophy-Herb, J. Barlow, P. O’Rourke, J. Todd Manly,
A. AbuAli, S. Maharaj and C. Kulkarni ..................................................4
Covid-19 and Mental Health in Pregnancy: A Cross-
sectional Study on Depression, Anxiety, and Stress
among Portuguese Pregnant women,
P. R. Figueiredo, J. M. Reis, F. P. Vieira, P. Lopes,
M. J. Nascimento, C. Marques and P. C. da
Silva..................................................................................................................6
Birth during the Coronavirus Pandemic: “When fear is
the uninvited guest”, From Desk of the President
M, Romero, C. Sieverson, M. Olhaberry) C. Honorato and T.
Tagle .............................................................................................................10 of WAIMH
Shared Pleasure in the Time of COVID 19: The By
Importance of the Shared Smile for Babies in a World of
Campbell Paul, Melbourne, Australia
Masked Faces,
A. Lachman.................................................................................................14 Associate Professor, President of WAIMH
Helping the Helpers. Relationships During the As we approach the end of the year 2020, it is important to look back and
Pandemic: “Good Morning, Margaret” “Good Morning, reflect upon what has been an exceptional year of stress and anxiety with
Heidi”,
the impact of the COVID-19 worldwide pandemic. The pandemic causing
M. Holmberg and H. Maderia ..............................................................17 severe illness and death of so many has impacted the health, relationships,
A Necessary Telemedicine Intervention for a Preschooler and well-being of infants and parents. Restrictions have been placed upon
with Anxiety during COVID-19: A Clinical Reflection, family and professional supports and services for mothers, babies, and
M. Shivers....................................................................................................20 fathers. Whole communities are experiencing job loss, financial insecurity,
and social upheaval. This means we must build our information base and
When the Screen Becomes a Playground: A Dyadic be even more insistent and creative in how we advocate for the needs of
Therapy Program’s Transition to Telehealth During
the infant within the family. Colleagues from the UK, USA, Poland, Turkey,
COVID-19,
the Netherlands, and Australia have initiated one of several surveys on
H. Mayers.....................................................................................................23 the impact of the pandemic upon children 0 to 4 years. Colleagues from
Symbolic Play using Telehealth: A Brief Case Study the Queensland Children’s Hospital, Australia, are taking the lead in this
during the COVID-19 Pandemic, project (https://www.childrens.health.qld.gov.au/covid-19-unmasked/). We
M. Alvarez....................................................................................................27 welcome news of other projects looking at the impact of the pandemic on
infants and families.
COVID-19 Confinement and Babies: Video-Call-Based
Developmental and Mental Health Approach, This year was to have been 40 years since the first Congress in Cascais,
C. M. Halpern, M. Alves, S. Pires and P. C. da Silva..........................30 Portugal, but now our Congress will be June 23-27, 2021 in Brisbane,
Australia. Each Congress, held in a different country, has had its own
Clinician Perspectives on Adapting Evidence-Based
Mental Health Treatment for Infants and Toddlers unique features, and the Brisbane Congress will be no exception.
during COVID-19,
This congress will be a “hybrid” one, with an innovative mixture of in-
A. E. Davis, G. Saad, D. Williams, W. Wortham, D. F. Perry, E. person, COVID-19-safe presentations in Brisbane, and live virtual symposia
Aron, A, Neff and M. G. Biel...................................................................34 and presentations through online media. In addition, most events
The Classrooms That Never Closed: Stories of Essential will be video-recorded, and congress participants will be able to view
Early Childhood Practitioners, these for some time after the event and exchange ideas and comment
C. Barriteau Phaire...................................................................................38 through “chat”. This means that effectively everybody has ready access to
the work of their colleagues, as you will have an opportunity to review
most of the sessions at your leisure. We will have a rich cultural and
(Continued on next page) arts program, and sessions particularly pertinent to Oceania and Asia.
(Continued on next page)
WAIMH Central Office
Tampere University, Faculty of Medicine and Life Sciences, Arvo Ylpön katu 34, Arvo-building, 33520 Tampere, Finland
Tel: + 358 50 4627379, E-mail: office@waimh.org, Web: www.waimh.org
The new crises in mental health present
Guidelines for 0-3 Childcare During COVID-19: Balancing
Physical Health and Safety with Social Emotional Development, challenges for all world governments and
there are public policy changes that must be
K. A. Lingras, K. Mrozinski, A. Clavin, A. Handevidt, L. addressed to meet the needs of all our babies.
Moberg, C. Michaels, M. Mischke, T. Schreifels and M.
Infants’ rights must be identified and upheld.
Fallon................................................................................................43
We will have plenty of opportunities for
“Co-Relation” Groups - Virtual support groups for Israeli parents
people across the world to meet in small
Understanding the messiness and repairs of relationships groups through zoom to discuss the plenary,
between parents and young children during COVID-19: A case symposia, and other presentations, and
study,
meet with some of the thought leaders in
G. Amshalom, M. Bar-Halpern, T. Lev-Ran Galai, D. Lahav-Meir and E. our field. Our important prominent plenary
Tronick.........................................................................................................51 speakers include Prof. Helen Milroy from the
Infants at a Distance during COVID-19: Adaptation of the University of Western Australia who will share
Building Early Attachment and Resilience (BEAR) Program crucial understandings about the resilience of
during COVID-19 for Online/ Virtual Delivery, Australian Aboriginal cultures in supporting
L. Newman, V. Newman-Morris, A. Komiti, B. Gammell, A. Braden and S-P.
infants and young children within families and
Carron.........................................................................................................57 community. There is more news about the
plenary and other speakers on the Congress
WAIMH Office News: Update of WAIMH Membership, website. With the amazing revolution in
M. Sorsa and S. Miettinen......................................................................62 opportunity for us to meet in real-time
using virtual media, we anticipate an even
larger number of people participating in the
Congress than those who attended in person
the Congress in Rome.
Editorial Staff
Please take care and keep safe, care well for
yourselves, your families, and colleagues in
these troubled times. We look forward to
seeing you in person or in virtual reality in
June next year.
Editor
Maree Foley, Switzerland
Special Edition Editors
Holly Brophy-Herb, United States
Jane Barlow, United Kingdom
Associate Editors
Azhar Abu-Ali, United Arab Emirates
Chaya Kulkarni, Canada
Patricia O’Rourke, Australia
Jody Todd Manly, United States
Intern Editor
Salisha Maharaj, South Africa
Production Editor
Minna Sorsa, Finland
Perspectives in Infant Mental Health is a quarterly publication of the World
Association for Infant Mental Health. Address correspondence to Maree Foley
(maree.foley@xtra.co.nz). ISSN 2323-4822. All opinions expressed in Perspectives
in Infant Mental Health are those of the authors, not necessarily those of WAIMH’s.
Permission to reprint materials from Perspectives in Infant Mental Health is
granted, provided appropriate citation for source is noted. Suggested format:
Perspectives in Infant Mental Health 2020, Vol 28 (3).
2 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
World Association for Infant Mental Health Vol 28 (3)
WAIMH Executive Director Corner
Dear colleagues and friends, also find a paper discussing the possible
effect of adult mask-wearing on infants
and young children. It is hard to reconcile
The year 2020 is nearing its end and there the need to prevent the Covid-19 virus
have been a lot of memes going around from spreading with the need of young
expressing the wish that the whole year children to see us showing emotions with
could be cancelled or erased. This issue our facial expressions. How then should
of Perspectives is about one of the major we advise parents in this difficult situation?
reasons for people wishing for this, the One thing we can tell parents is that if
Covid-19 pandemic. For those of us no one in the family is ill with the virus,
working with infants and their families in masks at home are not needed. Parents
different parts of the world the year has could also be encouraged to increase the
meant increased worrying. Prolonged time they are in face-to-face interaction
or repeated lockdowns of communities with their infants and young children, and
and cities have meant complete loss or leave smart phones and other gadgets
at least reduced accessibility of services alone until children have gone to bed.
for the families in both health care and Having said that, there is one thing where
social services, and we know how harmful computers and online connections can be
that can be for the wellbeing of our of use. Our president Campbell Paul has
client families. At the same time worries mentioned in many of his talks how infants
concerning the health of our own families and young children can be engaged
and ourselves have been in our minds all in interaction via video connection in
this time, and the worry for our colleagues remote clinical sessions. Maybe we could
working in the different occupations where encourage grandparents, aunts, uncles,
social distancing is not possible. As many cousins and other close adults to spend
of you may remember, I live in Finland some time weekly in interaction with
which in all the memes is the country with infants and young children. It is amazing
serious, silent people who like to keep at what we can do these days with our smart
least 2 meters distance from one another. phones, tablets and computers. I myself
So this year may perhaps have been a bit was lucky to have a lovely experience of
easier for us Finns concerning instructions exchanging recorded voice messages
of social distancing, as it is not our custom with my four-year-old grandson which
to kiss friends hello or goodbye, and even was really heartwarming in its simplicity.
hugging each other is a new custom that I also saw a lovely video of my nephew’s
youngsters have adopted far more easily newborn son (I am a four-time great aunt
than earlier generations. Yet, even for us as well), and was able to reassure the
the necessity of not meeting our relatives parents that the funny sounds he made
and friends has started taking its toll. The in his sleep meant that he was dreaming
most painful issue for us, too, has been and that there was nothing wrong with
not being able to see our elderly relatives the baby. A little thing for me, but a big
for fear of infecting them, and particularly question for the new parents.
grandchildren not being able to visit
grandparents for longer periods of time. I have often talked about how we all
Luckily there is now good news coming in need support and reassurance, no matter
from different countries concerning the whether we are old or young, experienced
development and effect of new vaccines or new to things. In these times with so
against the Covid-19, but it will still take a many uncertainties about the future, I
while before the pandemic is over. believe we need each other’s support
even more. And since we cannot meet and
In Finland the recommendation for touch each other as much as we would like
wearing protective masks in offices and to, let us send a nice message to, call or
public spaces was not issued until this videocall our near ones and encourage the
autumn. Slowly but steadily the number parents to reach out as well in all the ways
of adults wearing masks in public has they can. Let’s make all this technology
increased and questions concerning work for the good of us all, and particularly
young children’s reactions to this have for our young ones.
been raised here too. Just this morning I
read in our local newspaper a plea from My warmest wishes to all of you,
an early educator to allow the staff in day
care centers to work without face-covering
masks. In this issue of Perspectives you will Kaija
3 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
World Association for Infant Mental Health Vol 28 (3)
The Voices of COVID-19 Perspectives in Infant
Mental Health Special Issue: From the Editors
By Maree Foley (Switzerland), Holly Brophy-
Herb (USA), Jane Barlow (UK), Patricia
O’Rourke (Australia), Jody Todd Manly
(USA), Azhar AbuAli (UAE), Salisha Maharaj
(South Africa), and Chaya Kulkarni (Canada)
We welcome you all to this winter (2020)
special issue: The Voices of COVID-19
WAIMH Perspectives in Infant Mental
Health. We wanted to take this opportunity
to acknowledge every baby across the
globe, and to strengthen our resolve to be
actively engaged in ensuring that every
baby is seen, protected, and provided with
nurturing care, along with their families
and their communities. We also wanted to
take this opportunity to acknowledge all
infant and early childhood mental health
professionals who are working relentlessly
with, and on behalf of, babies and their
families amidst this COVID-19 pandemic.
Early in 2020, in response to COVID-19
and the emerging voices of families with person, we asked authors to keep in view Relationships During the Pandemic: “Good
infants, early childhood mental health both the baby in the families that are the Morning, Margaret” “Good Morning, Heidi”.
practitioners, and researchers, a tiered focus of their paper, and you the reader.
initiative with three unique but inter- Our hope in doing this was to bring each The next group of papers, from colleagues
related platforms was developed as a reader as close as possible to the infants in the USA and Portugal, are clustered
collaboration between the Infant Mental and families that the authors present to us around the theme of telemedicine and
Health Journal and WAIMH Perspectives in - as if we were together in the same room, telehealth: A necessary Telemedicine
Infant Mental Health. The initiative, “Infant sharing experiences, and learning from Intervention for a Pre-Schooler with
and Early Childhood Mental Health in the each other. Anxiety during COVID-19: A Clinical
Context of the COVID-19 Pandemic”, is led Reflection (Miller Shivers, USA); When the
by Holly Brophy-Herb (Editor of the Infant Work on this special issue began in July Screen becomes a Playground: A Dyadic
Mental Health Journal), Jane Barlow (Guest and we are delighted to now share with Therapy Program’s Transition to Telehealth
Editor), and Maree Foley (Editor of WAIMH you a series of papers. We begin the series during COVID-19 (Hillary Mayers, USA);
Perspectives in Infant Mental Health). with two research papers that focus on Symbolic Play using Telehealth: A
pregnancy and birthing. Brief Case Study during the COVID-19
This special issue of WAIMH Perspectives Pandemic (Martha Alverez, USA); COVID-19
in Infant Mental Health, represents the The first is a paper from colleagues in Confinement and Babies: Video-Call-
culmination of our efforts for Platform Portugal: COVID-19 and Mental Health Based Developmental and Mental Health
1: The Voices of COVID-19 WAIMH in Pregnancy: A Cross-sectional Study on Approach (Christina Halpern, Mariana
Perspectives in Infant Mental Health. At the Depression, Anxiety, and Stress among Alves, Sandra Pires, Pedro Caldeira de Silva,
outset, the goals of this platform were to: Portuguese Pregnant Women (Pedro Portugal); and Clinician Perspectives on
Rafael Figueiredo, Joana Mesquita Reis, Adapting Evidence-Based Mental Health
1. Capture some of the experiences of Francisca Padez Vieira, Patrícia Lopes, Maria Treatment for Infants and Toddlers during
individuals, families, and practitioners João Nascimento, Cristina Marques, Pedro COVID-19 (Annie E. Davis, Dorinda Williams,
of meeting and working together with Caldeira da Silva). The next paper is from Whitney Wortham, Deborah F. Perry, Emily
the shared purpose of supporting, colleagues in Chile, entitled Birth during Aron, Audrey Neff, and Matthew G. Biel,
promoting, and protecting the mental the Coronavirus Pandemic: “When fear is USA).
health of babies during this global the uninvited guest” (Macarena Romero,
COVID-19 pandemic. Catalina Sievereson, Marcia Olhaberry, We then present two papers that focus
Carolina Honorato, and Trinidad Tagle). on early childcare during COVID-19. First,
2. Make these learnings from these
The focus then turns to a paper on shared a paper by a colleague in the USA: The
experiences immediately available
pleasure by a colleague in South Africa, Classrooms that Never Closed: Stories of
to WAIMH and our allied WAIMH
Anusha Lachman entitled: Shared Pleasure Essential Early Childhood Practitioners
community; and
in the Time of COVID 19 – The Importance (Candace Barriteau Phaire). The second
3. Identify emerging themes that could of the Shared Smile for Babies in a World paper, also by colleagues in the USA,
inform future empirical COVID-19 of Masked Faces. We then feature a paper is entitled: Bolstering Social-Emotional
infant and early childhood mental that is oriented towards the care of the Development in 0-3 Childcare During a
health research. practitioner, written by colleagues in World Pandemic: Balancing Physical Health
the USA, Margaret Holmberg and Heidi and Safety with Emotional Well-Being
Furthermore, given that many of us are in
Maderia, entitled: Helping the Helpers. (Katherine A. Lingras, Krista Mrozinski,
virtual connection but not able to meet in
4 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
World Association for Infant Mental Health Vol 28 (3)
Anna Clavin, Arielle Handevidt, Lauren of infants, young children, and their
Moberg, Cari Michaels, Mary Mischke, Tracy families during this global crisis and inform
Schreifels, and Michele Fallon). innovative, applied practices to support
them, and to promote their development
The impact of COVID-19 and necessary and well-being.
adaptations to group programmes
are presented next. First a paper with Finally, we would like to acknowledge
colleagues from Israel and the USA: “Co- the support of the WAIMH Board and the
Relation” Groups - Virtual support groups WAIMH office in the creation of this issue
for Israeli parents. Understanding the and are delighted to feature messages
messiness and repairs of relationships from WAIMH President Campbell Paul and
between parents and young children WAIMH Executive Director Kaija Puura.
during COVID-19: A case study (Gilad We finish this issue with news from the
Amshalom, Miri Bar-Halpern, Tamar engine room of WAIMH, the WAIMH Office
Lev-Ran Galai, Dana Lahav-Meir, and Ed in Tampere, Finland, with Minna Sorsa and
Tronick). The second paper in this set is Sari Miettinen at the helm.
by colleagues in Australia, Infants at a
Distance: Adaptation of the Building Early
Attachment and Resilience (BEAR) program
during COVID-19 for Online Virtual Delivery
(Louise Newman, Vesna Newman-Morris,
Angela Komiti, Beth Gammell, Alice Braden,
and Sarah-Pia Carron).
Our next step in this initiative is to turn
our focus towards goal three of this first
platform: To identify an emerging research
agenda for understanding and responding
to the impact of COVID-19 on the mental
health of babies in their families and
communities. This emergent agenda will
be primarily constructed from each paper
published in this special issue and papers
from Platform 2 in this initiative (see
below). This overarching research agenda
paper will be published on the WAIMH
website in early-mid 2021.
As noted above, Perspectives in Infant
Mental Health and the Infant Mental
Health Journal are collaborating in a multi-
tiered approach to address infant and early
childhood mental health in the context of
the COVID-19 pandemic. Platform 2, the
next step in the response to the pandemic,
involves a special section of papers in the
Infant Mental Health Journal designed to
address research findings in the immediate
context of the pandemic. The call for a
special section of papers was issued in
Summer 2019 and abstract submissions
were received in December 2020.
Invitations for full manuscripts will be
issued in January 2021 with manuscripts
due in the spring and publication expected
by fall 2021. There is also the possibility of
Platform 3 that would consist of a special
issue of the Infant Mental Health Journal
focused fully on research that examines
the impact of the pandemic on infant and
early childhood mental health, including
how the field can respond most efficiently
and effectively in the face of similar crises
in the future. Collectively, the multi-
tiered collaboration between WAIMH
Perspectives in Infant Mental Health
and the Infant Mental Health Journal is
designed to amplify the voices and needs
5 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
World Association for Infant Mental Health Vol 28 (3)
Covid-19 and Mental Health in Pregnancy: A Cross-
sectional Study on Depression, Anxiety, and Stress
among Portuguese Pregnant women
By Pedro Rafael Figueiredo1, Joana
Mesquita Reis2,3, Francisca Padez Vieira2,
Patrícia Lopes3, Maria João Nascimento3,
Cristina Marques2, Pedro Caldeira da Silva2,3
1
Hospital Garcia de Orta, Department of
Child and Adolescent Psychiatry, Almada,
Portugal
2
Centro Hospitalar Universitário de
Lisboa Central, Department of Child and
Adolescent Psychiatry, Lisbon, Portugal
3
Centro Hospitalar Universitário de Lisboa
Central, Centro de Estudos do Bebé e da
Criança, Lisbon, Portugal
Corresponding Author: Pedro Rafael
Figueiredo, Rua Luís António Verney 35,
2800-025 Almada, Portugal. Email Address:
pedro.rafael.figueiredo@hgo.min-saude.pt
negative impact on the mental health of Despite the current knowledge on
this vulnerable population. psychiatric disorders during pregnancy,
Introduction less is known about the true impact of a
Mental health problems, including global pandemic like COVID-19 on the
Coronavirus disease (COVID-19) is an
depression and anxiety disorders, are mental health of pregnant women. In the
infectious disease, declared by the World
relatively common among women of present study, we aimed to determine
Health Organization (WHO) as a pandemic
reproductive age, affecting nearly one in the incidence of depression, anxiety, and
on March 2020. By September 2020, there
every five individuals (Charlson et al., 2019; stress among a Portuguese sample of
were more than 30 million confirmed
Kendig et al., 2017). During the perinatal pregnant women, during the national
cases spread beyond 180 countries and
period, evidence suggests that the global state of emergency lockdown. This study
territories around the world (WHO, 2020).
prevalence of these mental disorders also aimed to obtain a holistic view about
In this context, several measures were
may increase up to 25%, with relevant the risk factors, as well as the maternal
adopted by national authorities to limit the
morbidity features experienced by the characteristics associated with this
global transmission of disease. Collective
mother throughout the pregnancy and phenomenon.
control measures were introduced that
the post-partum period, especially amid
included specific recommendations for risk
stressful or traumatic events (Howard et
groups, including pregnant women (CDC,
al., 2014; Howard et al., 2018). Accordingly,
Methods
2020).
perinatal depression is now considered
Study Design and Sample
In Portugal, during the COVID-19 state one of the most common medical
of emergency lockdown (active from complications of pregnancy reaching 10- This study presents data from a cross-
18th March to 2nd May 2020), healthcare 15% of incidence (Woody, Ferrari, Siskind, sectional study performed among
resources were reorganized in response to Whiteford, & Harris, 2017). Portuguese pregnant women who
the pandemic, involving the reallocation completed an online self-report
A recent meta-analysis suggests an overall
of services and the suspension of non- questionnaire between 25th April and 30th
prevalence of any anxiety disorder during
urgent medical activities. In this context, April 2020. Eligibility criteria included
the perinatal period of more than 15%
Portuguese pregnant women had pregnant women aged more than 18
(Dennis, Falah-Hassani, & Shiri, 2017).
prenatal appointments, routine exams and years, who were living in Portugal, and
When left untreated, these conditions are
ultrasounds cancelled, and companions who agreed to take part on the study after
possibly linked to obstetric complications
were no longer allowed during labour completing an informed consent.
(i.e. preterm birth and low birth weight)
and postpartum. For women who tested
(Accortt, Cheadle, & Schetter, 2015; An online questionnaire, stored via Google
positive for COVID-19, protective measures
Becker, Weinberger, Chandy, & Schmukler, Forms (Google, 2020), was developed by
initially recommended no skin-to-skin
2016) and early child development the research team members, and took
contact between the mother and the baby,
difficulties, including emotional problems, approximately 10 minutes to complete.
wastage of all breastmilk and separation
insecure attachment, and low levels of We used a self-explanatory questionnaire
between infected mothers and the
cognitive development (Herba, Glover, which did not depend on additional
newborns (DGS, 2020). These measures
Ramchandani, & Rondon, 2016; Pearlstein, information or support in order to be
were intended to mitigate the spread of
2015).
the disease but might have had a possible
6 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
World Association for Infant Mental Health Vol 28 (3)
completed online (Portugese and English
versions available upon request). Table 1. Prevalence of depression, anxiety and stress symptoms reported by DASS 21.
A total of 1750 women participated in
the current study. Those who did not fully Depression Anxiety Stress
complete the questionnaire or refused to
give consent were automatically excluded. Normal 73,4% (n=1247) 55,4% (n=941) 62,2% (n=1056)
By joining in the completion of the
questionnaire, participants understood Mild 13,1% (n=222) 20,8% (n=20,8%) 15,6% (n=265)
that all the information obtained would Moderate 9,2% (n=156) 12,4% (n=12,4%) 13% (n=220)
be strictly confidential, with guarantee of
anonymity and data protection on future Severe 2,5% (n=42) 5,7% (n=97) 6,5% (n=110)
publications on the topic. In the end,
Extremely severe 1,8% (n=31) 5,7% (n=97) 2,8% (n=47)
participants were given advice to seek
medical support if needed and a contact
line of our hospital department (including
phone number and email) was also Statistical analysis (76%). Within the population covered by
provided. this study, 90.5% were working before the
Quantitative data analysis was performed pandemic. Of those, 46.4% suspended
The study protocol was approved by using Statistical Product and Service their professional activity, 23.6% were
the ethics committee of Hospital Dona Solutions (SPSS) software version 25.0 transferred to teleworking and only 3.2%
Estefania – Centro Hospitalar Universitário (IBM, 2017). The significance level chosen remained at their usual place of work. The
de Lisboa Central in Lisbon (reference corresponds to a p-value of ≤ 0.05. The current pregnancy was reported to be the
number: INV80-872/2020). mean and standard deviation were used to first one in 58.4% of our sample.
describe quantitative variables. Percentage
Study Measures and proportions were performed to Most women were in the third trimester
describe the variables and study measures of pregnancy (61.1%) and only 8.1% were
Edinburgh Postnatal Depression Scale – were rearranged into categories. in the first trimester. In 81.2 % the current
EPDS: The EPDS is a 10-item self-report pregnancy was being supervised by an
questionnaire, extensively used as a The association between categorical obstetrician and in 18.2% by the general
screening scale for perinatal depression variables were tested using the Chi-square practitioner. Regarding the psychiatric
(Bergink et al., 2011; Cox, Holden, & test or the Fisher’s exact test; comparisons history, only 6.6% were currently being
Sagovsky, 1987). A cut-off of 13 is generally between continuous variables were done followed up in psychiatry or psychology
used, with higher scores denoting more using a two-sample t-test or the non- consultations and 30.3% reported having
symptomatology. parametric Wilcoxon rank sum test (when been in the past. Of the 63.1% who
the data is not normally distributed). By answered that they had no previous
Depression, Anxiety and Stress Scale – using electronic data capture that required follow up in mental health appointments,
DASS-21: The DASS-21 is a 21-item self- participants to provide responses, there 14% said they feel they needed it at that
report questionnaire divided in three was very little missing data in the analysis moment. In our sample, 26% of pregnant
subscales of 7-items designed to measure variables. women reported symptoms of depression
the emotional states of depression, anxiety
(according to both used scales); 45%
and stress (Lovibond & Lovibond, 1995).
The DASS-21 and EPDS were both adapted
Results symptoms of anxiety and 38% symptoms
of stress (Table 1).
and validated for Portuguese (Areias, A total of 1750 women participated in the
Kumar, Barros, & Figueiredo, 1996; José L. current study. Of these, 52 were excluded The prevalence of depressive and anxious
Pais-Ribeiro, 2004). since they were not living in Portugal symptoms was higher in pregnant women
during lockdown. A final sample of 1698 in the third trimester (Table 2). Participants
Sociodemographic characteristics: Data
women was obtained. The average age were also divided according to the place
was obtained on age, place of residency,
of the participants was 31.89 years (SD of residency revealing that higher rates of
marital status, household, highest
4.334; min. 19 years; max. 49 years). The depression and anxiety symptomatology
qualification, and current employment
majority of women had a high school were encountered in Algarve, Alentejo,
status.
(20.7%) or university educational level Madeira, and Azores Islands regions.
Pregnancy data: Participants were asked to
give information regarding the gestational Table 2. Prevalence of depressive and anxiety symptoms by stage of pregnancy.
age, impact of COVID-19 on medical
vigilance, and family support.
Stage of EPDS DASS-21 (Anxiety)
Medical history: Medically relevant issues pregnancy No symptoms Symptoms No symptoms Symptoms
were requested, such as past and/or
current psychiatric disorders. 1st T 78,8% (n=108) 21,2% (n=29) 58,4% (n=80) 41,6% (n=57)
Stress factors associated with COVID-19:
2nd T 79,6% (n=417) 20,4% (n=107) 62,4% (n=327) 37,6% (n=197)
Pregnant women were asked to rate fear
of contamination and/or transmission of
the disease, fear of early separation from 3rd T 70,1% (n=727) 29,9% (n=310) 51,4% (n=534) 48,5% (n=503)
the baby after birth, and fear of not being
permitted to breastfeed due to COVID-19
safety measures.
7 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
World Association for Infant Mental Health Vol 28 (3)
The vast majority of participants (86.4%), seclusion of the newborn, and possible A strong feature of this study is that the
reported that the pandemic situation negative implications in breastfeeding. EPDS and DASS-21 are self-completed
was related to a subjective feeling of screening tools that are well validated
higher anxiety and concerns about the Although the protective measures applied for Portuguese, making them suitable for
current pregnancy. Circa 80% women by national health authorities were use during pregnancy in our population.
considered that the current pandemic designed to safeguard mothers and babies Despite the fact that these questionnaires
situation had a negative impact on the from the COVID-19 disease, we argue that do not make a clinical diagnosis, they
surveillance of their pregnancy, mainly they may have led to a negative impact do investigate a number of symptoms
due to a postponement of scheduled on the mental health of this population. experienced by each participant, providing
appointments (41%), impossibility or In fact, previous studies established more comparable results. Other strengths
difficulty in scheduling new appointments associations between worry, trauma and of this study are the large sample size
(27%), cancellation or postponement of conflict settings, and mental health issues and information on many maternal
ultrasounds (16%) or, due the impossibility during pregnancy (Charlson et al., 2019; characteristics throughout pregnancy.
of being accompanied by any family Erickson, Julian, & Muzik, 2019; Mourady et
member to medical appointments (72%). al., 2017). A limitation may be the fact that it was
Lack of support at this stage of their life limited in time and most participants
According to the place of residency, were from Greater Lisbon area, limiting
was reported by 43% of women. higher rates of symptomatology were the generalization of our findings.
Due to the current pandemic, 7.4% did the encountered in regions with lower Finally, response bias may exist if the
laboratory test to SARS COV 2 and 0.3% socioeconomic status and fewer mental nonrespondents were either too depressed
(n=5) had been diagnosed as infected health resources available in the or anxious to respond or, not at all
with COVID-19. All pregnant women community. interested in this survey due to the lack of
that had been infected had developed Other aspects related to the pandemic symptomatology. These factors should be
only mild symptoms. In our sample, 48.1 lockdown such as social distancing and taken in consideration by future studies.
% of the pregnant women reported lack of family support, may also have
high fear of contracting the virus and The main results of this study were
contributed to the escalation of psychiatric initially disclosed in several Portuguese
82.3% mentioned they felt afraid of the symptoms. Similarly, restricted access to
possibility of passing the infection to the media platforms (i.e. television, radio,
mental health services may have been newspapers), right after the state
newborn. Other concerns were related even more intense during the pandemic,
to the possible absence of a partner or of emergency lockdown. Given the
limiting early detection and intervention in widespread access to this information,
another family member during labour or these pregnant women.
postpartum (moderate to high concern in we believe that our work contributed
92.8%), impossibility of skin-to-skin contact If present in the antenatal period and if to a significant change in the national
(moderate to high concern in 93.8%), not treated, mental disorders (such as paradigm regarding safety control
initial seclusion of the newborn (moderate depression and anxiety) tend to persist measures for COVID-19 in pregnancy.
to high concern in 93.4%) and, possible during postpartum and may affect both In fact, the following official guidelines
implications in breastfeeding (moderate to the mother and the development of the conducted by national authorities started
high concern in 88.8%). infant (Grace, Evindar, & Stewart, 2003; to focus on the importance of periodic
Herba, 2014). These results emphasise the mental health assessments as part of
pregnancy surveillance routine, as well as
Discussion need for:
the mandatory presence of a companion
This cross-sectional study revealed a 1. More extensive antenatal screening in during delivery, when indicated.
significant increase in depression, anxiety, this population.
In order to better understand the
and stress-associated symptoms, presented 2. The importance of implementing true impact of these measures in this
by Portuguese pregnant women during additional mental health resources in population, we are currently conducting a
the national state of emergency lockdown. the community, and study focused on COVID-19 related effects
A large group of 1698 participants from
3. Rapid referral to specialized units (when during the postpartum period. With this
the general population in Portugal were
indicated). study, we strongly believe that mental
assessed by the EPDS and DASS-21. These
health awareness in our country was
results contrast with previous international Participants were divided in three groups enhanced, providing useful frameworks for
studies that reported lower prevalence according to their stage of pregnancy decision-makers and also reducing social
rates of depression and anxiety during with higher prevalence of depressive stigma and discrimination around mental
pregnancy (Howard et al., 2014). and anxiety symptoms found during the illness.
A large majority of the participants last trimester. This finding is in line with
reported that the pandemic situation was previous literature reports (Biaggi, Conroy, Conclusion
related to a subjective feeling of higher Pawlby, & Pariante, 2016; Marchesi, Bertoni,
anxiety and related concerns over the & Maggini, 2009). During this stage, A cross sectional study was conducted
course of pregnancy. In our sample, around pregnant women normally experience fear to evaluate the presence of depression,
half of the pregnant women reported and concerns regarding child birth and anxiety and stress symptoms in Portuguese
being very much afraid of contracting tend to request the presence of a close pregnant women during the pandemic
the virus and more than 80% described companion during labour with a positive lockdown. We found a significant increased
has being very much afraid of possibly impact on their psychological well-being rate of symptomatology in all stages of
spread the infection to the newborn. Other (Ip, 2000). Since this possibility was initially pregnancy with a reported subjective
concerns were related to the anticipated not allowed by the health authorities, feeling of psychiatric symptoms due
absence of a companion during labour, we argued that these circumstances also to COVID-19 and related concerns. The
impossibility of skin-to-skin contact, initial contributed to these findings. current analysis does not provide definite
diagnoses but these results should
not discourage the implementation
8 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
World Association for Infant Mental Health Vol 28 (3)
of additional mental health resources a systematic review and meta-analysis. Nursing, 9(2), 265-272.
specially focused on pregnancy, in order to Lancet, 394(10194), 240-248.
José L. Pais-Ribeiro, A.H., Isabel Leal.
help the mothers the future of their babies.
Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). (2004). ontribuição para o Estudo da
Conflicts of Interests Detection of postnatal depression - Adaptação Portuguesa das Escalas de
development of the 10-item Edinburgh Ansiedade, Depressão e Stress (EADS)
The authors have no conflicts of interest Postnatal Depression Scale. British de 21 itens de Lovibond e Lovibond.
with regard to the current work. Journal of Psychiatry, 150, 782-786. Psic., Saúde & Doenças, 5, 10.
Dennis, C.L., Falah-Hassani, K., & Shiri, R. Kendig, S., Keats, J.P., Hoffman, M.C., Kay,
Funding
(2017). Prevalence of antenatal and L.B., Miller, E.S., Simas, T.A.M., et al.
This research did not receive any specific postnatal anxiety: systematic review (2017). Consensus Bundle on Maternal
grant from funding agencies in the public, and meta-analysis. British Journal of Mental Health Perinatal Depression and
commercial, or not-for-profit sectors. Psychiatry, 210(5), 315-323. Anxiety. Obstetrics and Gynecology,
129(3), 422-430.
DGS. (2020). Orientação sobre gravidez e
Acknowledgement parto, from https://covid19.min-saude. Lovibond, P.F., & Lovibond, S.H. (1995). The
We thank to Centro de Estudos do Bebé pt/dgs-publica-orientacao-sobre- structure of negative emotional states
e da Criança (CEBC) of Centro Hospitalar gravidez-e-parto/ - comparison of the depression anxiety
Universitário de Lisboa Central (CHULC) for stress scales (dass) with the beck
Erickson, N., Julian, M., & Muzik, M. (2019).
their support. depression and anxiety inventories.
Perinatal depression, PTSD, and trauma:
Behaviour Research and Therapy, 33(3),
Impact on mother-infant attachment
335-343.
and interventions to mitigate the
transmission of risk. International Marchesi, C., Bertoni, S., & Maggini, C.
Review of Psychiatry, 31(3), 245-263. (2009). Major and Minor Depression in
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Biaggi, A., Conroy, S., Pawlby, S., &
Pariante, C.M. (2016). Identifying the Howard, L.M., Ryan, E.G., Trevillion, K.,
women at risk of antenatal anxiety Anderson, F., Bick, D., Bye, A., et al.
and depression: A systematic review. (2018). Accuracy of the Whooley
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Birth during the Coronavirus Pandemic: “When fear
is the uninvited guest”
By Macarena Romero (Programa de Salud Pregnancy and birth are transforming anxiety related to the risk of death
Mental Perinatal. Centro de Salud UC experiences for both parents and has been reported. Also, the following
Christus Pontificia Universidad Católica the newborn, typically requiring concerns have been identified:
de Chile), Catalina Sieverson (Programa adjustments and challenges at both an
de Salud Mental Perinatal. Centro de individual and family level (Epifanio, • Protocols during delivery and
Salud UC Christus, Pontificia Universidad Genna, Luca, Roccella, & Grutta, 2015; newborn care.
Católica de Chile), Marcia Olhaberry Stern, Bruschweiler-Stern, & Freeland, • Mothers fear being unaccompanied
(Programa de Salud Mental Perinatal. 1998). During pregnancy and birth, the during check-ups and labor.
Centro de Salud UC Christus Escuela de mother experiences physical, biological,
Psicología, Pontificia Universidad Católica psychological, and relational changes • Increased frequency on requests for
de Chile), Carolina Honorato (Programa (Carmona et al., 2019; Olza et al., 2020), c-sections.
de Salud Mental Perinatal. Centro de that favor the baby’s development while
• Induced labor.
Salud UC Christus, Pontificia Universidad requiring specific care and support from
Católica de Chile) and Trinidad Tagle a third party, frequently the partner or • A higher number of deliveries
(Programa de Salud Mental Perinatal. father. Both parents must guarantee at home without the necessary
Centro de Salud UC Christus Pontificia the baby’s survival, development, and assistance.
Universidad Católica de Chile). mental health while undergoing this
normative crisis and balancing their • Fear of exposition to toxic effects of
Corresponding author: Marcia Olhaberry, life roles (Epifano et al., 2015; Stern et disinfection products.
Escuela de Psicología, Pontificia al., 1998). Considering how sensitive
• Early mother-baby separation after
Universidad Católica de Chile. Vicuña these processes are to the environment
birth and
Mackenna 4860, Macul, Santiago, Chile. and the parents’ role in preparing the
E-mail: mpolhabe@uc.cl baby’s arrival (Olza et al., 2020), there is • Difficulties to start breastfeeding
a potential risk that life demands may (Rashidi et. al. 2020).
exceed the individual, interpersonal
Acknowledgments to: This study was and contextual resources available in There are also medical risks described
supported by the Fund for Innovation the triad. This could generate negative linked to lock down and the lack of sun,
and Competitiveness (FIC) of the Chilean consequences for the parents and the physical activity, and vitamin D, such as
Ministry of Economy, Development and baby (Baldwin & Kelly, 2015; Paulson & a higher risk of thromboembolism and
Tourism, through the Millennium Science Basemore, 2010). a rise in the mothers’ and family stress
Initiative, Grant N° IS130005 (Millennium (WHO, 2020). At a psychological level,
Institute for Research in Depression and Currently, the coronavirus pandemic recent studies describe an increase
Personality MIDAP, Chile). and its related health measures have in anxious and depressive symptoms
triggered high levels of fear in pregnant on pregnant women in isolation and/
and puerperal women and their partners, or with decreased social contact, even
due to the perceived vulnerability, and considering symptomatology before
The anonymous participant research
the risk of contracting the virus and its the pandemic, as well as an increase
data presented in this article, is part of a
consequences (Rashidi, Fakari, & Simbar, in gender violence during pregnancy
major study: “Learning about parenting
2020). Although fear is an emotion that and birth (Davenport, Meyer, Meah,
experiences with children and unborn
leads to protective and caring behaviours Strynadka, & Khurana, 2020; WHO, 2020).
babies during the Coronavirus (COVID-19)
in dangerous situations, when it is
pandemic in Chile”, led by Dr. Marcia Fortunately, preliminary findings from
activated for a significant amount of time
Olhaberry. scientific research on the effects of
during pregnancy, labor, and peripartum,
it can lead to negative consequences coronavirus during pregnancy and
(Olza, 2017). In the mother, it has been peripartum show a minimal probability
linked with anxiety and depression of vertical transmission, low risk for virus-
(Fontein-Kuipers et al., 2014), as well related complications in pregnant women
as attachment issues (Monk, Spicer and fast remission, as well as low impact
& Champagne, 2012). In the baby, a on the development of the unborn baby
neurotoxic effect from long-term stress (Chen et al., 2020; Khalil et al., 2020).
has been described, which interferes However, due to the lack of knowledge
with the later emotional management about the virus and its consequences to
skills, learning, and posterior executive date, and to the physical and inmunitary
functions (Nelson, 2020). changes that take place during
pregnancy, expecting mothers have been
Studies conducted during the pandemic considered, with their babies, a risk group
on parents going through the peripartum (Allotey et al., 2020; OMS, 2020a).
period, describe concerns, fears, stress,
and symptoms at different levels. Suggestions from the WHO for the care of
Concerning infection and childbirth, pregnant and puerperal women are the
same as for the general population and
emphasize that both breastfeeding and
10 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
World Association for Infant Mental Health Vol 28 (3)skin-to-skin contact should be prioritized
due to the lack of evidence of transmission
through breastfeeding (OMS, 2020b). The
fostering of these practices bolsters the
role that nursing and skin-to-skin contact
have in nurturing: physiological regulation,
sleep quality, health, development, and
mortality risk reduction in babies. In turn,
these elements, trigger the creation of
new neural circuits in the mother for the
care and protection of the baby (Bergman,
2014).
Despite all of the above, the protocols
and guidelines suggested by different
governments in some European and
Latin American countries can vary greatly
between each other. Moreover, the
enforcement of these protocols depends
on each particular establishment and
location, generating important differences
between the recommendation and what is
being practiced.
Evidence shows that overvaluing in the risk groups that include pregnant
Unfortunately, with the intention of
medical procedures at the expense and puerperal women and newborns.
controlling infection, professionals
of natural and instinctive processes
have made their own decisions based Guidelines must have clear information
of birthing can result in negative
on limitations within their healthcare based on current scientific research
experiences in childbirth for the
centers and fear. These measures include so that they safeguard the processes
mother and the baby (Olza et al., 2020).
interruption of partner support during of pregnancy and childbirth. In this
Studies indicate that, depending on
pregnancy check-ups and delivery, over- scenario pregnancy and after birth
the characteristics of the mother,
operated labors and restrictions in parents care and protocols must promote and
these experiences could lead to post-
visiting hospitalized premature babies guarantee mother and child contact,
traumatic stress disorder (Dekel, Stuebe
(GCABA, 2020; Martínez-Pérez et al., 2020; allowing that the mother deploys her
& Dishy, 2017). Common risk factors to
Minsal, 2020; Minsalud Colombia, 2020; competencies in relation to the health
developing PTSD have been described
Ministerio Sanidad España; Sadler, Leiva & and wellbeing of the baby (Olza et al.,
to include factors such as first-time
Olza, 2020). 2020).
mothers, preterm labors, c-section, and
Before COVID-19, evidence had shown early separation of the mother from A study carried out in Chile about
a considerable reduction of mortality at her newborn (Olza et al., 2014). Such COVID-19 and its impact on early
birth due to the medical advances and factors could even impact the future parenthood had almost 300 pregnant
the assistance of professionals during reproductive life plan of the mother women participating (Olhaberry et al.,
pregnancy and labor (OMS, 2019). (Gottvall & Waldenström, 2002), the 2020). They reported fear and worries
Nevertheless, the fear and uncertainty breastfeeding process, and the initial about the idea of getting infected,
associated with COVID-19, increased interaction of the mother and the of isolation, not having company
speculation of death and disease, which baby as it reduces the enjoyment and during checkups and delivery, and the
in some cases impacted decisions and increases the unpleasant emotions possibility of being separated from their
procedures during pregnancy and within this relationship (Beck & newborn should they have a positive
delivery. Furthermore, the concerns and Casavant, 2019). PCR test. For example:
uncertainties linked to COVID-19 that
As mentioned above, pregnancy,
intimidate the parents and their babies I fear that whilst going for a
delivery, and puerperium are
also affect the healthcare professionals that checkup I could get infected…
processes of large physical, biological,
assist the deliveries, who may change their
and psychological vulnerability for
professional behaviour. This could lead to Isolation... you already know
both parents and the baby. These
increased medicalisation, and imposed
subjective experiences cause deep and you are going to be alone
interventions of greater control that are
not necessarily in line with the available
lasting changes at a neurobiological, during the first months after
psychological, and relational level, your baby is born, but now,
information (O´Connell, Crowther, Ravaldi
that could leave a long-lasting and
& Homer, 2020; Wilson et al., 2020). All of also 3 months before! It makes
permanent mark, and that could
that could have negative effects during it so much harder to prepare
impact on the infant’s brain structure
the birthing process, in the mothers’ and
babies’ mental health, and in the creation
with the risk of later psychopathology for postpartum.
(Carmona et al., 2019). In the current
of a secure attachment, which may
context of the pandemic where the Going alone to the routine
reduce the mother’s participation in her
own experience of labor (Horsch, Lalor &
real risks of death and disease have checkups and exams, not being
increased, the levels of individual and able to share your pregnancy
Downe, 2020; Olza et al., 2020).
family stress, and especially, the feeling
with your loved ones…
of uncertainty are growing; particularly
11 PERSPECTIVES IN INFANT MENTAL HEALTH: The Voices of COVID-19 FALL 2020
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