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The pandemic impacted participants’ attainment of life and professional milestones.
•
Participants demonstrated strength and resiliency in reporting coping mechanisms.
Introduction
This study aimed to understand the impacts the COVID-19 pandemic has on the mental health and well-being of pregnant and parenting adolescents and young adults (AYA) to identify unique challenges they faced.
Method
Pregnant and parenting AYA from a teen and tot program at a safety-net hospital in the northeast participated in semistructured qualitative interviews. Interviews were audio-recorded, transcribed, and coded. Analysis was conducted using modified grounded theory and content analysis.
Results
Fifteen pregnant and parenting AYA participated in interviews. Participants were aged 19–28 years (mean age, 22.6). Participants reported adverse mental health experiences, namely increased loneliness, depression, and anxiety, engagement in preventive measures to protect their children's health, positive attitudes toward telemedicine because of efficiency and safety, delayed attainment of personal and professional goals, and increased attitudes of resilience.
Discussion
Health care professionals should offer expanded screening and support resources to pregnant and parenting AYA during this time.
Since the first documented case of COVID-19 in late 2019, the pandemic has drastically altered the lives of people worldwide and added new social and emotional stressors. Adjustments have included remote education, working from home, social distancing, and isolation from friends and family (
). Recent studies revealed increased reporting of adverse psychological symptoms because of these lifestyle adaptations in light of the COVID-19 pandemic, especially in women and young people (
Explaining the experience of prenatal care and investigating the association between psychological factors with self-care in pregnant women during COVID-19 pandemic: A mixed method study protocol.
Pregnant women have historically been considered at-risk populations for mental health disorders, and past natural disasters and national emergencies have been shown to have detrimental effects on pregnant people's mental health (
). This observation is of concern given that previous research has shown that perinatal stress can lead to poor postnatal outcomes for both the gestational carrier and neonate (
). Systematic reviews found that antenatal depression may adversely affect the fetus, including irregular fetal heart rate, neurodevelopmental problems, premature birth, low birth weight, and increased rates of neonatal intensive care unit admission (
). Therefore, it is necessary to address the mental health of these individuals amid the COVID-19 pandemic and beyond to protect the developing fetus from potential adverse outcomes.
It is imperative to additionally address the mental health of parenting adolescents after labor and delivery, as it can impact parent and neonatal health and well-being. Systematic reviews found that adolescent parenthood is associated with a range of adverse outcomes for young parents, including mental health disorders, substance use disorder, socioeconomic stress, and poor education outcomes (
). Specifically, postpartum depressive symptoms (PPS) are of concern; PPS is associated with poor maternal and infant bonding, increased likelihood of developmental delays in infants, and adverse longitudinal health outcomes for both parent and child (
). These postpartum depressive symptoms were particularly prevalent in patients who had given birth and were aged ≤ 19 years, with 20% reporting depressive symptoms (
Furthermore, systematic reviews found that children of adolescent parents are also at an increased risk of adverse health outcomes. These include low birth weight, developmental disabilities, and poorer developmental outcomes compared with children of older parents (
). Pinzon et al. review of adolescent parents and their children also demonstrated that the quality of parent–child interaction was predictive of a child's social and cognitive development. Compared with older mothers of similar socioeconomic status, Pinzon et al. found that adolescents may vocalize, touch, and smile at their infants less than older mothers of similar socioeconomic status. These factors contribute to poorer parent–child bonding, putting infants born to adolescent parents at a higher risk of adverse developmental outcomes later in life (
Given that PPS affects AYA parents at a higher rate than older parents, is associated with impaired parent–child bonding, and impaired parent–child bonding is associated with adverse health outcomes for infants, it is critical to screen for and treat PPS in AYA.
Purpose of This Study
It is well understood that the mental health of pregnant people, both during and after delivery, impacts the long-term health of the parent and their child. Adolescent parenthood is also associated with adverse physical and mental health outcomes for both parent and baby. Although many studies are addressing the mental health impact of the pandemic on pregnant adults, few have evaluated the impact on the pregnant and parenting AYA population (
). We undertook this study to understand better the broad range of impacts that the COVID-19 pandemic has on the mental health and well-being of pregnant and parenting AYAs, as well as highlight coping strategies that have been helpful to these individuals.
METHODS
This study was compliant with Health Insurance Portability and Accountability Act and approved by the Institutional Review Board at Boston Medical Center. Research participants were selected through purposive sampling techniques among pregnant and parenting adolescents who participate in a teen and tot program for adolescent mother–infant dyads, which serves these parents and infants in a single setting at a safety-net hospital in the northeast. This program treats high-risk, low-income, minority pregnant and parenting AYA. Pregnant AYA receives prenatal and postnatal care from a midwife specializing in adolescent care. Next, they transition to primary care with the same pediatrician as their child. This clinic, which began in 1971, treats > 900 mother–infant dyads annually. Inclusion criteria included English-speaking women who received health care from the teen and tot clinic as pregnant and/or parenting adolescents and had a cellular phone and internet access. Eligible participants were divided into two categories; those whose pregnancy occurred during the pandemic (delivered their child from April 2020 through August 2021) and those who delivered before the pandemic (delivered their child from December 2011 through March 2020). Exclusion criteria included non-English speakers, withdrawal, and nonattendance of the interview.
Participants were recruited via Health Insurance Portability and Accountability Act-secure phone calls after being screened by the physician director of the clinic for eligibility (Figure 1). Individuals described in the Figure as “not selected; other” were not selected for various reasons. Reasons include having no phone number in the medical record, not having custody of their child, or being lost to follow up with the teen and to the clinic. Once informed consent was obtained, qualitative interviews were conducted one-on-one via a Health Insurance Portability and Accountability Act–compliant webcam video platform. Qualitative data were collected using in-depth, open-ended questions from a semistructured interview guide continuously revised on the basis of emerging themes (
). Interviews began with “Tell me how the pandemic has impacted your life” and continued with probing questions such as “what do you mean? Why? Can you tell me more?” to explore the depth of participants’ experiences. Interviews explored topics including the effects of the pandemic on participant's day-to-day life, mental health, and attitudes toward resiliency. Questions were also modeled off the Patient Health Questionnaire-9 (
Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.
). First, investigators individually transcribed interviews and identified salient themes to create initial codes. The process of qualitative coding and analysis is circular and fluid. Therefore, researchers then went through several cycles of independently analyzing interview transcripts, identifying pertinent themes, and refining codes in the master codebook. Research team members met to compare consistency between the codebook and interview data, discussing results to ensure the codes reflected the data until a consensus was reached.
RESULTS
Of 92 people who fit the inclusion criteria, investigators reached 72 people by phone to obtain consent. Of these individuals, 32 AYA consented to be interviewed. The other 40 declined to participate, listing lack of time availability or disinterest as reasons for the decline. Of those who consented to be interviewed, 15 attended interviews, and 17 participants did not attend their interviews. Investigators were unable to reach these individuals to reschedule. Findings reported in this study were collected from the 15 participants aged 19–28 years (mean age, 22.6) who consented to and attended their interviews. Eight participants were sorted into the “pregnant” group; these individuals experienced their pregnancy and delivery during the pandemic (delivered their child from September 2020 through August 2021). Seven participants were sorted into the “parenting” group; these individuals gave birth before the onset of the pandemic (delivered their child December 2011 through January 2020).
Many recurrent themes regarding adverse mental health experiences were common to both the pregnant and parenting group, namely increased reports of isolation and loneliness and exacerbation of preexisting mental health challenges. Findings unique to pregnant AYAs include occupation loss, suicidal ideation, and lack of support during pregnancy and delivery because of limits on support people's attendance of pregnancy-related medical care. Findings unique to parenting AYAs include postpartum depressive symptoms, experiencing stigma as a young parent, and difficulties co-parenting with their children's fathers. Both parenting and pregnant AYAs described taking additional isolation measures to prevent viral spread, increased self-reported anxiety, depression, fear, and lack of parenting support because of social distancing and coping mechanisms that contributed to resilience.
Findings Unique to Pregnant AYA
Themes distinct to the pregnant AYA group include occupation loss and perceptions of low social support throughout their pregnancy and delivery because of limited support people's attendance when receiving medical care. In addition, the pandemic negatively affected the mental health of many of these AYA participants. Fear, loneliness, isolation, worsening anxiety and depression, and suicidal ideation were commonly discussed when participants spoke about their mental health.
Eight AYAs whose pregnancy and delivery occurred during the pandemic were interviewed. None of these participants had contracted COVID-19 at the time of the interview. Four had friends or family reportedly infected with COVID-19 with varying levels of severity, with one AYA saying her mother was so sick with the virus that she “almost passed away.”
Four out of eight pregnant participants reported becoming unemployed during the pandemic. Reasons for quitting or losing their jobs include fear of the virus, restrictions limiting the need for previous person-facing jobs and staying home to care for children given pandemic-related closures of child care centers. One mother said she had to quit her new job because her mother-in-law, who was supposed to watch her child, became seriously ill with COVID-19. Another mother lost her job as a concession attendant because of the pandemic-related professional athletics hiatus. A third mom lost her job working at a beauty salon for similar reasons.
Many mothers in the pregnant group reported feeling upset that their children's father and/or family members had limited ability to partake in their prenatal care and birth experience. Two participants highlighted feelings of loneliness when attending ultrasound appointments alone and sadness that their children's fathers could not experience those appointments alongside their partners. Not having the “moral support” of their partner in person was “straining,” one participant noted. Three additional mothers voiced frustrations with limitations on the number of support people who could be present during labor. For example, one mother said she would have liked to have close friends, siblings, and parents present. Another pregnant participant explained that, although her mother could attend her child's birth, the participant's mother could not leave the hospital after the baby's birth. She explained that her mother would have been denied re-entry had she left, creating an “uncomfortable situation.”
Several pregnant participants also reported increased feelings of anxiety because of stressors related to their children. One AYA pregnant mother, although anxious, said her anxiety was due to her impending birth, not the pandemic. A second AYA mother who gave birth during the pandemic said she felt very anxious about the future for herself and her son. “I'm anxious like what's to come next,” she described, “just very anxious, like always thinking about what's next, you know?” One AYA pregnant mother explained that deaths because of COVID made her contemplate her morality, worrying about its potential impact on her and her child. “I don't want to die, I want to see my baby grow up before I pass away,” she said.
Findings Unique to Parenting AYA
Themes distinct to parenting mothers, those who gave birth before the onset of the pandemic, included frustrations with their children's father and isolation guidelines, experiences of PPS, and challenges faced by the nature of being a young parent.
Four out of seven parenting mothers described frustrations with their children's father, particularly that lack of support from their partner contributed to feeling isolated and overwhelmed. “Honestly it was really hard,” one parenting AYA said. She further explained,I felt like in a sense I wasn't respected by my fiancé because he was working and I was at home . . . I was a bit hopeless. I felt like I had no control over my life, I felt like I had no say in what happened in my life because her father paid for everything.Another AYA who gave birth before the pandemic shared that she feels like a single mother. Her partner does provide, but when it comes to taking care of the kid, he just like, he doesn't wanna do that part, he wants me to do that part . . . I'm not supposed to beg for [him] to help, [he] should offer it to me.
Four mothers who gave birth before the pandemic also explained that closures because of the pandemic were a source of frustration and stress. “There was people around to help, but it wasn't much to do ’cause everything is closed,” one parenting mother said. Similarly, another mother felt “just really trapped in the house.” She continued, “there really wasn't much to do, it wasn't even like it was warm outside, so you couldn't just like go take walks.” Moreover, they found some COVID protocols frustrating, remarking that mask mandates, vaccine requirements for some occupations, and lockdowns felt extreme. One mother explained how she felt that there was inadequate communication regarding the necessity of such measures.It just don't make no sense, how everything is so affected now . . . but when swine flu and all these other viruses was around, stores weren't shutting down, none of that. So I don't think it's fair that they're treating this virus more serious than all the other viruses, a virus is a virus.
Furthermore, three of the seven parenting AYA mothers described how the pandemic also added challenges in overcoming their PPS. One mother explained that it was difficult to keep up with her child's doctor appointments and her schooling while navigating her PPS, thus “having to come home and be a full-time mom . . . It was really overwhelming.” Another mother talked about feeling underprepared to overcome her PPS because her symptoms were so intense. “I really thought I was going to be in prison, to be honest,” she said, because of the difficulties she experienced in bonding and caring for her child. She also noted the impact of PPS on her partner; “even my boyfriend was depressed after I gave birth to my son, but nobody paid attention to him.”
Some parenting mothers talked about adversities they faced by being pregnant and parenting AYA, irrespective of the pandemic. One mother described feeling overwhelmed as a first-time mother; “I find it so hard now, working five days a week with the toddler, being pregnant, and then my fiancé, trying to keep up with house, so it's a lot.” Three parenting mothers shared this sentiment, saying that they found it difficult to balance their sleep, diet, and well-being, in addition to caring for their children.
Two parenting mothers reflected on the hardships of being a young, single parent. One mother expressed frustration regarding how strangers witnessed her challenges without offering help.It's hard . . . I'm not even gonna lie. And I'm not even talking negative or talking like as if I need help, but this is why a lot of single parents end up, like dying, or like just taking their life, because it's stressful. People don't sit there and ask you if you want help. They just sit there and watch you struggle and it's frustrating.
Another parenting AYA spoke about how the stigma of adolescent parenthood negatively impacted her ability to form friendships.I did find a lot of judgment out here from older moms that had kids around the same age as mine. And you know, as soon as I told them how old I was, it was just kind of like, they kind of got turned off from me. So I found it really hard to just try and find support in those early months.
She elaborated that it was hurtful when people assumed that her child was unplanned. “I was embarrassed to tell people that I planned to have my daughter, it made it seem like the only, somewhat reasonable, thing to say was ‘Oh yeah, it was an accident.’”
Mothers who gave birth before the COVID-19 pandemic described their unique experiences during the COVID-19 pandemic, including frustrations with social distancing guidelines and their partner, adverse PPS for both themselves and their partner, and enduring the stigma of being an AYA parent.
Findings Common to Pregnant and Parenting AYA
Although there were findings unique to mothers who gave birth during the pandemic and unique to those who gave birth before the pandemic, there were also many recurrent themes voiced by both pregnant and parenting adolescent mothers. These include taking additional safety and isolation measures out of fear of adverse effects from the virus on both themselves and their children, feelings of loneliness and sadness because of extreme isolation, exacerbation of existing mental health conditions, and coping strategies that empower them with resilience.
Self-chosen isolation precautions
Both mothers in the pregnant group, who gave birth during the pandemic, and mothers in the parenting group, who gave birth before the pandemic, described isolation precautions they took in addition to government protocols to keep themselves and their children safe. They described motivations for these measures, including fear of infection and its potential outcomes, fear of exacerbating chronic diseases such as asthma, and fear of pregnancy complications. Of the eight AYA who gave birth during the pandemic, one pregnant mother said she isolated herself to prioritize her children's safety, given she did not know which public health precautions the people around her followed. She said, “the pandemic affected my life a lot . . . I'm definitely more distant because everyone has different beliefs.” A parenting mother felt similarly, expressing apprehension about public transit and grocery store safety, in which tight spaces make it difficult to maintain social distancing.Kids will get on the buses with no mask on, and they'll be coughing, and I just don't understand how parents will have a mask on but their kids won't . . . And if the bus is crowded, how are they gonna be 6 feet away from each other?
She concluded, “we should stay home instead of being out here in this world.”
One pregnant mother described her motivations for taking extra precautions stemmed from fear of contracting the virus for herself because of a chronic condition and her pregnancy. “I was so scared because you know I have asthma and I was expecting and all of those things. And I isolated myself for a long time without seeing my family or doing anything with anyone,” she explained.
Adolescent mothers who gave birth before and during the pandemic described taking extra isolation and infection prevention measures out of fear of the virus's negative impacts on themselves and their children.
Isolation from friends and family: loneliness and sadness
Both pregnant and parenting AYA mothers also described how isolation from friends and family contributed to feelings of loneliness and sadness. One pregnant AYA mother said her mood “sucked” because her family “couldn't see me for such a long time because there was no traveling between states or anything.” Another pregnant mother said the pandemic made connecting with other parenting friends difficult because of social restrictions.
Parenting mothers, those who gave birth before the pandemic, felt similarly. Four out of seven parenting mothers talked about the experience of being alone with their children. “I was in pain, I didn't have nobody around me to help me, it was only me and my boyfriend,” one mother shared. They further explained that isolation because of the pandemic created child care barriers and added further stressors. “I had people that were super helpful,” one mother explained. She continued, “but due to all this . . . I don't have them anymore. Because of COVID, they can't come.” The lack of child care support was taxing for parenting AYAs. One parenting mother remarked, “once we were in the house all the time, it was just like, I can't get a break. And everyone needs a break once in a while.” A third mother who gave birth before the pandemic exclaimed, “it was just kind of like really depressing, I mean . . . being a first-time mom . . . and not really having family support before, it was a lot.”
Novel challenges introduced by the pandemic, including isolation from friends and family because of social distancing, contributed to many adverse feelings and experiences for pregnant and parenting AYAs.
Stressors exacerbated by the pandemic
For some mothers, the pandemic intensified preexisting mental health conditions and introduced new hardships. One pregnant mom, who gave birth during the pandemic, said her depression became “worse” during the pandemic and is currently “worse than when I was pregnant. I am not feeling good at all.” A parenting mother who gave birth before the pandemic shared this sentiment, remarking that the pandemic worsened her depression. When asked how she feels now, she responded, “the best I can.” Another pregnant mother said she had been suicidal, and the pandemic made her feel that way again. “I was just so alone,” she said.
Ultimately, mothers who gave birth before and during the pandemic voiced similar experiences of taking extra isolation and safety measures to protect their family from the virus, and extreme loneliness, sadness, and aggravated preexisting mental health challenges because of feeling isolated.
Coping Strategies and Resilience
Participants who gave birth before and during the pandemic coped with the vast life changes brought about by the pandemic in various ways. Many cited that being able to adjust quickly was essential. One AYA pregnant mother said she was able to adapt “fast” to the circumstances surrounding the pandemic; “I was like this is my life right now so I'm just gonna, you know, go with it.” Two parenting mothers echoed this sentiment, saying they were “free balling it.”
One pregnant AYA participant said going to therapy and talking about her day with her partner helped her decompress and alleviate stress. Two parenting AYA mothers, who gave birth before the pandemic, drew on coping strategies they learned in therapy when they were younger. One mother explained that these included taking hot baths, writing down my feelings, doing poetry, drawing. I crocheted a lot while I was pregnant, and then after I was pregnant, just to get my mind off things, just to do something where I felt like I accomplished something for the day.
Four out of seven parenting mothers felt that social connections with family, friends, work, therapy, and more were pivotal in navigating mental health stressors. “Going to work definitely helped like with the social interaction, and a bit with my mental health, ’cause I didn't feel like I was fully trapped in the house,” one mother said. Another parenting AYA reflected on the impact of talking about her struggles in overcoming her postpartum depressive symptoms.[My doctor] talked to me, it helps me. And when I moved in with my boyfriend, it helped me to tell him what was going on. Then after that … I stopped crying, and I started talking about my feelings more. I even talked to my baby about it. And then I started liking him, I fell in love with him.
Three AYA mothers who gave birth before the pandemic talked about the positive effects group care programs had on their mental health. One mother explained, “even though I didn't have my family support, it felt like we had some family support.” Another mother attributed overcoming her postpartum depressive symptoms to the group, “they did save me and my son, ’cause I thought I was never gonna be able to take care of this baby,” she said.
Parenting mothers who gave birth before the pandemic also reflected that the pandemic reminded them of the importance of seeking the positives and building resilience. “I always hope that another day will be a better day. And sometimes it could be a little better, and then you know, I just hope that it all gets better,” one AYA parent said. “It takes a lot out of you to be negative than to be positive,” shared another. A third mother remarked:For a long time, I was scared to take risks, and I was scared to step out of my comfort zone. So it was hard for me to get things done. And I had to tell myself, “Even though you get anxiety about things, and you're not comfortable with things, no one is comfortable with doing everything.” Like sometimes, you have to step out of your comfort zone to get things done. . . . I would try to use COVID as an excuse. Like, I can't do it because of COVID . . . [COVID] made me realize a lot of things . . . like sometimes you have to stay on your tip toes because you never know what will happen. So it's like, you always, you also have to look at the bright side of things.
Despite highlighting the numerous stressors and challenges imposed by the pandemic, pregnant and parenting AYA mothers used various coping mechanisms to navigate and overcome these hardships. Ultimately, they reported increased perceptions of resilience and a more positive outlook on life because of these mechanisms and experiences.
DISCUSSION
Qualitative interviews of 15 AYAs from a teen and tot program at a safety-net hospital in the northeast identified the impacts of the pandemic on the mental health of this population. Findings suggest that self-chosen isolation measures taken out of fear for their children's safety may have contributed to feelings of loneliness. Similarly, feelings of loneliness because of social distancing and lack of parenting support from typical spaces, including daycare, friends and family help, and partner support, contributed to hopelessness and being overwhelmed. The pandemic introduced novel feelings of loneliness because of social distancing precautions and exacerbated other adverse experiences, including preexisting anxiety and postpartum depressive symptoms. Moreover, factors independent of the pandemic but related to AYA pregnancy and parenting, such as stigma toward young parents and pregnant people, further added to the mental health burdens. Ultimately, pregnant and parenting AYAs used many factors to cope with and overcome these mental stressors, including friends and family, therapists, group health care models, internalized resiliency and a positive mindset.
With respect to the existing mixed-methods study by
evaluating the impact of the COVID-19 pandemic on adolescent parents (n = 406 for quantitative analysis; n = 21 for qualitative analysis), our results were inconsistent. They reported decreased levels of depression and parental stress, inconsistent with our findings (
). However, their findings that participants were fearful of the virus, and feelings that social distancing negatively impacted their mental health and well-being, were consistent with our findings (
). These inconsistencies may be due to differences in geographic location, family support, population composition, and time of interview in relation to the pandemic.
Previous studies on the mental health of pregnant and parenting adults were more consistent with our reported findings of worsening mental health of pregnant and parenting people during the pandemic. One study on the effects of the pandemic on perinatal mental health in Spain (N = 724; n = 450 pregnant; n = 274 postpartum) found high reported rates of anxiety and depression (
). Another study (N = 1,987) of pregnant women in Canada in April 2020 also found increased levels of reported anxiety and depression, elevated compared with prepandemic cohorts, with 37% of participants reporting clinically relevant symptoms of depression and 57% reporting clinically relevant levels of anxiety (
). A study of pregnant women in Argentina described a more pronounced increase in mental health symptoms in pregnant women than in nonpregnant controls (
Our findings are subject to several limitations. First, this study and those cited examined the experiences of pregnant and parenting women. We acknowledge that this is not representative of how all people who may become pregnant identify, providing direction for future studies. Furthermore, the data we collected only represent pregnant and parenting AYA from this specific safety-net hospital in the northeast. Non-English speakers were not included. The mental health impact of the pandemic may differ on the basis of geographic location and language spoken. Secondly, data regarding race, marital status, income, religion, and education level were not collected, thus making it difficult to generalize the findings to the entire population of pregnant and parenting adolescents. Thirdly, no data were available regarding the mental health of AYA who had never been pregnant or given birth; therefore, we could not identify factors associated with the mental health of nonpregnant, nonparent AYA. In addition, interviews were conducted via Health Insurance Portability and Accountability Act–protected video calls, which may have led to response bias. Finally, our sample size was relatively small.
CONCLUSIONS
These findings highlight the impacts the COVID-19 pandemic had on this cohort of pregnant and parenting AYAs receiving care from a safety-net hospital in the northeast mental health, health care experiences, and coping mechanisms for stressors. Health professionals should be aware of pregnant and parenting AYAs challenges, including fathers and other parental figures, and offer more robust social determinants of health screening and support resources for this population. Further research with a larger sample size is warranted to validate the generalizability of these findings and better understand the complexities associated with the mental health of pregnant and parenting AYA during the COVID-19 pandemic.
The authors thank all participants for their time and willingness to share their experiences.
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A Little Bit Closer”: A mixed method analysis of the effect of the COVID-19 pandemic on the lives of adolescent parents.
Explaining the experience of prenatal care and investigating the association between psychological factors with self-care in pregnant women during COVID-19 pandemic: A mixed method study protocol.
Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.
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