Pregnancy was not the dreamy nine months that Sherell Robinson had hoped for. Shortly after finding out she was expecting last October, the South Philadelphia woman quit her teaching job because of an underlying heart condition and, by the end of the year, she was getting divorced.
Then the coronavirus pandemic hit, adding a plethora of new worries about a novel virus with unknown effects on pregnancy.
Robinson pushed through the dark moments by focusing on the future she would build for her baby and 11-year-old daughter, starting classes for a new career as a paralegal. When the baby was born May 19, Robinson named her Illiyin, an Arabic reference to the most supreme part of heaven.
But in the weeks that followed, the virus kept raging and with a colicky newborn to care for, Robinson was more anxious than ever about exposure for her family.
“I envisioned I’d be the savior for my kids and I, get back to work and be able to pick up where we left off — and that is not the case,” said Robinson, 33. “I feel like I’m drowning, trying to hold both of my kids up.”
Anxiety and depression before, during and after pregnancy — a range of conditions known as perinatal mood and anxiety disorders — are common, thanks to the long list of physical and emotional changes, plus waves of hormones. The most well-known of these, postpartum depression, affects about 1 in 5 people who give birth and is even more common among Black women — including Robinson. And it’s on the rise, shooting up 30% between 2015 and 2018, according to a new maternal-health study by the Blue Cross Blue Shield Association.
That’s without a pandemic. Now, maternity-care providers are worried about a surge in perinatal mood disorders sparked by the virus’ unknown health risks, fear of giving birth in a hospital treating COVID-19 patients, the stress of caring for a newborn without help, and social isolation that has canceled baby showers and kept partners out of prenatal appointments.
“It’s not a world you want to bring a newborn baby into,” said Kiera Masterpasqua, a nurse at Lifecycle WomanCare, a birth center in Bryn Mawr.
Maternity care providers are particularly concerned about Black patients, who are already at greater risk of childbirth complications and perinatal mood disorders, and now are disproportionately affected by COVID-19 — all largely due to systemic racism in society, and the health-care system specifically.
“The pandemic has put this additional stress on people, especially Black women, because we know there are racial disparities around COVID,” said Jabina Coleman, a social worker and reproductive psychotherapist in Philadelphia. “I can’t imagine if women were not being listened to before COVID, with all the additional barriers from COVID, what else is being missed.”
The troubling rise in postpartum depression identified in the Blue Cross Blue Shield Association report can be partly explained by high rates of preexisting health conditions — including mental-health conditions — that put pregnant women at greater risk of developing a perinatal mood disorder, said Ginny Calega, vice president of medical affairs for Independence Blue Cross.
About 85% of births during the study period were among millennials, with an average age of 31, according to the report, which analyzed claims data from 1.4 million births between 2015 and 2018.
Previous reports by the insurer have found that millennials are on average sicker, with higher rates of hypertension, diabetes and behavioral health disorders than older generations at their age.
What’s more, the report found that a third of women in the study group — all covered by private health insurance, suggesting they had higher-than-average family incomes — received less prenatal care than is recommended, which contributed to higher rates of pregnancy and childbirth complications.
The pandemic has made access to care more difficult for some patients who are unable to see their doctor in person or are worried about venturing to a medical office. A quarter of women surveyed by the Blue Cross Blue Shield Association reported skipping prenatal appointments after social distancing measures were put in place. And Philadelphia-area providers say they are beginning to see an increase in anxiety and depression among pregnant and postpartum patients.
Masterpasqua, who screens patients showing signs of a mood disorder, said her call list has tripled since March. The birth center has seen an influx of late-pregnancy transfers — women who no longer want to give birth at a hospital — but that only partly explains the increase in patients experiencing these mental-health issues, Masterpasqua believes.
“You already feel stuck and isolated as a new mom without the pandemic and now you’re not supposed to leave your house unless you absolutely have to — you feel more stuck than you normally would,” she said.
Alyssa Paul Maltby, a 33-year-old special-education teacher, didn’t look pregnant when she left work and won’t be pregnant when school reopens. She said it feels strange to go through such a major life change in isolation, without sharing the experience with her family, friends and coworkers.
“It’s almost felt like a secret pregnancy,” said Paul Maltby, who lives in Philadelphia with her husband and 2½-year-old daughter, Amelia.
Paul Maltby experienced postpartum anxiety after Amelia was born, becoming fixated on whether her daughter was sleeping and gaining enough weight, and ultimately not eating properly herself. She knows this puts her at greater risk of the condition after her son is born in August, and worries about how the pandemic will affect her options for treatment.
“One of the hard things now is a lot of those strategies I used after she was born — getting out of the house, going to a breastfeeding group, just being social — I’m not going to be able to do that with this baby,” she said.
Changes to care have also added stress for expectant parents and may trigger more cases of postpartum depression, said Saleemah McNeil, a psychotherapist and owner of Oshun Family Center in Jenkintown.
“A lot of what I see in postpartum clients is a grief and loss process that does not have anything to do with bringing a baby home. It’s the loss of the idea and picture of what your birth was planned to look like” — for instance, ending up with a C-section when a natural birth was planned, she said.
Most hospitals in the Philadelphia area currently allow only one support person in the delivery room, provided they test negative for COVID-19. That can trigger a sense of loss for women who wanted to hire a doula or expected grandparents to visit. The idea of their partner potentially being turned away due to a positive test is anxiety inducing for many women and having to actually do it can be traumatic. Additionally, research shows women with a support person are less likely to experience complications.
In addition to creating new anxieties, the pandemic has exacerbated common pregnancy worries, such as financial stability, said Jennifer Jones, a therapist with Maternity Care Coalition’s MOMobile program, which provides at-home services.
“A lot of the referrals during the quarantine have been people who worry about whether they’ll have a home to live in, their jobs, being separated from family and friends,” Jones said.
Providers are especially concerned about a potential increase in perinatal mood disorders among Black patients.
“We know that Black and Brown people are affected more by COVID and a lot of the issues of COVID are the issues of institutionalized racism,” such as the effects of unemployment and underemployment, lack of paid sick days, insufficient health insurance and housing insecurity, said Autumn Nelson, a certified nurse midwife at Lifecycle WomanCare in Bryn Mawr.
Systemic racism in health care, including unethical medical experiments, has fueled distrust of health-care providers among many Black patients. The “father of modern gynecology,” James Marion Sims, pioneered surgical techniques by experimenting on enslaved women without the use of anesthesia, under the false belief that Black people don’t feel pain.
To this day, Black women receive less pain medication during birth and are more likely to die during childbirth than white women, research shows.
“I’ve had white patients who say, ‘I’m having chest or leg pain’ and [the doctors] say, ‘OK, let me write you a script,’” said Veronica Briggs, a doula based in Cherry Hill. Meanwhile, concerns reported by her Black patients are often dismissed as normal pregnancy aches and pains, she said.
These disparities can create distrust between Black patients and their doctors. Briggs attributes her own case of postpartum depression to feeling unheard by doctors during her two pregnancies.
Briggs became a doula to make sure women of color have access to resources that weren’t available to her — namely, a health-care provider with shared racial background.
Research shows that patients are more likely to trust a doctor or therapist they believe can relate to their personal experience, yet just 5% of doctors identify as Black or African American, according to the Association of American Medical Colleges.
That shared experience is more important than ever for women such as Robinson, who said she felt overwhelmed thinking about all the ways she was at risk for the coronavirus: she’s Black, has two heart conditions and was pregnant.
“Here’s one thing that makes you at risk, and another, and another — and there’s nothing you can do about it,” she said. “I was crying so much, I was tired of crying.”