This story was originally published by The 19th on August 25, 2020.
For Amanda Feltner, pregnancy was already risky. At 39, she’s at a higher risk of complications, and she has an autoimmune disorder that makes it harder to maintain a pregnancy.
And now, Feltner, who is in her first trimester, has a pandemic to deal with.
She’s a public school teacher in Jackson, Michigan, and her district is requiring teachers to work in person, while students choose between virtual and in-person learning. Feltner is trying to get a disability accommodation to teach remotely, citing her pregnancy and intense anxiety. She doesn’t know what she’ll do if she’s denied.
Feltner is terrified. Her doctor has doubled her anxiety medication, she said.
“I’m not sleeping. I’m not eating right. I go for days where my stomach is in so much turmoil, I have to force myself to even take a few bites of anything,” she said. “Which is not healthy in general, but definitely not healthy in early pregnancy.”
It’s just one variation of a scenario playing out across the country as people struggle to navigate pregnancy during COVID-19. Between the virus and its economic fallout, the pandemic has added new risks to pregnancy in America: physical dangers, but also intense psychological strain in a nation whose maternal outcomes already lag well behind other developed countries. The full picture is only beginning to emerge, but experts warn it could amplify already-stark maternal health disparities.
According to the Guttmacher Institute, COVID-19 has caused about a third of people who could become pregnant to delay or rethink how many children they would like to have.
But a vast swath of Americans conceived before the coronavirus emerged as a major threat. Then there are those who got pregnant after — either by choice or, like almost half of all pregnant Americans, unintentionally.
“Already the stress of an unplanned pregnancy can be a lot,” said Dr. Marta Perez, a St. Louis-based OB/GYN. “Even women happily pregnant by intention will feel stress in this.” But in the pandemic, Perez said, “it’s a much greater burden.”
Evidence shows pregnant people are more likely to end up on a ventilator if they contract the virus — a June discovery that contradicted months of advice by the Centers for Disease Control and Prevention.
But other details are still emerging. It’s not clear whether pregnancy also increases the risk of mortality. And scientists don’t know whether the virus can be transmitted to a fetus in utero or result in other kinds of birth complications.
Experts are also concerned about surges in pregnancy-related depression and anxiety, compounding existing disparities. Already, perinatal and postpartum anxiety and depression are chronically undiagnosed and untreated, and for Black and Latinx people, access is already spottier, and treatment harder to come by. Simultaneously, systemic inequalities in housing, income and occupation means they are at greater risk of exposure to COVID-19, and maternal mortality and morbidity rates are drastically higher for Black people.
“There’s a huge uptick of anxiety,” said Dr. Pooja Lakshmin, a clinical assistant professor of psychiatry at the George Washington University School of Medicine, who focuses her treatment on maternal mental health. “Especially if you’re somebody who is working on the frontlines, there’s only so much you can do, other than deciding to quit your job. And a lot of folks don’t have the luxury of being able to do that.”
Doctors encourage people who are pregnant to minimize their risk of exposure to the virus. But in reality, it isn’t so simple — many people simply don’t have the option to stay home.
Allysha Shin, a 33-year-old nurse in Los Angeles, gave birth just three months ago. She had already lost a pregnancy and, as details about the virus emerged, Shin was concerned it could happen again. Public records show that, as of June, the hospital she works at is under government inspection for an employee death. In March (when Shin was still pregnant), a complaint had been filed with the Occupational Safety and Hazard Administration (OSHA) reporting insufficient personal protective equipment.
There isn’t a hard-and-fast policy for whether pregnant people treat COVID patients, Shin said, and, though she considered using her maternity benefit during pregnancy, that would have meant exhausting her leave.
“My anxiety was at an all-time high,” she said. “While being pregnant, it was, ‘What if I get the coronavirus? Am I going to miscarry and lose the pregnancy again?’”
Now, she’s back at work, with two small children at home. Her hospital, she said, requires employees to sanitize and reuse PPE, which reduces its effectiveness — she’s seen makeup stains on ostensibly clean masks.
A spokesperson for Keck USC Medical Center, where Shin works, said that pregnant nurses working on COVID floors are doing so voluntarily, and denied that hospital workers are reusing protective gear.
Shin is afraid of exposing her kids to COVID-19. On top of that, safe child care for her older child isn’t an option, so she and her husband are trying to juggle both of their jobs without extra help.
The mental strain is affecting Shin’s physical health, as well as her baby’s. Her sleep is even worse than it typically would be as a mother of a newborn; she’s so stressed she’s having trouble producing milk.
“It adds more stress, like, ‘Oh my God, is my baby going to get enough milk? Can she grow?’ It turns into this crazy avalanche of worry,” she said.
But the mental burden extends well beyond people on the frontlines — exacerbating existing disparities in maternal health. Regardless of employment status, Black and Latinx people are more likely to live in neighborhoods hard-hit by COVID-19.
That means seeing family is harder. For pregnant people, such isolation is especially painful, both prior to and after giving birth, said Dr. Crystal Clark, a physician at Northwestern University who focuses on perinatal mental health. Typically, relatives could provide extra hands in caring for a new child. Now they can’t. And the feeling of solitude in an already stressful time is even more burdensome for someone who is pregnant and more vulnerable to depression or anxiety.
The experience is “overwhelming,” said 28-year-old Dadriaunna Hayes, who lives in Atlanta, where the virus remains pervasive. “I have found moments when I felt completely alone in this.”
Hayes is in her last trimester. In 2019, she miscarried, and when she discovered her pregnancy this past December, both she and her husband were thrilled. But now, the pandemic has driven her anxiety through the roof.
“I was like, wait a minute, you mean I finally get pregnant after the loss, and now I’ve got to sit here and do it in a pandemic?” Hayes said.
Hayes avoids reading too much of the news. As a project manager for T-Mobile Corporate, she’s able to work from home, and she’s grateful for that protection. But she’s still worried about what the COVID recession could mean for both her and her husband’s work. The two of them are stashing away every dollar that doesn’t go to groceries or medical bills so that they have enough when the baby comes.
Earlier this year, her husband developed COVID-19, meaning they had to isolate from each other within their shared house. The newlyweds — they only married this past February — couldn’t even hold hands. Hayes cried constantly, she said. In normal times, her mother and sister would have come to help her through pregnancy and after birth. But her family is in Houston, another coronavirus hotspot. They can’t come, and she doesn’t know when her mother will be able to meet the baby.
And as a Black woman, she knows she’s at higher risk for pregnancy complications: Maternal mortality and morbidity are higher for Black pregnant people, which experts attribute to systemic racism in the medical system. But her husband, who is now healthy, can’t accompany her for doctors’ visits, and she isn’t permitted to video-call him in. Initially, she was told she would have to give birth alone — which is not only emotionally fraught, but can have also damaging health consequences if the person delivering doesn’t have someone there to advocate for them. Only after Hayes pushed back did the doctors change course.
“I get the safety concern but you guys are putting a larger stressor on new moms,” Hayes said.
Hayes sees a therapist, which she said has been invaluable. And in that regard, she’s lucky.
After all, Black and Latina women are already far less likely to access care for postpartum depression and anxiety, and the pandemic, experts worry, is building on those disparities. Although data is limited, preliminary research suggests that suicide and drug overdoses within a year of giving birth are a substantial contributor to maternal death.
One pre-existing factor is that Medicaid, which covers almost half of the country’s births (and a disproportionate level of Black and Latinx people), only guarantees 60 days of postpartum coverage. For many new parents, that makes it almost impossible to get and sustain postpartum mental health care. People who have given birth are supposed to be screened for postpartum depression one month, two months, four months and six months after giving birth. Research shows that people on Medicaid are more likely to be diagnosed with postpartum, but less likely to be treated.
Meanwhile, the pandemic has added to the already steep barriers for new parents accessing psychological care — issues of safe transportation, affordable child care and, critically, money.
The recession has hit Black and Latina women harder than others — Latinas have lost more jobs than any other single demographic. Many who lost work have also lost health insurance. Altogether, that burden not only exacerbates the risk of pregnancy-related mental illness, Clark said, but also makes it harder to treat the same problem.
There are policies that could help, experts said: Enhanced mental health coverage, access to insurance, more doctors available, and provision of benefits such as child care that alleviate even some of the strain of giving birth. But so far, those haven’t emerged.
“You have people feeling traumatized, particularly in the Black and Latinx communities, by all the losses — the disproportionate losses of lives due to the virus,” Clark said. “You put postpartum and all the physiological changes that go along with that, and the vulnerability. You have the perfect storm for a crisis.”