American Scientist

Families who carefully planned the perfect time to welcome a new child into their lives were thrown into chaos in early 2020 by the spread of the COVID-19 pandemic. As healthcare systems reorganized their care around treating and preventing the disease, expectant parents faced uncertainty about how these changes would affect their pregnancy and birth plans. Biological anthropologist Zaneta M. Thayer of Dartmouth College studies how stress caused by this unpredictability affected pregnant individuals and their families. Thayer’s approach is biocultural, meaning that the biological factors affecting a person cannot be separated from the cultural elements of their surroundings. The COVID-19 pandemic created a stressful environment that could not ethically be replicated in normal circumstances, but it allowed Thayer to examine the far-reaching effects of stress on mothers and children both during and after gestation. She expects her study will continue for years to come as she looks for lingering effects on the participants. Thayer spoke with Scott Knowles, a historian of risk and disaster at the Korean Advanced Institute of Science and Technology, on his daily podcast, COVIDCalls (episode 217: Maternity Care in the Pandemic). On the podcast, Knowles speaks to guests about the latest research and the far-reaching effects of the pandemic. This interview is part of an ongoing collaboration between American Scientist and COVIDCalls. It has been edited for length and clarity.

What effects of the pandemic have you seen on maternal care?

People need a lot of emotional support through pregnancy, childbirth, and postpartum. What we’ve observed in the pandemic is a huge disruption to systems of support and a huge increase in uncertainty.

As an example, people aren’t allowed to have support persons in prenatal appointments. They have to go to the ultrasound appointment by themselves. There were lots of stories last March and April about people having to give birth alone. Support persons who tested positive for COVID weren’t allowed to accompany them. Maybe they were planning on having a doula; now the doula can’t come to the birth because they’re allowed to have only one support person. There were even concerns and recommendations that if parents tested positive for COVID, their infant should be separated from them for two weeks, which is obviously severely traumatic.

One thing that came up in our study was a lot of uncertainty among participants about how hospital protocols would be affected by COVID. And since there was no national response strategy, every hospital had its own regulations. What this meant was that, maybe you picked your hospital based on where you gave birth last time, or where a friend gave birth. Now, whether you chose hospital A versus hospital B could mean a drastically different birth experience. Hospital A might allow only one support person. Or at hospital B your partner might not be able to leave the hospital after you give birth because once they do, they can’t come back in. All sorts of different regulations were constantly changing, which was causing a lot of uncertainty and stress.

And then after people come home with their babies, they normally have systems of support, such as friends and family bringing food and helping to watch the baby or other kids. But the parents didn’t have that either. So there’s been huge disruptions for people across this whole stage.

After the baby is born, parents normally have a support system—siblings, parents, extended friend networks—that must have been disrupted as well.

Yes, we’ve been working on another analysis about the postpartum period, when these systems of support are particularly important. We’ve found that individuals who say that they’ve received less help with housework or with caring for their newborn in that postpartum period were likely to have more severe depression than those who were still able to get that support during the pandemic. We also looked at childcare disruptions, because if you have older kids, and now they’re not at school or in day care, you’re having to care for them and a newborn and not getting help from anyone else. These childcare disruptions were also associated with more depression.

What are some of the ways you think about how these stresses on pregnant mothers manifest themselves as effects on children?

One of the big things we think about when we’re talking about maternal stress and pregnancy is how it affects the developing baby. We know that maternal stress hormones, such as cortisol, can cross the placenta and influence fetal development. We think it can affect things such as birth weight and gestation length, so it potentially increases the risk of having a preterm baby. In the longer term, it can increase risk for metabolic or immune disease, and some psychiatric conditions in children as well.

Now, obviously, the pandemic hasn’t quite been going on long enough to understand all of these long-term outcomes, but I am currently working on an analysis looking at fear of childbirth, which is something that happens independent of COVID, but which in our sample is very clearly exacerbated by COVID-related worries.

As an example, there were individuals in our sample who were really concerned about catching COVID and the effects that it would have on their developing baby or who were afraid that if they caught COVID their baby would be taken away from them at birth. All of these individuals had a higher “fear of childbirth” score. Basically, we give people a dial from zero to 100, and we say, “How calm or scared are you about your upcoming birth?” In the analysis I was running, I found associations between fear of childbirth and shorter gestation length as well as lower birth weight.

In our study, we don’t have the same sample without the pandemic, and our sample is not nationally representative, so I can’t compare it to a nonpandemic time. But qualitatively, in terms of our participant responses, as well as looking at the association with COVID-specific variables, I think it’s an appropriate interpretation that fear of childbirth has been exacerbated during the pandemic, because of all the reasons we’ve been talking about. People are more afraid than ever of being separated from their babies, of not having support people in labor, and of having their pain management strategies and labor altered.

What do you rely on to draw that causality between stress of a mother and the long-term health impact on a child?

In humans, we rely primarily on observational studies, such as this COVID study I’ve been describing, because it is unethical to experimentally expose people to stress during pregnancy. People are out in the world. Some of them are experiencing more stress during COVID than others. We’re interested in seeing how that natural variation and stress experience relates to outcomes in maternal and child health.

But COVID does provide a quasi-natural experiment, because it’s an unusual situation. Natural experiments can be particularly useful if you have a group of people before or after the incident or big natural disaster, or maybe two closely related populations, one of whom experiences it and the other doesn’t. I know there’s a whole proliferation of COVID-related studies, even many other studies looking at COVID and pregnancy.

All of this observational research is supported by animal model research. We have a lot of experimental research in animals showing that prenatal stress leads to changes in offspring stress hormones, and changes in metabolism or immune function, that’s consistent with our observational studies in humans. And so that gives us more confidence that the associations we’re finding are meaningful.

I’ve talked to people on COVIDCalls about radical changes they foresee in medical research, and also in the ways medicine is delivered. Is maternal care also wrapped up in that?

There’s been a predominant assumption within our society that hospitals are the place you give birth, and the pandemic caused a lot of people to rethink that for the first time on a much broader scale. There were people who thought, “I don’t want to go to the hospital—that’s where all the COVID patients are. What are my other options?” And when people explored those options, they realized that there are not that many alternatives, because there are lots of structural factors that inhibit access to out-of-hospital community birth.

Other places to give birth include freestanding birthing centers, but those are not available in all 50 states, and also home births, but they can also be difficult to access, they’re not covered by insurance, and they can only be attended by midwives. With the pandemic, you saw a lot of people trying to explore these community birth options for the first time.

Individuals who went to those community birthing centers, oftentimes were very satisfied with it. My colleague Theresa E. Gildner and I have a paper in Frontiers in Sociology (February 18, 2021) that discusses how the pandemic is affecting our participants’ future maternity care preferences. We asked, “If you were to become pregnant again, where would you give birth?” About 6 percent of our participants said that if they became pregnant again, they would give birth outside of a hospital; if you think back, only 3 percent of people give birth out of the hospital in the first place. Their responses suggest that the pandemic may be shifting some of the cultural norms about where we should be giving birth.

“The pandemic may be shifting some of the cultural norms about where we should be giving birth.”

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Are there documented cases of children being taken away from mothers for a quarantine period after giving birth?

Yes, there are. We asked about it in our survey, and there were people who were separated from their infants at birth in our sample.

One of the things I asked participants was whether the mothers felt like they had a choice or not. The official Centers for Disease Control and Prevention recommendations are for the provider to inform the patient that this was the recommended course of action, but that the patient has a right to decide about their medical care. So technically, the patient could refuse to be separated from their baby. We asked our participants whether they felt like it was presented to them as a choice or as something that they had to do. And all our participants said that they felt like it was something that they had to do and it was not presented to them as a choice.

The U.S. guidelines were disconnected from the World Health Organization guidelines, which said that keeping moms and babies together is extremely important and should always be a priority. And there was no evidence to suggest vertical transmission from mom to baby of COVID. The mom should be masked and wash her hands, but she and the baby should be together.

How did stress affect women who were pregnant but were also part of essential worker groups?

In our study, we asked people if they were working outside the home, and about whether the pandemic was affecting their work plans and how long they planned to work in pregnancy. We saw that work was a huge source of stress for people, because a lot of them felt like they had to choose between their health and their income. It caused a huge psychological burden for these people, because they didn’t feel like they had a choice, and they had to continue to expose themselves and their unborn baby.

Are there COVID babies who will be studied as a population group for the rest of their lives?

Absolutely. With our own cohort, we have the potential to follow these children as they grow and develop, which is certainly an opportunity I had not anticipated a year ago. We’ve done two rounds of data collection so far: one during pregnancy and one about one month postnatal. We’re gearing up for a third data collection wave with questionnaires again, and we’re also going to collect hair from our participants—from the mothers and their babies—to look at cortisol stress hormone levels in hair.

Based on research already out there, what effects might we be looking at for the life course of these children?

There’s certainly evidence for behavioral and psychological outcomes, such as anxiety or altered stress response. A lot of research suggests potential cardiovascular health effects. But I would say that when we look at those big cohort studies, there are modest associations that come out.

One thing that is important to make clear is that sometimes when we do this research, we describe these prenatal stressors as like programming offspring health in a way that’s irreversible. And I think that can be damaging and pathologizing. Human bodies are sensitive to the environment beyond just the prenatal period. Even if we were able to find some modest associations at a population level, when we’re talking about individuals, I don’t want to imply that they’re doomed to disaster.

What will be interesting to see is when and how, and in what way, life becomes normal again. And if there’s differences in the timing of that normalcy, how that can influence the long-term trajectories. Because again, the sensitive period of development isn’t only pregnancy.

There’s this whole cohort of people who have had to go through some really difficult things in pregnancy and postpartum. What can we do to support them now and to try and make sure that we improve environments in order to avoid the development of these adverse outcomes? There are still things that we can do.

How has the pandemic changed the way that you work?

I’m an anthropologist, so normally I like to go places and talk to people and build rapport. And so in some ways, the online survey has been challenging because I haven’t gotten to see my participants face to face yet. We did provide a lot of opportunities for participants to provide open-ended responses, and in that sense, it’s been amazing to be able to hear these women’s voices, and read about their individual experiences that they have so graciously shared with us. But I am hoping in subsequent rounds that we will be able to do more interviews, even if it’s just over video for now.

I’ve had to pivot and figure out how to use my skills differently. And certainly, even if I were to start a retrospective study anytime in the next few years where I generate a new cohort and talk to people, for better or worse, this pandemic has had a substantial enough effect that I think I can ask about specific things that have happened to people and have confidence that they’re being recalled with a high accuracy. For example, if I asked about whether someone’s financial situation was impacted by the pandemic, even five years down, hopefully, they can still give me a relatively accurate assessment about that. It’s always a new adventure.

Do you think online study design is now going to become a requirement for anthropological training?

I had three undergrads who were about to go to the field last year, so we were working on their human subjects approvals. And when COVID hit, two of them decided that was it. They were overwhelmed and didn’t want to try to shift. But one of them shifted, and we did her study online. She was originally going to go to Peru and Japan, but we did all these remote surveys and interviews instead. And now I’m designing some other studies with undergrads, and we’re doing all online surveys. And so I find myself training students in an area where I never received training.

I think there’s some value to internet surveys and to video interviews, in that we can reach more people quickly, and we can access people geographically who would otherwise be difficult to reach. But I still think there’s something about face to face that will never die. So I do think that maybe this will become another tool in our toolkit that we can certainly improve the methods on and do better. And that’s a good thing to learn. But I’d like to think that it will not replace our traditional bread-and-butter data collection methods.