Impact of the COVID-19 pandemic on Swiss pregnant and breastfeeding women – a cross-sectional study covering the first pandemic wave

Information on the impact of the COVID-19 pandemic on pregnancy and breastfeeding experiences, as well as on perinatal mental health in Switzerland is limited. In Switzerland, there are few national studies and little information. Using an anonymous online survey accessible after the first wave of the outbreak in Switzerland, we have investigated how this pandemic affected pregnant and breastfeeding women. Among women who completed the survey, 69.0% (1050/1518) indicated the first wave of the pandemic affected their personal habits, 61.0% (689/


Introduction
Since 11 March 2020, new virus SARS-CoV-2 expansion from China has been designated as a global pandemic by the World Health Organization (WHO) [1].There have been over 108.2 million cases of the disease related to this virus (COVID-19) over 2.3 million deaths worldwide as of 19 February 2021 [2].Certain categories of the population are more vulnerable to this virus, including pregnant women which have been described as a population at risk of severe outcomes [3][4][5][6].To slow down the transmission of the virus, drastic and unprecedented measures were taken in many countries: containment, quarantine, and closure of schools, workplaces and stores [7].In Switzerland, these measures were introduced during the first wave of the pandemic, from the middle of March to the end of May 2020 [8].
In addition to professional and financial concerns, pregnant and breastfeeding women may have been affected in their relationship with healthcare professionals and in their perinatal care, owing to restricted access to hospitals and postponement of non-urgent care.Furthermore, lack of in-formation about this new virus may have generated concerns about maternal and fetal outcomes in the case of infection and could have influenced maternal choices with regard to personal restrictions, home birthing and breastfeeding.Such occurrences could have led to psychological distress, particularly because this specific population is vulnerable to mental health problems [9,10].According to the WHO, about 10% of women will experience symptoms of depression during pregnancy or post-partum independently of the COVID-19 pandemic [11].Risks factors known to contribute to antenatal depression are lack of a partner or social support, unplanned pregnancy, comorbidities and a history of mental illness, and adverse/unplanned events modifying life habits [12].Previous studies have indicated increased rates of depressive symptoms and anxiety among pregnant and breastfeeding women during the early stages of the COVID-19 pandemic and during quarantine [9,13,14].However, the extent to which their experience of pregnancy and breastfeeding and their mental health have been affected by the pandemic remains poorly described.Furthermore, direct (exposure, hospitalisation, adverse outcomes) and indirect (alteration in personal and professional habits, access to prenatal care, fears) factors associated with mental health symptoms during the pandemic have not been clearly identified.
The first aim of this study was to describe the potential association between the changes in the pregnancy/breastfeeding experience in the COVID-19 pandemic and the changes related to the healthcare system and life and professional habits.The second aim was to describe pregnant and breastfeeding women's mental health symptoms during the first wave of the pandemic, as well as sociodemographic, health, exposure and indirect factors contributing to such mental health symptoms.

Study design
This Swiss cross-sectional online study is part of a European multicentre study led by the University of Leuven and conducted in several countries (Belgium, Ireland, Norway, the Netherlands, the United Kingdom and Switzerland), with a questionnaire available in German, French and Italian used in Switzerland.In 2019, 62.1% of Swiss population spoke German as their main language, 22.8% French and 8.0% Italian [15].The multicentre study aimed to examine the impact of the COVID-19 pandemic on pregnant and breastfeeding women from a broad perspective (on pregnancy/breastfeeding experience, relationship with the healthcare system, life and professional habits, personal fears, as well as mental health) [16].In Switzerland, the questionnaire link was accessible from 18 June to 12 July 2020 through websites and forums dedicated to pregnant and breastfeeding women: www.letsfamily.ch(German and French),www.swissmom.ch(German and French), www.medela.ch(German, French and Italian), hospital website: www.chuv.ch(French), and social media, in the form of an advertisement inviting them to participate.All data were stored and handled anonymously.

Study population
Women aged 18 years or more, pregnant at the time of survey or who had breastfed during the previous 3 months, were eligible.The questionnaire was available in the three predominant national languages in Switzerland and women from each linguistic region had the opportunity to be represented.

Variables
The questionnaire was divided in several parts.The first part collected information on the current pregnancy (gravidity, parity, previous children, pregnancy planning status and gestational age) or on the infant and breastfeeding status (age of the infant, admission to a neonatal intensive care unit [NICU], change or cessation of breastfeeding because of SARS-CoV-2, precautions taken during breastfeeding) according to the situation of the participant.Information on how the pandemic influenced their pregnancy/ breastfeeding experience compared with a previous experience and on how their relationship with healthcare services had been affected were also collected.
The second part recorded the exposure to COVID-19 using questions on potential symptoms, testing (reverse transcription polymerase chain reaction [RT-PCR], serology and/or computed tomography) and COVID-19 related hospitalisation.Fears and beliefs related to the infection were also gathered (fetal adverse outcomes, willingness to consider abortion in case of early infection).
The third part evaluated personal restrictions and mental health symptoms using validated screening tests: the Edinburgh Postnatal Depression Scale for depression [17,18], the Generalized Anxiety Disorder 7-item Scale for anxiety [19] and the Perceived Stress Scale for stress [20,21] .
Finally, information on sociodemographic and medical history was gathered, including country of residence, age, language, marital status, working status, education level, smoking during pregnancy, comorbidities, professional and financial situation during the pandemic, as well as information on people living in the same home (number, age and whether they presented COVID-19 symptoms or had been tested).

Impact on pregnancy and breastfeeding experience
The impact of the pandemic on pregnancy or breastfeeding experience was evaluated through participants' graded answers: "had a great impact", "had rather an impact", "had little impact" or "had no impact".Open answers were also analysed and grouped according to frequently discussed themes, to illustrate more precisely how the pandemic and the restrictive measures had had an impact on these pregnancy and breastfeeding experiences.
The impact of the pandemic on the relationship with healthcare systems, on personal and professional habits, on fears of adverse maternal and fetal/neonatal outcomes were also assessed through graduated answers.

Statistical analysis
The prevalence of baseline characteristics and exposure (COVID-19 testing, symptoms and hospitalisation) was presented for both pregnant and breastfeeding women.The impact on their pregnancy and breastfeeding experience was presented as descriptive statistics.Fears, relationships with healthcare systems and mental health symptoms were also presented as descriptive statistics.The scores for depression, anxiety and perceived stress were presented as minimal/low, mild, moderate and severe/high according to the definition above.
A nested case-control study was conducted to compare sociodemographic and health characteristics, exposure parameters and impacts on personal and professional habits of pregnant and breastfeeding women, taken together, with high levels of mental health symptoms, considered as cases, with those of women with low levels of mental health symptoms, considered as controls.Having symptoms of severe depression score (EPDS ≥13), having a severe anxiety score (GAD-7 ≥15) or experiencing a high perceived stress score (PSS ≥7) were combined into a unique "poor mental health" variable for this analysis.These associations were estimated by univariable and multivariable logistic regression and were presented as crude odds radio (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs).Variables were not considered for the multivariable model if p >0.10 in the univariable analysis.The association between variables specific to pregnant or breastfeeding women (gravidity, parity, pregnancy planning and current gestational age were asked only for pregnant women whereas hospitalisation of the neonate in an NICU was asked only for breastfeeding mothers) and "poor mental health" was estimated in additional univariable and multivariable models including only pregnant and breastfeeding women.

Missing values
Maternal comorbidities were considered as absent if not reported, based on the assumption that severe comorbidities are normally well documented.Based on the hypothesis of missing variables completely at random (MCAR), multiple imputations (chained equations) were performed to increase the power of comparisons for missing covariates.

Study population
A total of 2064 respondents participated in the survey (1161 using the French, 868 the German and 35 the Italian questionnaires), including 1501 breastfeeding and 563 pregnant women.A total of 369 (17.9%) women did not complete the questions on the impact of the pandemic on pregnancy or breastfeeding experience.Therefore, 1695 (82.1%) contributed to the analyses addressing the primary aim of the study (1136 breastfeeding mothers and 559 pregnant women).Of these, 1467 (86.5%) patients completed the scales for depression, anxiety or stress, including 980 breastfeeding women and 487 pregnant women (fig.1).

Baseline characteristics
Baseline characteristics are presented in table 1.The median age of responders was 33 years and the majority were married or cohabiting (73.0%).A significant proportion of women were healthcare providers (18.7%) or housewives (8.2%).The educational level was high (42.5% had an education level higher than high school) and 12.9% reported smoking during pregnancy and/or breastfeeding.Less than 5% reported a language different from the official ones.
In total, 8.9% of women reported comorbidities.Among pregnant women, 94.1% of pregnancies were planned and the median gestational age at the time the women participated in the survey was 28 weeks.In total, 46.5% were pregnant for the first time.Among the multigravida participants, 74.2% had one previous infant and 18.4% had more than one infant.

Impact on pregnancy and breastfeeding experiences
Overall, 36.8% (110/299) of pregnant women and 8.2% (46/555) of breastfeeding women who answered the question indicated that the pandemic had "rather an impact"  or "had a great impact" (9.7% and 4.1%, respectively) on their current pregnancy experience or breastfeeding experience.Among pregnant women who specified how the pandemic impacted their pregnancy, 29/168 (17.3%) and 21/168 (12.5%) indicated they had "concerns about precautions" to take and experienced "some anxiety during social contact", respectively.Among breastfeeding women who specified the impact of the pandemic in the open question, 9/30 (30.0%) indicated their breastfeeding experience was an "additional stress factor" during the pandemic.Among women experiencing symptoms potentially related to COVID- A large majority (69.2%; 1050/1518) of both pregnant and breastfeeding women indicated that the pandemic restricted their life habits, such as self-imposed strict confinement because of "fear of catching the virus and that it will endanger breastfeeding", as an example.A large majority of pregnant (71,1%; 295/415) and breastfeeding women (55%; 394/716) mentioned that the COVID-19 pandemic had an impact on their professional life, with negative (30/42, 71.4%) or positive (12/42, 28.6%) aspects, such as "positive impact of working from home with less stress and fatigue from the commuting, and more time to rest" but also "working from home and no daycare for my daughter, so it's hard to manage both and enjoy my pregnancy at the same time (e.g., shopping for baby)." A substantial proportion of pregnant (47.5%; 264/556) and breastfeeding women (36.2%; 368/1017) indicated that the pandemic affected their interaction with healthcare services (fig.2).Among pregnant women, "restricted visits to the medical office", "absence of the father at the medical office or ultrasounds" and "the absence of care related to the comfort of pregnancy" were repeated concerns in 42/ 168 (

Main results
The first wave of the COVID-19 pandemic had a significant impact on the current pregnancy or breastfeeding experiences of one-fifth of the sample of Swiss women.Two thirds of pregnant and breastfeeding women restricted their life habits during the first containment period in Switzerland in Spring 2020.The pandemic significantly altered their relationship with healthcare services according to half of the pregnant women and one third of the breastfeeding women.More than half of the breastfeeding women felt less supported during this period.Moreover, 11.6% of participants reported significant psychological distress (symptoms of severe depression, severe anxiety or high perceived stress).Potential risk factors associated with poor mental health status were being a housewife, having comorbidities, presenting symptoms potentially related to COVID-19, being hospitalized, living with someone presenting symptoms, having personal habits affected and having restricted access to healthcare services.Potential protective factors associated with fewer symptoms of potential mental health problems were a high level of education and living with a partner.

Interpretation
The prevalence of symptoms potentially compatible with COVID-19 among respondents seems to be high in our sample (54.9%; 806/1467).Some of the symptomatic participants may have had other infections indistinguishable from COVID-19.Surprisingly, a very low proportion of the participants reported having been tested (10.0%; 170/ 1695) despite the high prevalence of reported symptoms.This might reflect the testing policy at the beginning of the pandemic, the limited availability of nasopharyngeal RT-PCR or the reluctance to visit a health facility at the time of the first wave.
Overall, the rate of Swiss pregnant and breastfeeding women who reported poor mental health in our survey (11.6%) is comparable to the 10% of pregnant women experiencing clinically significant mental health problems worldwide before the COVID-19 pandemic, according to the WHO [11] .This rate is also similar to the 11.7% of the general Swiss population surveyed between 11 May and 1 June 2020, as described by Quervain et al.They noticed an increase in the prevalence of moderate and severe depressive symptoms compared with the pre-pandemic period (3.4%) [25].However, a few previous studies have shown that middle-and lower-income countries have a higher prevalence of poor mental health in the perinatal period compared with western countries [26,27] .In highincome countries such as Switzerland, 9.5% of women of childbearing age had moderate or severe major depression in 2017 [28].Moreover, we selected only women presenting severe mental health symptoms, and therefore have underestimated the impact of moderate psychological distress, as found in a study by Wu et al. [29].
In the literature, several studies highlighted similar results on the impact of the COVID-19 pandemic on perinatal mental health of women living in different countries [10,13,[29][30][31][32][33][34].Most of them focused on pregnant women who experienced a range of disorders, such as anxiety, symptoms of depression and sleep disturbances during the COVID-19 pandemic.Extreme changes in daily life have been associated with an increased risk of depression, in line with our findings [30] .However, it is interesting to note that in our results, a quarter of the women indicating that the pandemic has had an impact on their daily lives described a positive impact, particularly the implementation of "working from home", which reduced their stress and fatigue.Low education level and working part-time or less were risk factors for depression according to Wu et al. [29].This supports our finding of a high educational level as a protective factor for psychological distress and being a housewife as a risk factor.Low familial support could participate in developing a depression [29], just as having good social support seems protective against stress [10,35].This is in line with our finding of a possible protective effect of being married / cohabiting.Changes in prenatal care during the confinement period has been depicted as a stress factor by Preis et al. [36] which seems in accordance with the impact of restricted access to healthcare services on perinatal health in our study.Among the general Chinese population, having confirmed or suspected COVID-19 or having relatives with confirmed or suspected COVID-19 were factors associated with poor mental health according to Shi et al. [37] , in line with our findings.Future studies might investigate the role of other protective factors against stress and depression, such as adequate sleep duration [10] and regular physical activity [29,36] .
During the pandemic, a higher percentage of women with thoughts of self-harm has been found in China [29].Moreover, mental health issues have a severe impact on quality of life, social and partner relationships and on child development [38,39].Therefore, future searches for effective interventions to manage potential psychological distress among pregnant and breastfeeding women are urgently needed.Psychological first aid and telehealth could be appropriate tools to support pregnant and breastfeeding women with mental health problems during outbreaks [40].

Strengths and limitations
The large number of participants and the fact that the survey was performed in three official languages (women from different parts of Switzerland were reached) are important strengths of the present study.The content analysis of the open-ended quotations provides a good overview of the reality of these women during this outbreak.
However, sociodemographic characteristics of the participants differ from those presented by the official Swiss statistics (appendix), particularly regarding age distribution, professional activity and education.Women who participated in our survey seem to be more representative of a population over 26 years of age, with a high level of education and a high activity rate, preventing the generalisation of these results to the general population of Swiss pregnant and breastfeeding women.Although Swiss women do have good internet access (95%) [15], selection bias in favour of more motivated or concerned women could have occurred, as the survey was online.Women seeking information about their pregnancy or breastfeeding were more likely to encounter the online survey than less worried women.They may represent a more educated population of website users.The high proportion of healthcare providers participating in this survey (18.7%) may also represent a more educated population, leading to a potential selection bias for a protective factor for mental health, which could underestimate the prevalence of psychological distress.Severely ill women were most probably not included as they would not have the capacity to participate.In our survey, 4.7% of respondents indicated speaking another language as main language, whereas a higher proportion (17.7%) of people living in Switzerland report speaking language other than the official ones [28] .Therefore, it is possible that the immigrant population was underrepresented.The high proportion of French-speaking answers compared with the proportion of Swiss people who speak French as their primary language (23%) could reflect a selection bias, partly explained by the fact that the distribution of the survey was initiated by the CHUV (Centre Hospitalier Universitaire Vaudois, university hospital of the biggest Frenchspeaking canton) [15].Another explanation may be that the French-speaking part of Switzerland has been more seriously affected by the pandemic than the German-speaking part [41].This may have led to an overrepresentation of one of the linguistic regions.
A limitation could be the fact that symptoms could not specifically be assigned to SARS-CoV-2 infection.
The mental health scores only measure depressive symptoms, anxiety and stress experienced over the last 4 weeks, preventing us from drawing any conclusions on mental health status during the peak of the first pandemic wave.
The study was a cross-sectional study and no information was collected on the long-term impact of the pandemic on mental health and perinatal experiences.
The drop-out from the survey (17.9%) could be attributed to the length of the questionnaire, with a certain proportion of open-ended questions.Some questions might have also triggered emotions (fear, irritability or feeling misunderstood, for example) and might thus have been skipped by participants, selecting women with a lower risk of psychological distress, thus violating the assumption of information missing at random.Finally, recall bias as a result of better recall among women with stronger negative experiences due to the pandemic cannot be excluded.

Conclusion
Our findings suggest that the first wave of the COVID-19 pandemic may have had a severe impact on the mental health and perinatal experiences of pregnant and breastfeeding women in Switzerland, both directly through exposure to SARS-CoV-2, and indirectly through the impact on their life habits and contact with healthcare facilities.Prevention and support strategies should be set-up to counter these consequences of the COVID-19 epidemic for maternal-child health.

Table 3 :
Factors associated with an altered mental health status in 1467 patients.
aOR: adjusted odds ratio; CI: confidence interval; OR: odds ratio; RT-PCR: reverse transcription polymerase chain reaction a Multiple imputations were performed on missing values, for variables with a denominator different from the overall denominator b Tested only in pregnant women c Tested only in breastfeeding women d Only significant risk factors have been included in the multivariable analysis Original article Swiss Med Wkly.2021;151:w30009 Swiss Medical Weekly • PDF of the online version • www.smw.chPublished under the copyright license "Attribution-NonCommercial-ShareAlike 4.0".No commercial reuse without permission.See https://smw.ch/permissions