The Effect of Giving Birth While Infected With COVID-19 During the COVID-19 Pandemic on Maternal Anxiety, Depression, and Mother-Infant Bonding: A Comparative Study

The Effect of Giving Birth While Infected With COVID-19 During the COVID-19 Pandemic on Maternal Anxiety, Depression, and Mother-Infant Bonding: A Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Giving Birth While Infected With COVID-19 During the COVID-19 Pandemic on Maternal Anxiety, Depression, and Mother-Infant Bonding: A Comparative Study Merve Dilli Gürkan, Erdem Gürkan, Özlem Yıldız Gündoğdu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7807915/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Giving birth while infected with COVID-19 during the pandemic has brought additional restrictions and practices, it is important to carefully examine the difficulties this group may have faced. Aims This study aims to compare women who gave birth while infected with COVID-19 during the COVID-19 pandemic with women who healthily gave birth in terms of depression, anxiety, and mother-infant bonding levels experienced during the postpartum period. Methods A total of 107 postpartum women, including 53 with positive COVID-19 PCR tests and 54 with negative PCR tests, were included. A clinician administered the following to the patients: a sociodemographic information form, the Edinburgh Postpartum Depression Scale (EPDS), the State-Trait Anxiety Inventory (STAI) I-II, and the Postpartum Bonding Questionnaire (PBQ). Results In the study, PBQ, EPDS, and STAI-I scores were found to be statistically significantly higher in women who gave birth while infected with COVID-19 compared to those who tested negative for COVID-19 via PCR; however, no significant difference was observed between the groups in terms of STAI-II scores. Additionally, a moderate correlation was observed between EPDS and PBQ scores, and also STAI-I and PBQ scores in women with negative COVID-19 PCR tests, while a strong and statistically significant correlation was seen in women with positive COVID-19 PCR tests. Conclusions This study emphasizes the importance of thoroughly examining the psychological, physical, and social hurdles mothers encounter during this time and the bond they form with their infants. It is believed that this study will help inform hospital birth policies that prioritize the mother-infant bond in future outbreak scenarios. Psychiatry COVID-19 pregnancy maternal anxiety depression maternal bonding Introduction Pregnancy and the postnatal period are different for each woman and are part of the natural cycle of life. They typically bring joy and excitement, along with significant changes and challenges. During this time, women experience hormonal, physical, and social shifts changes.[ 1 ] Women are at risk of mental health disorders during the perinatal period, which extends from pregnancy to one year postpartum birth.[ 2 ] Symptoms of depression and anxiety are especially common during pregnancy.[ 3 ] Approximately 40 percent of women experience their first depressive episode during the postnatal period, while around 33 percent experience it during pregnancy.[ 4 ] Postpartum depression is the most common complication of childbirth[ 5 ] and it adversely impacts the role of motherhood in many ways.[ 6 ] A strong link has been identified between postpartum depression and anxiety.[ 7 ] Despite numerous studies conducted in recent years on postpartum depression, anxiety during pregnancy and after childbirth has been relatively understudied.[ 8 ], [ 9 ] Attachment is defined as an emotional bond that develops between a child and their caregiver, characterized by the child's search for closeness with the caregiver, which becomes especially evident in stressful situations, and shows consistency and stability.[ 10 ] Interfering with a newborn baby's interaction with its mother, separating the baby from her, and fearing for the baby's well-being can hinder the development of a strong bond between mother and baby and make mother-baby bonding more difficult process.[ 11 ] Research indicates that postpartum depression and anxiety serve as risk factors for mother-infant attachment disorders.[ 12 ], [ 13 ], [ 14 ] Disruption in the mother-infant relationship also has a lasting impact on the infant.[ 15 ], [ 16 ] These effects also encompass long-term negative consequences such as delayed mental development in children.[ 17 ] Extremely stressful situations such as emergencies, conflicts, and natural disasters can increase the risk of perinatal mental health issues morbidity.[ 18 ] During the COVID-19 pandemic, which was declared a global health crisis, the quarantine and isolation measures implemented caused intense fear, anxiety, feelings of uncertainty, disruption of daily routines, and changes in social relationships among expectant mothers or new mothers.[ 19 ] Furthermore, the amount of stress they experienced during the pandemic has also increased.[ 20 ] The difficulty of maintaining mental well-being while infected during the pandemic, combined with the challenges of pregnancy and childbirth, has made managing infected pregnant women during and after delivery even more important.[ 21 ] It is possible that pregnant women experiencing more severe illness, reported premature births, and maternal and infant mortality have impacted their mental wellbeing.[ 22 ], [ 23 ] The procedures related to the method of delivery and postnatal infant care have changed during the pandemic period due to new recommendations.[ 24 ] Following studies indicating that COVID-19 infection can be transmitted to the baby through vaginal fluid, research has been published recommending that cesarean delivery be prioritized over vaginal delivery.[ 25 ], [ 26 ] Although transmission of SARS-CoV-2 through breast milk is unlikely, some infected women have chosen to temporarily refrain from breastfeeding to avoid direct contact with their newborns and reduce the risk of neonatal infection.[ 27 ], [ 28 ] Additionally, the Centers for Disease Control and Prevention (CDC) has recommended temporarily separating newborns from mothers who have tested positive for COVID-19 or are suspected of having it to reduce the risk of transmission newborn.[ 29 ] Hospitals have implemented policies to decrease infection rates while maintaining postnatal healthcare services, which has resulted in a decline in the quality of maternity care.[ 30 ], [ 31 ], [ 32 ] These established policies have been stricter for mothers who have tested positive for COVID-19 or are suspected of having it.[ 32 ] Parental experiences have indicated that practices diverging from the WHO's recommendations for quality birth care were quite common during the pandemic.[ 33 ] The aim of our study is to compare women who gave birth while infected with COVID-19 to women who gave birth under healthy conditions during the COVID-19 pandemic, focusing on depression, anxiety, and mother-infant bonding levels experienced during the postpartum period. Given that the pandemic period itself was a significant source of stress due to strict measures, fear, uncertainty, and changes in daily routines and social interactions, it is expected that mothers' postpartum depression and anxiety levels, as well as their bonding process with their babies, would be influenced by the pandemic. This effect is likely to be more pronounced in women who gave birth while testing positive for COVID-19. Materials and Methods Participants A total of 107 postpartum women, including 53 with positive COVID-19 test results and 54 with negative test results, who gave birth during the pandemic period (December 2021–June 2022) at Derince Education and Research Hospital, were included. All women in both groups delivered via cesarean section. Patients in both groups were women who gave birth between December 2021 and June 2022 and were subsequently admitted to the obstetrics and gynecology service during the first few days postpartum. Procedure Patients who met the inclusion criteria were asked to complete a sociodemographic information form regarding pandemic-related variables, the Edinburgh Postpartum Depression Scale (EPDS), the State-Trait Anxiety Inventory (STAI) I-II, and the Postpartum Bonding Questionnaire (PBQ) during their postpartum hospitalization, with their consent obtained. Pregnant women whose babies had to be admitted to intensive care for reasons unrelated to COVID-19 or who experienced complications unrelated to pregnancy or childbirth were not included in the study. Measures Participants were asked to complete a sociodemographic information form prepared by the researchers, which included questions related to the pandemic process. Edinburgh Postnatal Depression Scale (EPDS): Developed for screening purposes to identify the risk of depression in women during the postnatal period. It is a self-assessment scale consisting of 10 items covering the individual's psychological state over the past seven days. A high total score indicates the severity of depression.[34] Engindeniz conducted the Turkish adaptation of this scale, developed by Cox et al. (1987), to assess the risk of postpartum depression (1996).[35] State-Trait Anxiety Inventory (STAI): Developed by Spielberger and colleagues, this inventory has two subscales, each containing 20 questions: one for trait anxiety and one for state anxiety. It is suitable for individuals aged 14 and older. The State Anxiety Scale (STAI-I) measures how a person feels at a specific moment under particular conditions, while the Trait Anxiety Scale (STAI-II) assesses how a person feels regardless of their current situation or conditions. The cut-off score is 40 for STAI-I and 37 for STAI-II. The Turkish version was adapted by Öner and Le Compte (1983), and validity and reliability studies were conducted.[36] Postpartum Bonding Questionnaire (PBQ): Developed by Brockington and colleagues to identify early problems in the mother-infant relationship, it is completed by the mother. The scale has four subscales and a total of 25 questions: "attachment disorder" (12 items), "rejection and irritability" (seven items), "tension regarding care" (four items), and "risk of abuse" (two items). The scale includes 25 items, with 17 being reverse-scored, and as the score for each subscale increases, the risk associated with that area rises. Similarly, an increase in the total score indicates a decline in the quality of attachment.[37] Yalçın et al. conducted a validity and reliability study of the scale in Turkish (2014).[38] Data Analysis Data analysis was carried out using SPSS 25 software. The data was examined, and no errors in data entry were found. Missing value checks were also performed, and no missing data was detected. For data analysis, frequency and percentage distributions, descriptive statistics, and group comparisons were conducted. The independent groups t-test, a parametric method, was used to assess the relationship between variables, along with Pearson's correlation, also a parametric method. All statistical tests were performed at a 95% confidence level, meaning a significance threshold of p<.05. The independent groups t-test was employed to compare patients' attachment disorder, depression, and anxiety scores based on their COVID-19 pcr test results. This test compares the means of continuous variables (scale scores) between two groups defined by an independent variable (COVID-19 pcr test result). The key assumptions for this method are that the sample size exceeds 30 (N>30), and that the scores are normally distributed; these assumptions were satisfied. The reliability of the scales used in this study was assessed with Cronbach's alpha coefficient. The Postpartum Attachment Scale demonstrated a reliability coefficient of 0.977, the Edinburgh Postnatal Depression Scale scored 0.956, and the STAI I-II scored 0.935. Overall, the scales used are highly reliable. Ethical Approval The study was approved by the Clinical Research Ethics Committee of Derince Education and Research Hospital, with decision number 2021-137 dated 12/23/2021. The study was carried out in accordance with the Declaration of Helsinki Principles. Results The study included a total of 107 postpartum women who gave birth during the pandemic at Derince Training and Research Hospital. 50.5% (n=54) tested negative for COVID-19 PCR, while 49.5% (n=53) tested positive. No significant difference was observed between the groups regarding mean age (p=0.530). Women who reported that their pregnancy was planned were significantly more common among those with negative COVID-19 PCR tests compared to those with positive tests (p=0.000). Increased duration of staying at home and inability to continue working were more prevalent in both groups; however, there was no statistically significant difference between them (p=0.588 and p=0.719). Regarding sources of information about the COVID-19 pandemic, women with negative COVID-19 PCR tests were more likely to obtain information from healthcare workers, while women with positive tests more often obtained information from other people, with a statistically significant difference between the groups. Additionally, a significantly higher proportion of women with positive COVID-19 PCR tests had a relative who died due to COVID-19 compared to those with negative tests. (Table 1) Table 1. Comparison of Variables Related to COVID-19 Infection Variable Group Negative Positive p f(%) f(%) Age (mean±sd) 28,8±5,9 31,0±5,4 0,530 Time spent at home It hasn't changed 9(16,7) 11(20,8) 0,588 Increased 45(83,3) 42(79,2) Unable to Continue Working It didn't work out. 17(31,5) 15(28,3) 0,719 It did work out. 37(68,5) 38(71,7) Ways to obtain information about COVID-19 From the internet No 9(16,7) 9(17) 0,965 Yes 45(83,3) 44(83) On television No 23(42,6) 19(35,8) 0,475 Yes 31(57,4) 34(64,2) From People No 17(31,5)a 3(5,7)b 0,001 Yes 37(68,5)a 50(94,3)b Healthcare Workers No 33(61,1)a 47(88,7)b 0,001 Yes 21(38,9)a 6(11,3)b Acquaintance Who Has Had COVID-19 No 8(14,8) 4(7,5) 0,234 Yes 46(85,2) 49(92,5) Acquaintance Who Died From COVID-19 No 38(70,4)a 19(35,8)b ,000 Yes 16(29,6)a 34(64,2)b p:chi-square signidicance value; a,b: For significant chi-square results, the Bonferroni correction indicates which column the difference relates to between groups, with different lowercase letters indicating a significant difference between those groups. Descriptive statistics for the PBQ, EPBS, and STAI scales and their subscales are shown in Table 2. Table 2. PBQ, EPDS, and STAI scores based on COVID-19 infection status Scale Scores Negative Positive t p mean±sd mean±sd Attachment Disorder 4,3±3,6 18,1±16,2 -6,098 ,000* Rejection and Irritability 1,2±2,6 10,8±11,1 -6,186 ,000* Tension Regarding Care 2,4±2,3 8,2±7 -5,879 ,000* Risk of Abuse 0,04±0,3 1,8±2 -6,35 ,000* Postpartum Bonding Questionnaire Total Score 7,9±6,6 39±35,8 -6,256 ,000* EPDS 6,8±5,5 14,6±10,3 -4,952 ,000* STAI-I 31,3±8,8 54,4±21,7 -7,271 ,000* STAI-II 46,5±4,8 47,1±3,5 -0,729 0,467 T test, *p<.05 PBQ: Postpartum Bonding Questionnaire, EPDS: Edinburgh Postpartum Depression Scale, STAI: State-Trait Anxiety Inventory In patients with a negative COVID-19 PCR test, there is a positive and moderately significant correlation between PBQ and EPDS (r=0.436) and also STAI-I (r=0.403) scores (p<0.05). In patients with a positive COVID-19 PCR test, there is a positive and highly significant relationship between the PBQ total score and the EPDS and STAI-I scores (p<0.01). Women with a positive COVID-19 PCR test showed a positive and moderately statistically significant relationship (p<.05) between their STAI-II and PBQ (r=0.460), EPDS (r=0.426), STAI-I (r=0.426) scores. However, no significant relationship was found in women with a negative COVID-19 PCR test result. Additionally, there is a positive and highly significant correlation between EPDS and STAI-I scores in both patients with negative and positive COVID-19 PCR tests—in order; r=0.713, p<0.01; r=0.951, p<0.01. (Table 3) Table 3. Correlation Table Between Attachment, Depression and Anxiety Scores Group Scale Scores 1 2 3 4 Covid Negative 1. Attachment All 1 2. Depression ,436* 1 3. Condition ,403* ,713** 1 4. Continuity 0,116 0,013 -0,014 1 Covid Positive 1. Attachment All 1 2. Depression ,954** 1 3. Condition ,943** ,951** 1 4. Continuity ,460* ,426* ,426* 1 *p<.05;**p<.01 Discussion The aim of this study is to compare the levels of depression, anxiety, and maternal attachment among women who gave birth during the COVID-19 pandemic, depending on whether or not they had COVID-19. Studies show that women who gave birth during the pandemic experienced higher levels of depression and anxiety compared to before the pandemic.[39], [40], [41], [42] Considering that prenatal stress increases the risk of neurodevelopmental disorders and a number of emotional, behavioral and/or cognitive problems in later life, it can be predicted that the COVID-19 pandemic may also negatively affect mother-baby bonding.[43] So far, studies have compared mothers' stress levels and mother-infant interactions during the pandemic with those before it bonding.[44], [45], [46], [47] These studies have conflicting results. Some show that the mother-infant bond is of lower quality compared to the pre-pandemic period. [46], [47] There are also studies showing that the mother-baby bond was not affected during the pandemic.[44], [45] Compared to the pre-pandemic period, a study also showed that during the COVID-19 pandemic, mothers experienced more intense acute stress responses during childbirth, which caused disruptions in their postnatal bonding with their babies.[48] When the literature was reviewed, a study was found that examined postpartum women who had COVID-19 infection in the last two trimesters of pregnancy and postpartum women who had no history of COVID-19 infection during pregnancy in terms of depression and mother-baby bonding, and showed that having COVID infection during pregnancy did not affect mother-baby bonding.[49] However, no study has been identified that examines the impact of childbirth while COVID-19 PCR positive during the pandemic on maternal depression, anxiety, and the bond formed with the baby. In our study, the attachment disorder score was significantly higher in women who gave birth while infected with COVID-19 compared to those who tested negative for COVID-19 PCR. Pain, weakness, fatigue, and limited or slowed movement after a cesarean section may prevent mothers from meeting all of their baby’s needs on their own and in a timely manner.[50] In this situation, mothers' feelings of inadequacy and inability to cope may hinder bonding with their baby. Specifically, in mothers affected by COVID-19, more severe illness-related pain, weakness, and fatigue may have caused greater challenges in caring for and meeting the baby's needs. Additionally, infected postpartum women face extra stressors such as separation from their baby and the uncertain health outcomes of COVID-19 infection for both mother and infant. Considering that increased postpartum stress may negatively affect mother-baby bonding, the attachment disorder score in our study may have been higher in puerperal women with a positive COVID-19 PCR test for this reason.[14] It has been shown that in the first days after birth, mothers can develop a way of identifying their own child's needs through physical and visual contact, indicating that the mother-infant bond has been successfully established.[51]. In our study, attachment disorder scores were higher in mothers who gave birth while infected with COVID-19 compared to healthy pregnant women due to the greater disruption of physical and visual contact. There are also studies that contradict our findings. One study suggests that COVID-19-related stress may have triggered defensive strategies, leading to greater investment in attachment, thus increasing prenatal attachment.[52] Similarly, a study shows that psychological growth results in more secure attachment in women who have experienced traumatic births during the pandemic. [53] In addition to studies highlighting increased anxiety and depression symptoms in the postpartum period during the pandemic compared to the pre-pandemic period, our study found that depression and anxiety symptoms were more severe in women who gave birth during this time infected. [44], [45], [46] Additionally, in our study the group with a positive COVID-19 PCR test preferred to get information about the pandemic from other people, while the uninfected group preferred to obtain information from healthcare professionals. Pregnant women with a positive COVID-19 PCR test had more acquaintances who died from the infection. This may have increased their anxiety when they became infected themselves. In our study, the average continuity anxiety scores were above the cut-off point in both groups and showed no statistically significant difference between them. This could be because both groups consisted of pregnant women who gave birth under generally similar difficult conditions during the pandemic. Other studies have also shown that giving birth alone during the pandemic, with restrictions on companions, reduced perceived emotional support and increased depression and anxiety rates.[54], [55] In a study by Handelzalt and colleagues (2022) examining the effect of COVID-19-related anxiety on postpartum depression and mother-infant bonding, it was found that the link between postpartum depression and impaired bonding was stronger in women with high anxiety levels, while bonding was unaffected by postpartum depression in other women.[56] Additionally, in our study, a moderate relationship was found between depression and attachment disorde, as well as state anxiety level and attachment disorder, in women with a negative COVID-19 PCR test; however, a strong relationship was found in women with a positive COVID-19 test. We believe that the stricter hospital protocols related to childbirth (mode of delivery, breastfeeding, temporary separation from the baby, early skin-to-skin contact, visitor restrictions) in cases of COVID-19 infection may have increased stress-related psychological symptoms (anxiety, depressive complaints), thereby potentially affecting attachment. [33] Additionally, the continuity anxiety score showed a statistically significant positive correlation with attachment, depression, and state anxiety scores in postpartum women who tested positive for COVID-19 via PCR, while no such relationship was observed in women with a negative COVID-19 PCR test. This may indicate that general anxiety levels will have a more negative impact on depression and attachment in the presence of a negative life event (such as having an infection). A strong and statistically significant correlation was found between the state anxiety score and depression in postpartum women regardless of their COVID-19 PCR results. This finding underscores the strong link between postpartum depression and anxiety symptoms. While the current anxiety level shows a strong relationship with depression, regardless of the COVID-19 PCR test result, the fact that the relationship between current anxiety level-attachment disorder and depression-attachment disorder is stronger in those with a positive PCR test suggests that the mother-baby bond is more durable than depression and anxiety symptoms because it has many emotional, psychological, sociological and cognitive aspects, and its influence from external factors may be limited.[7] Limitations This study is based on a cross-sectional assessment and was conducted at a single clinic. Additionally, although highly reliable and valid, the use of self-report measures and the lack of clinical or structured diagnostic interviews are also limitations. There is a need for prospective studies with larger sample sizes to explore the long-term effects of the intense stress experienced by women who had to give birth under strict precautions during the pandemic on bonding and child development. Conclusion In this study, maternal anxiety, depression levels, and mother-infant attachment disorder scale scores were found to be higher in women who gave birth while infected with COVID-19 during the pandemic, especially during the peak of the disease, compared to women who gave birth without infection. Furthermore, testing positive for COVID-19 was linked to a stronger relationship between depression, anxiety symptoms, and attachment disorder. This study aims to highlight the additional challenges that mothers of children born to COVID-19-infected mothers may face during pregnancy, delivery, and infant care in our clinical practice during the pandemic. It emphasizes the importance of thoroughly examining the mental, physical, and social difficulties experienced by mothers during this period and the bond they develop with their babies. It is believed that this research will help inform hospital birth policies that prioritize the mother-infant bond in potential future outbreaks. Abbreviations EPDS Edinburgh Postpartum Depression Scale STAI State-Trait Anxiety Inventory PBQ Postpartum Bonding Questionnaire CDC Centers for Disease Control and Prevention Declarations Data Availability The data that support the findings of this study are available from the first author, [Merve Dilli Gürkan], upon reasonable request. Human Ethics and consent to participate: The study was approved by the Clinical Research Ethics Committee of Derince Education and Research Hospital, with decision number 2021-137 dated 12/23/2021. The study was carried out in accordance with the Declaration of Helsinki Principles. Informed concent was obtained from all patients. Competing interests :The authors have no conflicts of interest to declare that are relevant to the content of this article. Conflict of Interest: The authors declared no potential conflicts of interest for his study. Funding: The authors received no financial support for this research. Authors' contributions: Merve Dilli Gürkan; literature review, writing of the manuscript Erdem Gürkan: Data collection, writing of the manuscript Özlem Yıldız Gündoğdu: Design of the study Acknowledgements :Not applicable. 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Women Birth 36(2):e203–e212. 10.1016/j.wombi.2022.08.004 Cox JL, Holden JM, Sagovsky R (1987) Detection of Postnatal Depression, British Journal of Psychiatry , vol. 150, no. 6, pp. 782–786, Jun. 10.1192/bjp.150.6.782 Engindeniz N (1996) Edinburgh Doğum Sonrası Depresyon Ölçeği’nin Türkçe Formu için Geçerlilik ve Güvenirlilik Çalışması. Ege Üniversitesi, İzmir Öner N, Le Compte A (1983) Süreksiz durumluk /sürekli kaygı envanteri el kitabı, 1st edn. Boğaziçi Üniversitesi Yayını, İstanbul Brockington IF et al (2001) A Screening Questionnaire for mother-infant bonding disorders, Arch Womens Ment Health , vol. 3, no. 4, pp. 133–140, Mar. 10.1007/s007370170010 Yalçın SS, Örün E, Özdemir P, Mutlu B, Dursun A (2014) Türk Annelerde Doğum Sonrası Bağlanma Ölçeklerinin güvenilirliği, Çocuk Sağlığı ve Hastalıkları Dergisi , vol. 57, pp. 246–251 Cameron EE, Joyce KM, Delaquis CP, Reynolds K, Protudjer JLP, Roos LE (2020) Maternal psychological distress & mental health service use during the COVID-19 pandemic, J Affect Disord , vol. 276, pp. 765–774, Nov. 10.1016/j.jad.2020.07.081 Davenport MH, Meyer S, Meah VL, Strynadka MC, Khurana R (Jun. 2020) Moms Are Not OK: COVID-19 and Maternal Mental Health. Front Glob Womens Health 1. 10.3389/fgwh.2020.00001 Hessami K, Romanelli C, Chiurazzi M, Cozzolino M (2022) COVID-19 pandemic and maternal mental health: a systematic review and meta-analysis, The Journal of Maternal-Fetal & Neonatal Medicine , vol. 35, no. 20, pp. 4014–4021, Oct. 10.1080/14767058.2020.1843155 Kerker BD, Willheim E, Weis JR (2023) The COVID-19 Pandemic: Implications for Maternal Mental Health and Early Childhood Development, American Journal of Health Promotion , vol. 37, no. 2, pp. 265–269, Feb. 10.1177/08901171221140641b Lautarescu A, Craig MC, Glover V (2020) Prenatal stress: Effects on fetal and child brain development, pp. 17–40. doi: 10.1016/bs.irn.2019.11.002 Schaming C, Wendland J (Feb. 2023) Postnatal mental health during the COVID-19 pandemic: Impact on mothers’ postnatal sense of security and on mother-to-infant bonding. Midwifery 117:103557. 10.1016/j.midw.2022.103557 Layton H, Owais S, Savoy CD, Van Lieshout RJ (Jul. 2021) Depression, Anxiety, and Mother-Infant Bonding in Women Seeking Treatment for Postpartum Depression Before and During the COVID-19 Pandemic. J Clin Psychiatry 82(4). 10.4088/JCP.21m13874 Fernandes DV, Canavarro MC, Moreira H (Sep. 2021) Postpartum during COVID-19 pandemic: Portuguese mothers’ mental health, mindful parenting, and mother–infant bonding. J Clin Psychol 77(9):1997–2010. 10.1002/jclp.23130 Suzuki S (May 2022) Psychological status of postpartum women under the COVID-19 pandemic in Japan. J Maternal-Fetal Neonatal Med 35(9):1798–1800. 10.1080/14767058.2020.1763949 Mayopoulos GA et al (2021) COVID-19 is associated with traumatic childbirth and subsequent mother-infant bonding problems, J Affect Disord , vol. 282, pp. 122–125, Mar. 10.1016/j.jad.2020.12.101 Özel CS, Bilir RA, Şenkal E, Telatar TG, Turgut A (1971) The effect of COVID-19 during pregnancy on postpartum depression and mother-infant attachment, Irish Journal of Medical Science ( vol. 194, no. 3, pp. 1039–1048, Jun. 2025. 10.1007/s11845-025-03928-1 Pereira TRC, De Souza FG, Beleza ACS (Jan. 2017) Implications of pain in functional activities in immediate postpartum period according to the mode of delivery and parity: an observational study. Braz J Phys Ther 21(1):37–43. 10.1016/j.bjpt.2016.12.003 Rendón Quintero E E and, Rodríguez-Gómez R (Jul. 2016) La importancia del vínculo en la infancia: entre el psicoanálisis y la neurobiología. Ciencias de la Salud 14(2):261–281. 10.12804/revsalud14.02.2016.10 Tohme P, Abi-Habib R, Nassar E, Hamed N, Abou-Ghannam G, Chalouhi GE (2022) The Psychological Impact of the COVID-19 Outbreak on Pregnancy and Mother-infant Prenatal Bonding, Matern Child Health J , vol. 26, no. 11, pp. 2221–2227, Nov. 10.1007/s10995-022-03464-9 Babu MS, Chan SJ, Ein-Dor T, Dekel S (2022) Traumatic childbirth during COVID-19 triggers maternal psychological growth and in turn better mother-infant bonding, J Affect Disord , vol. 313, pp. 163–166, Sep. 10.1016/j.jad.2022.06.076 Iyengar U, Jaiprakash B, Haitsuka H, Kim S (2021) One Year Into the Pandemic: A Systematic Review of Perinatal Mental Health Outcomes During COVID-19, Front Psychiatry , vol. 12, Jun. 10.3389/fpsyt.2021.674194 Diamond RM, Brown KS, Miranda J (2020) Impact of COVID-19 on the Perinatal Period Through a Biopsychosocial Systemic Framework, Contemp Fam Ther , vol. 42, no. 3, pp. 205–216, Sep. 10.1007/s10591-020-09544-8 Handelzalts JE, Hairston IS, Levy S, Orkaby N, Krissi H, Peled Y (May 2022) COVID-19 related worry moderates the association between postpartum depression and mother-infant bonding. J Psychiatr Res 149:83–86. 10.1016/j.jpsychires.2022.02.039 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePregnancy and the postnatal period are different for each woman and are part of the natural cycle of life. They typically bring joy and excitement, along with significant changes and challenges. During this time, women experience hormonal, physical, and social shifts changes.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eWomen are at risk of mental health disorders during the perinatal period, which extends from pregnancy to one year postpartum birth.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Symptoms of depression and anxiety are especially common during pregnancy.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Approximately 40 percent of women experience their first depressive episode during the postnatal period, while around 33 percent experience it during pregnancy.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Postpartum depression is the most common complication of childbirth[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and it adversely impacts the role of motherhood in many ways.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] A strong link has been identified between postpartum depression and anxiety.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Despite numerous studies conducted in recent years on postpartum depression, anxiety during pregnancy and after childbirth has been relatively understudied.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e Attachment is defined as an emotional bond that develops between a child and their caregiver, characterized by the child's search for closeness with the caregiver, which becomes especially evident in stressful situations, and shows consistency and stability.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Interfering with a newborn baby's interaction with its mother, separating the baby from her, and fearing for the baby's well-being can hinder the development of a strong bond between mother and baby and make mother-baby bonding more difficult process.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Research indicates that postpartum depression and anxiety serve as risk factors for mother-infant attachment disorders.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Disruption in the mother-infant relationship also has a lasting impact on the infant.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] These effects also encompass long-term negative consequences such as delayed mental development in children.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eExtremely stressful situations such as emergencies, conflicts, and natural disasters can increase the risk of perinatal mental health issues morbidity.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] During the COVID-19 pandemic, which was declared a global health crisis, the quarantine and isolation measures implemented caused intense fear, anxiety, feelings of uncertainty, disruption of daily routines, and changes in social relationships among expectant mothers or new mothers.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] Furthermore, the amount of stress they experienced during the pandemic has also increased.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] The difficulty of maintaining mental well-being while infected during the pandemic, combined with the challenges of pregnancy and childbirth, has made managing infected pregnant women during and after delivery even more important.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] It is possible that pregnant women experiencing more severe illness, reported premature births, and maternal and infant mortality have impacted their mental wellbeing.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] The procedures related to the method of delivery and postnatal infant care have changed during the pandemic period due to new recommendations.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Following studies indicating that COVID-19 infection can be transmitted to the baby through vaginal fluid, research has been published recommending that cesarean delivery be prioritized over vaginal delivery.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Although transmission of SARS-CoV-2 through breast milk is unlikely, some infected women have chosen to temporarily refrain from breastfeeding to avoid direct contact with their newborns and reduce the risk of neonatal infection.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] Additionally, the Centers for Disease Control and Prevention (CDC) has recommended temporarily separating newborns from mothers who have tested positive for COVID-19 or are suspected of having it to reduce the risk of transmission newborn.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] Hospitals have implemented policies to decrease infection rates while maintaining postnatal healthcare services, which has resulted in a decline in the quality of maternity care.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] These established policies have been stricter for mothers who have tested positive for COVID-19 or are suspected of having it.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] Parental experiences have indicated that practices diverging from the WHO's recommendations for quality birth care were quite common during the pandemic.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe aim of our study is to compare women who gave birth while infected with COVID-19 to women who gave birth under healthy conditions during the COVID-19 pandemic, focusing on depression, anxiety, and mother-infant bonding levels experienced during the postpartum period. Given that the pandemic period itself was a significant source of stress due to strict measures, fear, uncertainty, and changes in daily routines and social interactions, it is expected that mothers' postpartum depression and anxiety levels, as well as their bonding process with their babies, would be influenced by the pandemic. This effect is likely to be more pronounced in women who gave birth while testing positive for COVID-19.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 107 postpartum women, including 53 with positive COVID-19 test results and 54 with negative test results, who gave birth during the pandemic period (December 2021\u0026ndash;June 2022) at Derince Education and Research Hospital, were included. All women in both groups delivered via cesarean section. Patients in both groups were women who gave birth between December 2021 and June 2022 and were subsequently admitted to the obstetrics and gynecology service during the first few days postpartum.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients who met the inclusion criteria were asked to complete a sociodemographic information form regarding pandemic-related variables, the Edinburgh Postpartum Depression Scale (EPDS), the State-Trait Anxiety Inventory (STAI) I-II, and the Postpartum Bonding Questionnaire (PBQ) during their postpartum hospitalization, with their consent obtained. Pregnant women whose babies had to be admitted to intensive care for reasons unrelated to COVID-19 or who experienced complications unrelated to pregnancy or childbirth were not included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were asked to complete a sociodemographic information form prepared by the researchers, which included questions related to the pandemic process.\u003c/p\u003e\n\u003cp\u003eEdinburgh Postnatal Depression Scale (EPDS): Developed for screening purposes to identify the risk of depression in women during the postnatal period. It is a self-assessment scale consisting of 10 items covering the individual\u0026apos;s psychological state over the past seven days. A high total score indicates the severity of depression.[34]\u003csup\u003e\u0026nbsp;\u003c/sup\u003e Engindeniz conducted the Turkish adaptation of this scale, developed by Cox et al. (1987), to assess the risk of postpartum depression (1996).[35]\u003c/p\u003e\n\u003cp\u003eState-Trait Anxiety Inventory (STAI): Developed by Spielberger and colleagues, this inventory has two subscales, each containing 20 questions: one for trait anxiety and one for state anxiety. It is suitable for individuals aged 14 and older. The State Anxiety Scale (STAI-I) measures how a person feels at a specific moment under particular conditions, while the Trait Anxiety Scale (STAI-II) assesses how a person feels regardless of their current situation or conditions. The cut-off score is 40 for STAI-I and 37 for STAI-II. The Turkish version was adapted by \u0026Ouml;ner and Le Compte (1983), and validity and reliability studies were conducted.[36]\u003c/p\u003e\n\u003cp\u003ePostpartum Bonding Questionnaire (PBQ): Developed by Brockington and colleagues to identify early problems in the mother-infant relationship, it is completed by the mother. The scale has four subscales and a total of 25 questions: \u0026quot;attachment disorder\u0026quot; (12 items), \u0026quot;rejection and irritability\u0026quot; (seven items), \u0026quot;tension regarding care\u0026quot; (four items), and \u0026quot;risk of abuse\u0026quot; (two items). The scale includes 25 items, with 17 being reverse-scored, and as the score for each subscale increases, the risk associated with that area rises. Similarly, an increase in the total score indicates a decline in the quality of attachment.[37] Yal\u0026ccedil;ın et al. conducted a validity and reliability study of the scale in Turkish (2014).[38]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was carried out using SPSS 25 software. The data was examined, and no errors in data entry were found. Missing value checks were also performed, and no missing data was detected. For data analysis, frequency and percentage distributions, descriptive statistics, and group comparisons were conducted. The independent groups t-test, a parametric method, was used to assess the relationship between variables, along with Pearson\u0026apos;s correlation, also a parametric method. All statistical tests were performed at a 95% confidence level, meaning a significance threshold of p\u0026lt;.05.\u003c/p\u003e\n\u003cp\u003eThe independent groups t-test was employed to compare patients\u0026apos; attachment disorder, depression, and anxiety scores based on their COVID-19 pcr test results. This test compares the means of continuous variables (scale scores) between two groups defined by an independent variable (COVID-19 pcr test result). The key assumptions for this method are that the sample size exceeds 30 (N\u0026gt;30), and that the scores are normally distributed; these assumptions were satisfied.\u003c/p\u003e\n\u003cp\u003eThe reliability of the scales used in this study was assessed with Cronbach\u0026apos;s alpha coefficient. The Postpartum Attachment Scale demonstrated a reliability coefficient of 0.977, the Edinburgh Postnatal Depression Scale scored 0.956, and the STAI I-II scored 0.935. Overall, the scales used are highly reliable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Clinical Research Ethics Committee of Derince Education and Research Hospital, with decision number 2021-137 dated 12/23/2021. The study was carried out in accordance with the Declaration of Helsinki Principles.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included a total of 107 postpartum women who gave birth during the pandemic at Derince Training and Research Hospital. 50.5% (n=54) tested negative for COVID-19 PCR, while 49.5% (n=53) tested positive. No significant difference was observed between the groups regarding mean age (p=0.530). Women who reported that their pregnancy was planned were significantly more common among those with negative COVID-19 PCR tests compared to those with positive tests (p=0.000). Increased duration of staying at home and inability to continue working were more prevalent in both groups; however, there was no statistically significant difference between them (p=0.588 and p=0.719). Regarding sources of information about the COVID-19 pandemic, women with negative COVID-19 PCR tests were more likely to obtain information from healthcare workers, while women with positive tests more often obtained information from other people, with a statistically significant difference between the groups. Additionally, a significantly higher proportion of women with positive COVID-19 PCR tests had a relative who died due to COVID-19 compared to those with negative tests. (Table 1)\u003c/p\u003e\n\u003cp\u003eTable 1. Comparison of Variables Related to COVID-19 Infection\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"563\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNegative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePositive\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ef(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ef(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge\u0026nbsp;(mean\u0026plusmn;sd)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28,8\u0026plusmn;5,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31,0\u0026plusmn;5,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0,530\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eTime spent at home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIt hasn\u0026apos;t changed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9(16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11(20,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0,588\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIncreased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45(83,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42(79,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eUnable to Continue Working\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIt didn\u0026apos;t work out.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17(31,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15(28,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0,719\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIt did work out.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37(68,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38(71,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWays to obtain information about COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eFrom the internet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9(16,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0,965\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45(83,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44(83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eOn television\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23(42,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(35,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0,475\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31(57,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34(64,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eFrom People\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17(31,5)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3(5,7)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37(68,5)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50(94,3)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eHealthcare Workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33(61,1)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47(88,7)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21(38,9)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6(11,3)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eAcquaintance Who Has Had COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8(14,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4(7,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0,234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46(85,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49(92,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eAcquaintance Who Died From COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38(70,4)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(35,8)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e,000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16(29,6)a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34(64,2)b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ep:chi-square signidicance value; a,b: For significant chi-square results, the Bonferroni correction indicates which column the difference relates to between groups, with different lowercase letters indicating a significant difference between those groups.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics for the PBQ, EPBS, and STAI scales and their subscales are shown in Table 2.\u003c/p\u003e\n\u003cp\u003eTable 2. PBQ, EPDS, and STAI scores based on COVID-19 infection status\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"540\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 128px;\"\u003e\n \u003cp\u003eScale Scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 74px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 74px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003emean\u0026plusmn;sd\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003emean\u0026plusmn;sd\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003eAttachment Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e4,3\u0026plusmn;3,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e18,1\u0026plusmn;16,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-6,098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e,000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003eRejection and Irritability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e1,2\u0026plusmn;2,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e10,8\u0026plusmn;11,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-6,186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e,000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003eTension Regarding Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e2,4\u0026plusmn;2,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e8,2\u0026plusmn;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-5,879\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e,000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003eRisk of Abuse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e0,04\u0026plusmn;0,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e1,8\u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-6,35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e,000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003ePostpartum Bonding Questionnaire Total Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e7,9\u0026plusmn;6,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e39\u0026plusmn;35,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-6,256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e,000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003eEPDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e6,8\u0026plusmn;5,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e14,6\u0026plusmn;10,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-4,952\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e,000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003eSTAI-I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e31,3\u0026plusmn;8,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e54,4\u0026plusmn;21,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-7,271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e,000*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 128px;\"\u003e\n \u003cp\u003eSTAI-II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e46,5\u0026plusmn;4,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117px;\"\u003e\n \u003cp\u003e47,1\u0026plusmn;3,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e-0,729\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0,467\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eT test,\u0026nbsp;\u003cstrong\u003e\u003cem\u003e*p\u0026lt;.05\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ePBQ:\u0026nbsp;Postpartum Bonding Questionnaire, EPDS: Edinburgh Postpartum Depression Scale, STAI: State-Trait Anxiety Inventory\u003c/p\u003e\n\u003cp\u003eIn patients with a negative COVID-19 PCR test, there is a positive and moderately significant correlation between PBQ and EPDS (r=0.436) and also STAI-I (r=0.403) scores (p\u0026lt;0.05). In patients with a positive COVID-19 PCR test, there is a positive and highly significant relationship between the PBQ total score and the EPDS and STAI-I scores (p\u0026lt;0.01). Women with a positive COVID-19 PCR test showed a positive and moderately statistically significant relationship (p\u0026lt;.05) between their STAI-II and PBQ (r=0.460), EPDS (r=0.426), STAI-I (r=0.426) scores. However, no significant relationship was found in women with a negative COVID-19 PCR test result. Additionally, there is a positive and highly significant correlation between EPDS and STAI-I scores in both patients with negative and positive COVID-19 PCR tests\u0026mdash;in order; r=0.713, p\u0026lt;0.01; r=0.951, p\u0026lt;0.01. (Table 3)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. Correlation Table Between Attachment, Depression and Anxiety Scores\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"473\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eScale Scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003eCovid Negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.\u0026nbsp;Attachment All\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.\u0026nbsp;Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,436*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3.\u0026nbsp;Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,403*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,713**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.\u0026nbsp;Continuity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0,116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0,013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-0,014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003eCovid Positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.\u0026nbsp;Attachment All\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.\u0026nbsp;Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,954**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3.\u0026nbsp;Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,943**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,951**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.\u0026nbsp;Continuity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,460*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,426*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e,426*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e*p\u0026lt;.05;**p\u0026lt;.01\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this study is to compare the levels of depression, anxiety, and maternal attachment among women who gave birth during the COVID-19 pandemic, depending on whether or not they had COVID-19. Studies show that women who gave birth during the pandemic experienced higher levels of depression and anxiety compared to before the pandemic.[39], [40], [41], [42] Considering that prenatal stress increases the risk of neurodevelopmental disorders and a number of emotional, behavioral and/or cognitive problems in later life, it can be predicted that the COVID-19 pandemic may also negatively affect mother-baby bonding.[43] So far, studies have compared mothers\u0026apos; stress levels and mother-infant interactions during the pandemic with those before it bonding.[44], [45], [46], [47] These studies have conflicting results. Some show that the mother-infant bond is of lower quality compared to the pre-pandemic period. [46], [47] There are also studies showing that the mother-baby bond was not affected during the pandemic.[44], [45] Compared to the pre-pandemic period, a study also showed that during the COVID-19 pandemic, mothers experienced more intense acute stress responses during childbirth, which caused disruptions in their postnatal bonding with their babies.[48] When the literature was reviewed, a study was found that examined postpartum women who had COVID-19 infection in the last two trimesters of pregnancy and postpartum women who had no history of COVID-19 infection during pregnancy in terms of depression and mother-baby bonding, and showed that having COVID infection during pregnancy did not affect mother-baby bonding.[49] However, no study has been identified that examines the impact of childbirth while COVID-19 PCR positive during the pandemic on maternal depression, anxiety, and the bond formed with the baby.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, the attachment disorder score was significantly higher in women who gave birth while infected with COVID-19 compared to those who tested negative for COVID-19 PCR. Pain, weakness, fatigue, and limited or slowed movement after a cesarean section may prevent mothers from meeting all of their baby\u0026rsquo;s needs on their own and in a timely manner.[50] In this situation, mothers\u0026apos; feelings of inadequacy and inability to cope may hinder bonding with their baby. Specifically, in mothers affected by COVID-19, more severe illness-related pain, weakness, and fatigue may have caused greater challenges in caring for and meeting the baby\u0026apos;s needs. Additionally, infected postpartum women face extra stressors such as separation from their baby and the uncertain health outcomes of COVID-19 infection for both mother and infant. Considering that increased postpartum stress may negatively affect mother-baby bonding, the attachment disorder score in our study may have been higher in puerperal women with a positive COVID-19 PCR test for this reason.[14] \u0026nbsp;It has been shown that in the first days after birth, mothers can develop a way of identifying their own child\u0026apos;s needs through physical and visual contact, indicating that the mother-infant bond has been successfully established.[51]. In our study, attachment disorder scores were higher in mothers who gave birth while infected with COVID-19 compared to healthy pregnant women due to the greater disruption of physical and visual contact. There are also studies that contradict our findings. One study suggests that COVID-19-related stress may have triggered defensive strategies, leading to greater investment in attachment, thus increasing prenatal attachment.[52] Similarly, a study shows that psychological growth results in more secure attachment in women who have experienced traumatic births during the pandemic. [53]\u003c/p\u003e\n\u003cp\u003eIn addition to studies highlighting increased anxiety and depression symptoms in the postpartum period during the pandemic compared to the pre-pandemic period, our study found that depression and anxiety symptoms were more severe in women who gave birth during this time infected.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[44], [45], [46] Additionally, in our study the group with a positive COVID-19 PCR test preferred to get information about the pandemic from other people, while the uninfected group preferred to obtain information from healthcare professionals. Pregnant women with a positive COVID-19 PCR test had more acquaintances who died from the infection. This may have increased their anxiety when they became infected themselves. In our study, the average continuity anxiety scores were above the cut-off point in both groups and showed no statistically significant difference between them. This could be because both groups consisted of pregnant women who gave birth under generally similar difficult conditions during the pandemic. Other studies have also shown that giving birth alone during the pandemic, with restrictions on companions, reduced perceived emotional support and increased depression and anxiety rates.[54], [55]\u003csup\u003e\u0026nbsp;\u003c/sup\u003e In a study by Handelzalt and colleagues (2022) examining the effect of COVID-19-related anxiety on postpartum depression and mother-infant bonding, it was found that the link between postpartum depression and impaired bonding was stronger in women with high anxiety levels, while bonding was unaffected by postpartum depression in other women.[56]\u003csup\u003e\u0026nbsp;\u003c/sup\u003e Additionally, in our study, a moderate relationship was found between depression and attachment disorde, as well as state anxiety level and attachment disorder, in women with a negative COVID-19 PCR test; however, a strong relationship was found in women with a positive COVID-19 test. We believe that the stricter hospital protocols related to childbirth (mode of delivery, breastfeeding, temporary separation from the baby, early skin-to-skin contact, visitor restrictions) in cases of COVID-19 infection may have increased stress-related psychological symptoms (anxiety, depressive complaints), thereby potentially affecting attachment.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e[33] Additionally, the continuity anxiety score showed a statistically significant positive correlation with attachment, depression, and state anxiety scores in postpartum women who tested positive for COVID-19 via PCR, while no such relationship was observed in women with a negative COVID-19 PCR test. This may indicate that general anxiety levels will have a more negative impact on depression and attachment in the presence of a negative life event (such as having an infection). A strong and statistically significant correlation was found between the state anxiety score and depression in postpartum women regardless of their COVID-19 PCR results. This finding underscores the strong link between postpartum depression and anxiety symptoms. While the current anxiety level shows a strong relationship with depression, regardless of the COVID-19 PCR test result, the fact that the relationship between current anxiety level-attachment disorder and depression-attachment disorder is stronger in those with a positive PCR test suggests that the mother-baby bond is more durable than depression and anxiety symptoms because it has many emotional, psychological, sociological and cognitive aspects, and its influence from external factors may be limited.[7]\u0026nbsp;\u003c/p\u003e\u003cp\u003eLimitations\u003c/p\u003e\n\u003cp\u003eThis study is based on a cross-sectional assessment and was conducted at a single clinic. Additionally, although highly reliable and valid, the use of self-report measures and the lack of clinical or structured diagnostic interviews are also limitations. There is a need for prospective studies with larger sample sizes to explore the long-term effects of the intense stress experienced by women who had to give birth under strict precautions during the pandemic on bonding and child development.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, maternal anxiety, depression levels, and mother-infant attachment disorder scale scores were found to be higher in women who gave birth while infected with COVID-19 during the pandemic, especially during the peak of the disease, compared to women who gave birth without infection. Furthermore, testing positive for COVID-19 was linked to a stronger relationship between depression, anxiety symptoms, and attachment disorder. This study aims to highlight the additional challenges that mothers of children born to COVID-19-infected mothers may face during pregnancy, delivery, and infant care in our clinical practice during the pandemic. It emphasizes the importance of thoroughly examining the mental, physical, and social difficulties experienced by mothers during this period and the bond they develop with their babies. It is believed that this research will help inform hospital birth policies that prioritize the mother-infant bond in potential future outbreaks.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEPDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEdinburgh Postpartum Depression Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSTAI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eState-Trait Anxiety Inventory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePBQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePostpartum Bonding Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCDC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCenters for Disease Control and Prevention\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the first author, [Merve Dilli G\u0026uuml;rkan], upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and consent to participate:\u003c/strong\u003e The study was approved by the Clinical Research Ethics Committee of Derince Education and Research Hospital, with decision number 2021-137 dated 12/23/2021. The study was carried out in accordance with the Declaration of Helsinki Principles. Informed concent was obtained from all patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e :The authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u003c/strong\u003e The authors declared no potential conflicts of interest for his study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors received no financial support for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e Merve Dilli G\u0026uuml;rkan; \u0026nbsp;literature review, writing of the manuscript\u003c/p\u003e\n\u003cp\u003eErdem G\u0026uuml;rkan: Data collection, writing of the manuscript\u003c/p\u003e\n\u003cp\u003e\u0026Ouml;zlem Yıldız G\u0026uuml;ndoğdu: Design of the study\u003c/p\u003e\n\u003cp\u003eAcknowledgements :Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePinto TM, Samorinha C, Tendais I, Silva S, Figueiredo B (Jan. 2018) Antenatal paternal adjustment and paternal attitudes after infertility treatment. 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J Psychiatr Res 149:83\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jpsychires.2022.02.039\u003c/span\u003e\u003cspan address=\"10.1016/j.jpsychires.2022.02.039\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, pregnancy, maternal anxiety, depression, maternal bonding","lastPublishedDoi":"10.21203/rs.3.rs-7807915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7807915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eGiving birth while infected with COVID-19 during the pandemic has brought additional restrictions and practices, it is important to carefully examine the difficulties this group may have faced.\u003c/p\u003e\u003ch2\u003eAims\u003c/h2\u003e\u003cp\u003eThis study aims to compare women who gave birth while infected with COVID-19 during the COVID-19 pandemic with women who healthily gave birth in terms of depression, anxiety, and mother-infant bonding levels experienced during the postpartum period.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA total of 107 postpartum women, including 53 with positive COVID-19 PCR tests and 54 with negative PCR tests, were included. A clinician administered the following to the patients: a sociodemographic information form, the Edinburgh Postpartum Depression Scale (EPDS), the State-Trait Anxiety Inventory (STAI) I-II, and the Postpartum Bonding Questionnaire (PBQ).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eIn the study, PBQ, EPDS, and STAI-I scores were found to be statistically significantly higher in women who gave birth while infected with COVID-19 compared to those who tested negative for COVID-19 via PCR; however, no significant difference was observed between the groups in terms of STAI-II scores. Additionally, a moderate correlation was observed between EPDS and PBQ scores, and also STAI-I and PBQ scores in women with negative COVID-19 PCR tests, while a strong and statistically significant correlation was seen in women with positive COVID-19 PCR tests.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThis study emphasizes the importance of thoroughly examining the psychological, physical, and social hurdles mothers encounter during this time and the bond they form with their infants. It is believed that this study will help inform hospital birth policies that prioritize the mother-infant bond in future outbreak scenarios.\u003c/p\u003e","manuscriptTitle":"The Effect of Giving Birth While Infected With COVID-19 During the COVID-19 Pandemic on Maternal Anxiety, Depression, and Mother-Infant Bonding: A Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-09 07:07:53","doi":"10.21203/rs.3.rs-7807915/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"77378126-a785-40d3-9caf-c278231fab5c","owner":[],"postedDate":"October 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56002653,"name":"Psychiatry"}],"tags":[],"updatedAt":"2025-10-09T07:07:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-09 07:07:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7807915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7807915","identity":"rs-7807915","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}