The influence of healthcare support and outdoor access on pregnancy-related anxiety and attachment to the unborn baby, during COVID-19 in England

The influence of healthcare support and outdoor access on pregnancy-related anxiety and attachment to the unborn baby, during COVID-19 in England | 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 Article The influence of healthcare support and outdoor access on pregnancy-related anxiety and attachment to the unborn baby, during COVID-19 in England Ezra Aydin, Jessica Frater, Staci Meredith Weiss, Topun Austin, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4751681/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 Limited research has been conducted to evaluate the impact of governmental guidance during the COVID-19 pandemic on prenatal maternal anxiety and maternal-fetal attachment. Using survey data from the UK longitudinal Covid in the Context of Pregnancy, Infancy and Parenting (CoCoPIP) Study, we investigated the impact of perceived healthcare support and access to outdoor space on pregnancy-related anxiety and attachment to their unborn baby. 304 families were recruited during pregnancy (maternal age 17–46 years; between July 2020 and April 2021). Anxiety and attachment in expectant women were measured using the Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R) and the Antenatal Emotional Attachment Scale (AEAS). Findings show reduced healthcare support (p < .001) and access to outdoor spaces (p < .001) coupled with heightened COVID-related depressive symptoms (p < .001) heightened pregnancy-related anxiety (p < .001). In addition, results revealed that the relationship between heightened experience of depressive symptoms and pregnancy related anxiety was moderated by social support (p < .01). No significant associations were found between healthcare support and access to outdoor space in relation to attachment to the unborn baby. These findings are discussed alongside possible avenues for future research as well as recommendations with regard to the need for support for expectant families in the event of future events similar to COVID-19. Health sciences/Medical research/Translational research Health sciences/Health care/Health policy Health sciences/Health care/Public health Earth and environmental sciences/Environmental social sciences/Psychology and behaviour pregnancy attachment anxiety COVID-19 social support financial stability Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction COVID-19 is now firmly established as the most significant new infectious disease seen so far in the 21st century, with the secondary consequences being as significant as the primary impact. Disaster cycles, and population influences go beyond preparing for and responding to the initial impact and immediate aftermath of the pandemic, and researchers are now shifting their attention to the possible lessons to be learnt for future such events. One group of individuals heavily affected by COVID-19, and the associated governmental restrictions and guidance, were expectant parents. The World Health Organisation (WHO) estimates that approximately 10% of pregnant individuals, and 13% of individuals post-birth, experience mental health conditions, with depression being the most prevalent 1 . Existing research within this population has made it apparent that challenges presented by the COVID-19 pandemic exacerbated these existing vulnerabilities, with studies reporting a prevalence for depression and anxiety as high as 25.6–30.5% 2 . To mitigate the rapid spread of COVID-19, the UK government enforced strict “stay at home” guidance, with restrictions and duration varying between England, Wales and Scotland. In England regulations such as social distancing, restricted access to outdoor space and free movement, not socialising with individuals outside of their immediate household and school closures were implemented. In expectant women, these restrictions resulted in elevated mental health symptoms, with stress, anxiety, and depression being especially heightened e.g., 3,4 , and remaining high as the pandemic progressed 5 . Due to concerns about the transmission of the virus during pregnancy and the unknown impact the virus could have on the fetus, changes to healthcare policies were quickly enacted and expectant families accordingly experienced further drastic disruptions to their social, healthcare support and access 6–8 . However, research is beginning to demonstrate that use of the ‘lockdown’ strategy to mitigate the spread of the virus, may have not only negatively impacted the mental health of expectant women but also negatively shaped their experience of parenthood. Persisting poor maternal mental health has been found to compromise the formation of an attachment to the unborn child 9–11 and negatively influence future parenting behaviours, including warmth and responsiveness to the infant 12,13 and consequently long term attachment to the offspring 14,15 . In addition, poor maternal mental health during pregnancy has been demonstrated to alter maternal neuroendocrine and inflammatory processes and in turn early neurological development of the fetus, contributing to risk for psychopathology in offspring 16–18 . Hence, it is important to identify factors related to COVID-19 governmental restrictions and guidance that may have heightened feelings of anxiety, stress and depression, as well as reduced the capacity for parents to form a bond with their unborn child. Expectant parents typically experience greater healthcare needs, mental health concerns and economic considerations to support their transition to parenthood. The potential effect of restrictions to these factors (e.g., social distancing and restricted access to outside space) combined with a general lack of considerations and guidance resulted in significantly lower levels of prenatal attachment demonstrated in other global populations 9–11 . Research aiming to quantify the influence of the pandemic on the mental health of pregnant women should be considered not only in the light of varying samples and methods, disparities in socio-economic factors amongst families, and varying subjective experiences of pregnancy between women, but also considering differences in governmental restrictions and healthcare provisions. Amongst imposed disruptions to daily life and additional stressors, there was a distinct lack of guidance for pregnant women throughout the pandemic 13 . Initially, only 1.7% of COVID-19 -related trials were pregnancy specific 19 . This manifested in uncertainty surrounding the dangers of contracting the virus whilst pregnant 20 and reports of heightened depressive and anxiety symptoms compared to pre- COVID-19 cohorts 3,4 . COVID-19 specific pregnancy worries were prevalent, including fear of vertical transmission of the virus to the fetus 4,21 , limited access to healthcare services 8,21 , not having their partner with them at birth 22,23 , and worries about the transition to parenting 6 . Social support is known to alleviate the emotional and physical pressures during this period. The positive effects of social support have been observed during labour (i.e., spontaneous vaginal birth) 24 , diminish postnatal depression 25 and influence the duration of breastfeeding 25,26 . Overall social support has been consistently highlighted as a ‘protective factor’ against decreased mental health, in both pre- and pandemic literature 27,28 . During the pandemic expectant women consistently reported feelings of isolation and loneliness, balancing the desire for social support (from relatives, friends, and healthcare professionals) with staying safe 8 . For some, this resulted in general worries about pregnancy or parenting not being normalised 7 due to limited medical appointments during the pandemic 29 of which most were moved to online platforms 30 . Indicating the vulnerability and sensitivity of this population to the restrictions. A study conducted by Zou et al 31 in the USA found decreased social support in expectant women was associated with poor mental health, however this was mitigated via virtual means of social support (e.g., video calls). Additional research from China 32 , found that risk perception (i.e., risk of COVID-19) played a mediating role between social support and feelings of anxiety during the third trimester of pregnancy. However, it should still be noted that some expectant women in Korea 33 and Australia 29 found the reduced social contact to be a positive experience, due to the availability of more time to spend with their family and bond with their unborn baby. The disparity in findings may be attributed to the differences in country specific governmental guidance and restrictions throughout the pandemic. In addition to social support, pre- COVID-19 research demonstrated the benefits that access to nature has on both physical (i.e., increased cardiovascular and respiratory health 34 ) and mental health (i.e., lower levels of stress and anxiety 34 ). In pregnancy the surrounding greenness and distance to outdoors space has been found to have a modifying effect on low birth weight and preterm birth, suggesting a potential physiological impact of outdoor space on pregnancy outcomes and fetal growth 35 . In England, the guidance during COVID-19 allowed the public to exercise outdoors once a day (within an 8km radius (or local area) from their homes 36 ) with contact restricted to members of their household. In this context, it has been suggested that these restrictions surrounding access to outdoor space may have contributed to worse mental health outcomes 37 . For example, during the pandemic within a German and Swiss cohort, expectant parents' access to outdoor space was implicated as a protective factor against prenatal stress and anxiety during pregnancy 38 . It must be notes that Germany guidance advised a 15km radius 39 and in Switzerland no specific radius was given. However, research to date, has not examined the influence restriction of outdoor access had on maternal attachment and bonding to their unborn child. Furthermore, pre- COVID-19, research also highlighted the influence of socioeconomic factors on access to outdoor space and nature resources – individuals with higher incomes having greater access to outdoor spaces 40 , whilst more vulnerable populations, especially those living in large cities, often have limited access to natural spaces such as parks. Taken together, these findings suggest that potential socioeconomic disparities could have been exacerbated by governmental guidance during the pandemic, further influencing mental health and prenatal experiences for expectant families living in deprived areas. Last, in England ‘stay-at-home’ restrictions also resulted in experiences of financial instability 6,41 , including worries about job loss or decreases in household income 42 . This is of concern, as pre-pandemic studies have associated extreme financial or housing insecurity with adverse perinatal outcomes, including low birth weight and higher likelihood of admittance to intensive care 43 which in turn, increases the likelihood of later developmental delay in offspring 44 . Previous findings from the Covid in the Context of Pregnancy, Infancy and Parenting (CoCoPIP) cohort found that expectant women in England faced a number of significant changes and challenges to their healthcare 45 , pregnancy and expectations around giving birth 45 . Drawing on data from the same cohort, we aimed to explore the relationship between COVID-19-related anxiety, experiences of prenatal attachment and how factors relating to the ‘stay-at-home’ restrictions imposed by the government (i.e., perceived healthcare support, access to outdoor space and socioeconomic factors) may have heightened pregnancy-related anxiety during the pandemic and influenced their attachment to their unborn child. Methods Participants Survey data from the CoCoPIP study was taken from the period of July 2020 – April 2021. A total of 2084 families were followed during the pandemic, including 888 expectant parents and 1196 new parents. The current study considers a sub-sample of these participants (n = 304, see Fig. 1 ), including participants who ( 1 ) were in their second or third trimester and ( 2 ) located in England. Due to the differences in restrictions and guidance between England, Wales and Scotland this study only utilises those families residing in England at the time of their response to the survey. All participants gave informed consent to take part in the CoCoPIP online survey ( https://www.pipkinstudy.com/covid ) 46 . Ethics approval for the survey was given by the University of Cambridge, Psychology Research Ethics Committee (PREC) (PRE.2020.077). All experiments were performed in accordance with relevant guidelines and regulations. Procedure The CoCoPIP survey used a mixed-methods approach, in which both quantitative and qualitative data was collected. This survey was logic-dependent and adaptive, only showing questions relevant to the parent’s current situation (i.e., first trimester/second trimester/infant aged 0–3/3–6 months). For the full survey, response time was ~ 30 minutes and respondents were included in a £100 gift card prize draw (for full survey see Aydin, Weiss, et al., 2021 46 ). As part of this survey, parents or caregivers (including adoptive parents, same sex partners etc) were asked to complete two validated questionnaires ( 1 ) the Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R) with additional COVID-19 specific pregnancy questions, ( 2 ) the Antenatal Emotional Attachment Scale (AEAS) that captured the nature of the relationship between an expectant parent with their unborn baby, separate from attitudes to pregnancy or motherhood 37 and ( 3 ) the Impact of Event Scale-Revised (IES-R) to observe anxiety related to COVID-19 at the time of participation in study. Standardised scoring for all measures was used. In addition, we assessed perceived antenatal healthcare support, social support, and access to outdoor space (see Fig. 2 ). Analysis Analyses were carried out in SPSS v29. Hierarchical multiple regression analyses were used to assess the directional relationships between the variables of interest. For standardised questionnaires (PRAQ and AEAS), missing values of individual items were imputed with the mean of the other item responses provided by the participant, with a maximum of ¼ missing responses being acceptable for being included in the dataset. Moderators Social support and financial instability were explored as potential moderators within the model – social support was assessed by combining responses from three questions addressing (a) support from spouse/partner, (b) support from friends and family, and (c) difficulty in separation from these loved ones due to lockdown to create a total score. Financial instability was assessed using combined responses from two questions, addressing (a) changes to financial or housing situation due to COVID-19, and (b) difficulty coping with the financial impact of COVID-19 (see Fig. 2 for questions). Moderation analyses were performed using SPSS PROCESS macro (Hayes, 2013). The variables were mean centred (in related to total sample) prior to the moderated mediation analyses. The number of bootstrap samples for the bias-corrected bootstrap confidence intervals (CIs) was 5000. The present study used Model 21 in PROCESS to test the moderated mediation analysis. Scoring ( 1 ) For perceived antenatal healthcare support, participants' responses were scored on a 5-point scale ranging from 1 (I do not feel supported at all) to 5 (I feel extremely supported). ( 2 ) For outdoor space, the total number of options selected gave the outside space score per participant. A greater score indicated more access to outdoor space ( see Fig. 1 for questions ). Scores ranged from 0 (no access) to 10 (abundant access). ( 3 ) For social support, questions (a) and (b) were reverse coded so direction of the scales became more intuitive (with a higher score relating to higher degree of social support). Scores for the three questions were summed and averaged, to give the final social support score per participant. ( 4 ) For financial instability, scores from questions (a) and (b) were summed to produce the overall financial instability score, which encompassed participants’ difficulty coping with the financial impact of COVID-19, as well as the number of financial aspects that had been impacted by the pandemic. In response to ‘(a) changes to financial or housing situation due to COVID-19’, participants were able to select multiple answers from multiple options provided, participants would be given a total score out of 9 and ‘(b) difficulty coping with the financial impact of COVID-19’ a max score of 5 was giving in response to one question. Greater scores illustrated greater levels of financial instability, with a range of 1 ( low ) to 14 ( high ). Additional variables Maternal age, household income, participant education, depression diagnosis or symptoms (self-reported from the start of COVID-19 or within the last month) and event related anxiety (measures via the IERS) were used as contextual control variables within the reported analysis ( see Fig. 1 ). Sub analysis A sub-group of participants (n = 105) disclosed their postcodes to researchers. Full postcodes were used to assign an ‘Indices of Multiple Deprivation’ (IMD) utilising UK governmental open data sources ( see Fig. 1 ). Results None of the identified contextual control variables were significantly related to prenatal attachment; maternal age (p = .41), household income (p = .07), participant education level (p = .13), experienced depression (p = .35) and event related stress (p = .20). These variables were still included within the final model as covariates and accounted for 1.9% of the variation in pregnancy-related anxiety (p = .37), and within all models. The main regression analysis to identify the influence of perceived healthcare support and access to outdoor space with prenatal attachment showed a nonsignificant association; ( 1 ) perceived healthcare support accounted for 1.2% of the variance (B = .36, SE = .19, p = .06, CI 95% = − .01 (upper), .73 (lower)) and ( 2 ) access to outdoor space accounted for 0.1% of the variance (B=-.13, SE = .26, p = .61, CI 95% = − .64 (upper), .38 (lower)). In total the final model accounted for 3.1% (Cohens f = .018) of the variance in prenatal attachment level. Initial correlation ( see Fig. 3 ) demonstrated a significant correlation between perceived healthcare support and antenatal attachment (p = .016), when included within the regression this significance did not remain. In addition, social support and financial instability had no moderating effect on this relationship ( see Fig. 3 ). Several identified contextual control variables were significantly related to pregnancy-related anxiety; depression experienced during the pandemic (p = .00), maternal age (p = .05), and participant education level (p = .04) were significantly positively related to pregnancy-related anxiety. No other variables were significantly related. These variables were still included within the final model as covariates, to observe their overall contribution to the final model, and accounted for 10.6% of the variation in pregnancy-related anxiety (p = .00), and within all models. The main regression analysis to explore the influence of perceived healthcare support and access to outdoor space on pregnancy-related anxiety scores revealed a significant association; ( 1 ) perceived healthcare support accounted for 18.5% of the variance (B =-4.06, SE = 1.17, p < .001, CI 95%= -6.36 (upper), -1.76 (lower)) and ( 2 ) access to outdoor space accounted for an additional 6.2% (B=-5.76, SE = 1.55, p < .001, CI 95% = -8.81 (upper) -2.70 (lower)). In total the final model accounted for 24.7% (Cohens f = .57) of the variance in pregnancy-related anxiety. Both variables, lower perceived healthcare support and less access to outdoor space, were associated with higher pregnancy-related anxiety scores. Social support had a significant moderating effect on the relationship between pregnancy-related anxiety and COVID-19 related depression (p = .01). Expectant women who did not report experiencing feelings of depression during COVID-19 showed a negative relationship between pregnancy related anxiety and perceived level of social support, whilst a positive association was observed between these two variables when the individual reported COVID-19-related depression ( see Figs. 3 & 4 ). Within a subsample (n = 105) we explored the influence of Index of Multiple Depreviation (IMD) on the above-mentioned models. Whilst, IMD did not have a significant association with prenatal attachment level, IMD showed a negative correlation with pregnancy-related anxiety (p = .009) adding 3.8% (Cohens f = .61) to the variation in pregnancy-related anxiety (B = -1.28, SE = .57, p = 0.026) with the final model (inc. experienced depression, perceived healthcare support, access to outdoor space and IMD) accounting for 26.8% of the variance in pregnancy-related anxiety score. This suggests that levels of pregnancy-related anxiety decreased as IMD increased (Fig. 4 ). Discussion During this period of global uncertainty, expectant women consistently reported higher levels of anxiety, stress, and depression 2,47 . We sought to identify how the impact of specific changes in public health guidance and governmental restrictions instigated during the pandemic affected pregnancy-related anxiety and prenatal attachment. Our previous qualitative analysis of participants responses highlighted how the changes to healthcare services for pregnant individuals during the pandemic increased feelings of anxiety and left women feeling inadequately supported 22,45 . Here we quantify these descriptions of anxiety during pregnancy, to changes in healthcare services and imposed governmental restrictions to outdoor space. Increased mental health issues were observed globally within this vulnerable population; however, the factors contributing to pregnancy-related anxiety differed across populations mainly due to differing governmental guidance and restrictions. In the USA, COVID-19-related stressors such as food availability, tension/conflict within the home, and fear of COVID-19 infection increased pregnancy-related anxiety 42 . Whilst in Iran predictors of pregnancy-related anxiety were related to COVID-19 practices and guidance (e.g., use of gloves and face masks outdoors and in attendance at public places) as well as social support 48 . Similarly, in Northern Italy 49 , Israel 50 and China 51 perceived social support was significantly associated with reduction in severity of antenatal and postnatal depression and anxiety. Within our UK sample the level of social support had a moderating effect on pregnancy-related anxiety, adding to this body of literature. Perceived social support, acted as a potential ‘protective factor’ reducing pregnancy-related anxiety in expectant women who did not experience COVID-19-related depression. However, this was not reflected in individuals who reported experiencing COVID-19-related depression in which higher levels of social support were also related to high levels of pregnancy related anxiety. Overall, our findings indicate that social support alone in women experiencing COVID-19-related depression was not enough to reduce the level of pregnancy-related anxiety. We also explored financial instability related to COVID-19 as a moderating factor for pregnancy-related anxiety. In the USA, researchers found ‘preparedness stress’ defined as feeling unprepared for the birth (i.e., changes to birth plan) was significantly related to levels of financial instability 52 , with COVID-19-related financial stress being associated with increased likelihood of depression in expectant women 53 . While financial instability was not a moderating factor within our sample, this may be due to the fact that over half our sample reported little to no financial instability. Whilst studies have reported a significant influence of household financial instability during COVID-19 on anxiety and depression 54 , no other studies reported financial instability influencing prenatal attachment within their cohorts. One factor consistently highlighted in studies as mitigating pregnancy-related anxiety was access to outdoor space. Cohorts from Germany and Switzerland reported access to an outdoor space as reducing anxiety, including prenatal and pandemic-related stress in expectant women 38 – and acting as a ‘protective factor’ for pandemic-related pregnancy stress in expectant populations in the USA 38,52 . We add to this body of literature showing that it was not only in relation to whether they had access to outdoor space as previously reported, but also the number of independent outdoor spaces they had access to, such that the level of pregnancy-related anxiety decreased as the individual had access to more of a range of outdoor spaces. This highlights and further supports the potential aggravating effects governmental restrictions related to outdoor accesses had on expectant populations, and the importance of research to observe and quantify the differences (i.e., urban vs rural and socioeconomic influence) to ensure that future policy addresses these issues. During COVID-19, a number of studies identified an association between parity 50 , maternal age, education level and pregnancy-related anxiety. In particular a study from the USA noted expectant women with a ‘less than high school education’ as a significant interaction term 24 . Similar relationships were also observed in a Turkish cohort in relation to prenatal attachment; maternal age, education, parity, and trimester of pregnancy 55 . While we demonstrated a significant relationship between pregnancy-related anxiety, maternal age and education level, these variables did not significantly add to our final model and were included only for clarity. Conversely, we observed a noteworthy influence of IMD on pregnancy-related anxiety. To our knowledge other studies have not explored geographic deprivation as a potential influence on pregnancy-related anxiety or prenatal attachment during COVID-19. Whilst other socio-demographic and economic factors included within the models did not relate to pregnancy-related anxiety, within our England-based population IMD may be a more accurate measure, as it is not reliant on self-report and accounts for multiple factors such as income, employment, education, living environment, health deprivation, disability, crime as well as barriers to housing and services. Our results demonstrated a negative relationship between IMD and pregnancy-related anxiety, suggesting expectant women from more deprived areas experienced higher levels of pregnancy-related anxiety. Last, it is well documented that distress during pregnancy is associated with reduced mother-offspring bonding. During the pandemic various factors were attributed to reduced prenatal and mother-infant bonding. Researchers identified high COVID-19-related anxiety and increased fear of childbirth to have a negative impact on prenatal attachment 11,55,56 . Furthermore, in a UK based sample of 150 expectant women, Filipetti et al. 27 concluded that increased symptoms of depression were associated with reduced levels of attachment, with level of perceived social support serving as a ‘protective factor’ (social support included: spouse/partner, family/friends and healthcare professionals/midwife). Within the current study we did not find any association between experienced depression and prenatal attachment. This could be related to our larger and more selective sample that included expectant women residing in England. In addition, our study began data collection three months after that of Filipetti et al 27 (April 2020 vs Jul 2020 respectively), and thus Filipetti et al. may have tapped in to the initial heightened feelings of depression and prenatal attachment at the start of the pandemic which then declined as the UK population adapted to the healthcare crisis and governmental guidance. Limitations The collected data (July 2020 – April 2021) reflects experiences during a period of unpredictable and fluctuating COVID-19-related government and healthcare restrictions, from the most severe national lockdown measures to a combination of severe to mild national/local restrictions. Due to the rapidly evolving nature of the governmental guidance related to the pandemic and regional variations in between national lockdowns 13 , it was not possible to collect equal sample sizes at each timepoint making us unable to further distinguish the effects of country-wide variance in local lockdown restrictions. Further, the introduction of “tiers” that differed geographically across England could have confounded our data relating to both outside space and social support. Furthermore, as this study was conducted as a voluntary online survey, we cannot independently confirm that all responses were actually from expectant parents or exclude bias in respondents with either positive or negative experiences of their pregnancy. Whilst we advertised this study nationally and specifically worked with national childbirth trusts (NCTs) with an emphasis on areas of low socio-economic status, the majority of participants were white (86.5%), marginally higher than the reported ethnic composition of the population (81.0%, 2021 census 47 ); therefore, caution should be taken when generalising findings to a more ethnically diverse population. Further research is needed to explore the potential mechanisms involved, such as whether these effects are influenced by other factors such as population density or resource access. Implications for practice and research The mitigation measures implemented by the government and the healthcare system throughout the pandemic have had a significant secondary impact on expectant women and families. It is becoming apparent that disaster planners have consistently given much less attention to the need for ongoing supportive care for childbearing aged individuals and young families during disaster recovery as compared to care effort (i.e., protecting elderly and vulnerable populations), during and in the immediate aftermath of a natural disaster 57 . Research consistently identifies expectant women and young families as ‘high risk’ and in need of not only immediate social, mental, and health-care support but continued long-term care and guidance in the aftermath of such an event 58,59 . Going forward, the current findings along with findings from previous natural disaster research show the need for clear and consistent guidance to be in place for expectant women giving birth. This guidance should include the development of health education resources to positively influence the well-being of the pregnant population throughout their pregnancy, implemented within the healthcare policy, as well as preparing and responding to the long-term impact of such events. In addition, the present study provides initial insight into the influence of location-based deprivation and the need for governmental consideration of location when imposing guidance and restrictions. Conclusion To date this is the first study to explore the influence of governmental restrictions in England on expectant parents’ pregnancy-related anxiety and attachment, identifying alongside reduced healthcare support and access to outdoor spaces, that there was an increase in COVID-19 related depressive symptoms and heightened pregnancy-related anxiety. These findings should inform future policy makers in disaster planning for this vulnerable population group. Declarations Competing Interests The authors have no potential conflicts of interest to disclose. Funding This research was funded by a Medical Research Council Programme Grant MR/T003057/1 to MJ, and a UKRI Future Leaders fellowship (grant MR/S018425/1) to SLF. T.A. is supported by the NIHR Cambridge Biomedical Research Centre (BRC), which is a partnership between Cambridge University Hospitals NHS Foundation Trust and the University of Cambridge, funded by the National Institute for Health Research (NIHR). T.A. is also supported by the NIHR HealthTech Research Centre in Brain Injury. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Author Contribution EA: Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Validation, Writing - Original Draft. JF: Investigation, Data Curation, Validation. SMW: Conceptualization, Methodology, Writing - Review & Editing. TA: Methodology, Supervision, Writing - Review & Editing. JB: Supervision, Writing - Review & Editing. MHJ: Supervision, Funding acquisition, Writing - Review & Editing. SLF: Conceptualization, Methodology, Supervision, Funding acquisition, Writing - Review & Editing. The author(s) read and approved the final manuscript. Acknowledgement We are extremely grateful to all those families who gave their time to participate. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Author Accepted Manuscript version arising from this submission. Data Availability Data generated and analysed during the study will not be made publicly available due to ethical and privacy restrictions, however researchers can submit a research proposal to the Data Sharing Management Committee to request access and collaboration. References World Health Organization. Maternal mental health. https://www.who.int/teams/mental-health-and-substance-use/promotion-prevention/maternal-mental-health . Tomfohr-Madsen, L. M., Racine, N., Giesbrecht, G. F., Lebel, C. & Madigan, S. Depression and anxiety in pregnancy during COVID-19: A rapid review and meta-analysis. Psychiatry Res. 300, 113912 (2021). Berthelot, N. et al. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstet. Gynecol. Scand. 99, 848–855 (2020). 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Womens Ment. Health 23, 757–765 (2020). Leifheit, K. M. et al. Severe Housing Insecurity during Pregnancy: Association with Adverse Birth and Infant Outcomes. Int. J. Environ. Res. Public. Health 17, 8659 (2020). Sandoval, V. S., Jackson, A., Saleeby, E., Smith, L. & Schickedanz, A. Associations Between Prenatal Food Insecurity and Prematurity, Pediatric Health Care Utilization, and Postnatal Social Needs. Acad. Pediatr. 21, 455–461 (2021). Aydin, E. et al. Expectant Parents’ Perceptions of Healthcare and Support during COVID-19 in the UK: A Thematic Analysis . http://medrxiv.org/lookup/doi/10.1101/2021.04.14.21255490 (2021) doi:10.1101/2021.04.14.21255490. Aydin, E. et al. The COVID in the Context of Pregnancy, Infancy and Parenting (CoCoPIP) Study: Protocol for a Longitudinal Study of Parental Mental Health, Social Interactions, Physical Growth, and Cognitive Development of Infants during the Pandemic . http://medrxiv.org/lookup/doi/10.1101/2021.05.22.21257649 (2021) doi:10.1101/2021.05.22.21257649. Davenport, M. H., Meyer, S., Meah, V. L., Strynadka, M. C. & Khurana, R. Moms are not ok: COVID-19 and maternal mental health. Front. Glob. Womens Health 1, 1 (2020). Hamzehgardeshi, Z., Omidvar, S., Amoli, A. A. & Firouzbakht, M. Pregnancy-related anxiety and its associated factors during COVID-19 pandemic in Iranian pregnant women: a web-based cross-sectional study. BMC Pregnancy Childbirth 21, 208 (2021). Grumi, S. et al. Depression and Anxiety in Mothers Who Were Pregnant During the COVID-19 Outbreak in Northern Italy: The Role of Pandemic-Related Emotional Stress and Perceived Social Support. Front. Psychiatry 12, 716488 (2021). Chasson, M., Taubman - Ben-Ari, O. & Abu-Sharkia, S. Jewish and Arab pregnant women’s psychological distress during the COVID-19 pandemic: the contribution of personal resources. Ethn. Health 26, 139–151 (2021). Wang, C. et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain. Behav. Immun. 87, 40–48 (2020). Preis, H., Mahaffey, B., Heiselman, C. & Lobel, M. Vulnerability and resilience to pandemic-related stress among U.S. women pregnant at the start of the COVID-19 pandemic. Soc. Sci. Med. 266, 113348 (2020). Thayer, Z. M. & Gildner, T. E. COVID -19‐related financial stress associated with higher likelihood of depression among pregnant women living in the United States. Am. J. Hum. Biol. 33, e23508 (2021). Luo, Y., Zhang, K., Huang, M. & Qiu, C. Risk factors for depression and anxiety in pregnant women during the COVID-19 pandemic: Evidence from meta-analysis. PLOS ONE 17, e0265021 (2022). Department of Gynecology, Training and Research Hospital, Van, Turkey et al. The Relationship Between COVID-19 Fear and Prenatal Attachment of Pregnant Women in the Pandemic. Florence Nightingale J. Nurs. (2022) doi: 10.5152/FNJN.2022.22078 . Schaal, N. K. et al. The influence of being pregnant during the COVID-19 pandemic on birth expectations and antenatal bonding. J. Reprod. Infant Psychol. 41, 15–25 (2023). Phillips, B. & Morrow, B. H. Women and disasters: From theory to practice. No Title (2008). Giarratano, G. P., Barcelona, V., Savage, J. & Harville, E. Mental health and worries of pregnant women living through disaster recovery. Health Care Women Int. 40, 259–277 (2019). King, S., Matvienko-Sikar, K. & Laplante, D. P. Natural Disasters and Pregnancy: Population-Level Stressors and Interventions. in Prenatal Stress and Child Development (eds. Wazana, A., Székely, E. & Oberlander, T. F.) 523–564 (Springer International Publishing, Cham, 2021). doi: 10.1007/978-3-030-60159-1_18 . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4751681","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":335426998,"identity":"26b938f1-74d9-4b4f-beb7-9d08f4d5f46d","order_by":0,"name":"Ezra Aydin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/klEQVRIiWNgGAWjYFAC9gMHEn7YwHgWDAwSjA1ABjMeLTyJDx72pMF4EsRoYTA2fMB2GFkLmIFbCz/7gTSJBJ7z8gbXDj9g+FEhkbh2dnPjB4YK68QGHFokexKPSSRY3DbccDvNgLHnjETitjsHmyUYzqTj1GJwIAFky+0Eg9s5DMyMbUAtNxIbJBjbDuPUYn/+gZlEAts5FC3NPxj/4dZiIJFgbJDAdgBFSxsw0HBrkbjxJvFBYk+y4UygXw4C/WIM9EubRcKxdGNcWvj70w8c/PHDTp7vdvLDBz8qbGS33W5/fONDjbUsLi0o4ACclUCM8lEwCkbBKBgFOAEAQhFig3O3ye0AAAAASUVORK5CYII=","orcid":"","institution":"Columbia University","correspondingAuthor":true,"prefix":"","firstName":"Ezra","middleName":"","lastName":"Aydin","suffix":""},{"id":335426999,"identity":"7aa2aa2d-44b8-42d5-9dfe-95598575239b","order_by":1,"name":"Jessica Frater","email":"","orcid":"","institution":"University of Cambridge","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Frater","suffix":""},{"id":335427000,"identity":"31c3ae12-4e40-478e-8977-b37704670d05","order_by":2,"name":"Staci Meredith Weiss","email":"","orcid":"","institution":"University of Cambridge","correspondingAuthor":false,"prefix":"","firstName":"Staci","middleName":"Meredith","lastName":"Weiss","suffix":""},{"id":335427002,"identity":"cc7c9b31-f0bb-4a45-904c-fb5c821b975d","order_by":3,"name":"Topun Austin","email":"","orcid":"","institution":"Cambridge University Hospitals NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Topun","middleName":"","lastName":"Austin","suffix":""},{"id":335427005,"identity":"b3d7eca7-2ebf-4865-99dd-5c2a7d28264d","order_by":4,"name":"Jane Barlow","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Jane","middleName":"","lastName":"Barlow","suffix":""},{"id":335427006,"identity":"e2ab0fcb-a6e6-4837-86d0-f416c06aa932","order_by":5,"name":"Mark H. Johnson","email":"","orcid":"","institution":"University of Cambridge","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"H.","lastName":"Johnson","suffix":""},{"id":335427007,"identity":"d657dea5-99b4-492a-b55c-1a8e1fe61143","order_by":6,"name":"Sarah Lloyd-Fox","email":"","orcid":"","institution":"University of Cambridge","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Lloyd-Fox","suffix":""}],"badges":[],"createdAt":"2024-07-16 18:06:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4751681/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4751681/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62273709,"identity":"a3d27da7-0b4d-43cd-afab-78f36e6cb021","added_by":"auto","created_at":"2024-08-12 10:49:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":934153,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eParticipant Demographics. \u003c/em\u003e(Top Left) Bubble map depicting spread of participations location in the UK (if postcode was provided) colour coded with respondent’s Index of Multiple Deprivation (IMD). A breakdown of participants, IMD, education level, household income breakdown and ethnicity (Right). Lastly, we provide a visual depiction of participants’ access to total number of outdoors spaces (Bottom Left).\u003c/p\u003e","description":"","filename":"Figure1final.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4751681/v1/3ba70d9fc0a882de57870371.jpg"},{"id":62273299,"identity":"c5c7de89-9445-409f-8958-07c5b5b0b439","added_by":"auto","created_at":"2024-08-12 10:41:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1165226,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eA detailed list of questions and composite scores from participant responses.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4751681/v1/dbf1fce595b75f9e39969214.jpg"},{"id":62273301,"identity":"2fd3d48e-18c7-4552-98a2-aa0db760e10f","added_by":"auto","created_at":"2024-08-12 10:41:31","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":436932,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eConceptual and statistical diagram (*p\u0026lt;.05, **p\u0026lt;.01, ***p\u0026lt;.001)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4751681/v1/c58ba38e6f8d2bbb6c66ce4f.jpg"},{"id":62273708,"identity":"7f251479-6a51-442b-bb3f-8d8d13bda3e3","added_by":"auto","created_at":"2024-08-12 10:49:31","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":738349,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBox plot visualisation of significant associations; \u003c/em\u003e(a) demonstrates a negative relationship between pregnancy related anxiety score and perceived level of healthcare support, the higher the perceived support the lower the pregnancy related anxiety score; (b) demonstrates a individuals who experienced COVID-related depression had higher levels of pregnancy related anxiety; (c) demonstrates a negative relationship between pregnancy related anxiety and number of individual accesses to outdoor spaces, showing more access to outdoor space reduced experienced pregnancy related anxiety; (d) demonstrates the moderating effect of social support on pregnancy related anxiety in individuals who experienced and did not experience COVID-related depression, showing a higher levels of social support to have a moderating effect on pregnancy related anxiety in those who did not experience COVID-related depression, whilst having the opposite effect on those experiencing COVID-related depression. \u003cstrong\u003eWithin our sub-analysis\u003c/strong\u003e, (e) demonstrates a negative relationship between IMD and pregnancy related anxiety, showing individuals residing in areas of higher deprivation (lower IMD score) experiences higher pregnancy related anxiety and (f) demonstrates individuals who have less access to outdoor space experienced higher levels of pregnancy related anxiety, in addition overall those individuals residing in areas of higher deprivation (lower IMD score) consistently demonstrated higher levels of pregnancy related anxiety across the three outdoor access groups. Note: standard error bars given on figures a-e, but for clarity was not included on figure f.\u003c/p\u003e","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4751681/v1/0ba51f3e1c1b32dff0f2927a.jpg"},{"id":68418773,"identity":"233952b1-705d-4d43-a72b-f8d330ae43f5","added_by":"auto","created_at":"2024-11-07 05:39:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3696779,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4751681/v1/48a2fcbb-8808-48f7-90fc-e27408852569.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The influence of healthcare support and outdoor access on pregnancy-related anxiety and attachment to the unborn baby, during COVID-19 in England","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCOVID-19 is now firmly established as the most significant new infectious disease seen so far in the 21st century, with the secondary consequences being as significant as the primary impact. Disaster cycles, and population influences go beyond preparing for and responding to the initial impact and immediate aftermath of the pandemic, and researchers are now shifting their attention to the possible lessons to be learnt for future such events. One group of individuals heavily affected by COVID-19, and the associated governmental restrictions and guidance, were expectant parents.\u003c/p\u003e \u003cp\u003eThe World Health Organisation (WHO) estimates that approximately 10% of pregnant individuals, and 13% of individuals post-birth, experience mental health conditions, with depression being the most prevalent\u003csup\u003e1\u003c/sup\u003e. Existing research within this population has made it apparent that challenges presented by the COVID-19 pandemic exacerbated these existing vulnerabilities, with studies reporting a prevalence for depression and anxiety as high as 25.6\u0026ndash;30.5%\u003csup\u003e2\u003c/sup\u003e. To mitigate the rapid spread of COVID-19, the UK government enforced strict \u0026ldquo;stay at home\u0026rdquo; guidance, with restrictions and duration varying between England, Wales and Scotland. In England regulations such as social distancing, restricted access to outdoor space and free movement, not socialising with individuals outside of their immediate household and school closures were implemented. In expectant women, these restrictions resulted in elevated mental health symptoms, with stress, anxiety, and depression being especially heightened \u003csup\u003ee.g., 3,4\u003c/sup\u003e, and remaining high as the pandemic progressed\u003csup\u003e5\u003c/sup\u003e. Due to concerns about the transmission of the virus during pregnancy and the unknown impact the virus could have on the fetus, changes to healthcare policies were quickly enacted and expectant families accordingly experienced further drastic disruptions to their social, healthcare support and access\u003csup\u003e6\u0026ndash;8\u003c/sup\u003e. However, research is beginning to demonstrate that use of the \u0026lsquo;lockdown\u0026rsquo; strategy to mitigate the spread of the virus, may have not only negatively impacted the mental health of expectant women but also negatively shaped their experience of parenthood.\u003c/p\u003e \u003cp\u003ePersisting poor maternal mental health has been found to compromise the formation of an attachment to the unborn child\u003csup\u003e9\u0026ndash;11\u003c/sup\u003e and negatively influence future parenting behaviours, including warmth and responsiveness to the infant\u003csup\u003e12,13\u003c/sup\u003e and consequently long term attachment to the offspring\u003csup\u003e14,15\u003c/sup\u003e. In addition, poor maternal mental health during pregnancy has been demonstrated to alter maternal neuroendocrine and inflammatory processes and in turn early neurological development of the fetus, contributing to risk for psychopathology in offspring \u003csup\u003e16\u0026ndash;18\u003c/sup\u003e. Hence, it is important to identify factors related to COVID-19 governmental restrictions and guidance that may have heightened feelings of anxiety, stress and depression, as well as reduced the capacity for parents to form a bond with their unborn child. Expectant parents typically experience greater healthcare needs, mental health concerns and economic considerations to support their transition to parenthood. The potential effect of restrictions to these factors (e.g., social distancing and restricted access to outside space) combined with a general lack of considerations and guidance resulted in significantly lower levels of prenatal attachment demonstrated in other global populations\u003csup\u003e9\u0026ndash;11\u003c/sup\u003e. Research aiming to quantify the influence of the pandemic on the mental health of pregnant women should be considered not only in the light of varying samples and methods, disparities in socio-economic factors amongst families, and varying subjective experiences of pregnancy between women, but also considering differences in governmental restrictions and healthcare provisions.\u003c/p\u003e \u003cp\u003eAmongst imposed disruptions to daily life and additional stressors, there was a distinct lack of guidance for pregnant women throughout the pandemic\u003csup\u003e13\u003c/sup\u003e. Initially, only 1.7% of COVID-19 -related trials were pregnancy specific\u003csup\u003e19\u003c/sup\u003e. This manifested in uncertainty surrounding the dangers of contracting the virus whilst pregnant\u003csup\u003e20\u003c/sup\u003e and reports of heightened depressive and anxiety symptoms compared to pre- COVID-19 cohorts\u003csup\u003e3,4\u003c/sup\u003e. COVID-19 specific pregnancy worries were prevalent, including fear of vertical transmission of the virus to the fetus\u003csup\u003e4,21\u003c/sup\u003e, limited access to healthcare services\u003csup\u003e8,21\u003c/sup\u003e, not having their partner with them at birth\u003csup\u003e22,23\u003c/sup\u003e, and worries about the transition to parenting\u003csup\u003e6\u003c/sup\u003e. Social support is known to alleviate the emotional and physical pressures during this period. The positive effects of social support have been observed during labour (i.e., spontaneous vaginal birth)\u003csup\u003e24\u003c/sup\u003e, diminish postnatal depression\u003csup\u003e25\u003c/sup\u003e and influence the duration of breastfeeding\u003csup\u003e25,26\u003c/sup\u003e. Overall social support has been consistently highlighted as a \u0026lsquo;protective factor\u0026rsquo; against decreased mental health, in both pre- and pandemic literature\u003csup\u003e27,28\u003c/sup\u003e. During the pandemic expectant women consistently reported feelings of isolation and loneliness, balancing the desire for social support (from relatives, friends, and healthcare professionals) with staying safe\u003csup\u003e8\u003c/sup\u003e. For some, this resulted in general worries about pregnancy or parenting not being normalised\u003csup\u003e7\u003c/sup\u003e due to limited medical appointments during the pandemic\u003csup\u003e29\u003c/sup\u003e of which most were moved to online platforms\u003csup\u003e30\u003c/sup\u003e. Indicating the vulnerability and sensitivity of this population to the restrictions. A study conducted by Zou et al\u003csup\u003e31\u003c/sup\u003e in the USA found decreased social support in expectant women was associated with poor mental health, however this was mitigated via virtual means of social support (e.g., video calls). Additional research from China\u003csup\u003e32\u003c/sup\u003e, found that risk perception (i.e., risk of COVID-19) played a mediating role between social support and feelings of anxiety during the third trimester of pregnancy. However, it should still be noted that some expectant women in Korea\u003csup\u003e33\u003c/sup\u003e and Australia\u003csup\u003e29\u003c/sup\u003e found the reduced social contact to be a positive experience, due to the availability of more time to spend with their family and bond with their unborn baby. The disparity in findings may be attributed to the differences in country specific governmental guidance and restrictions throughout the pandemic.\u003c/p\u003e \u003cp\u003eIn addition to social support, pre- COVID-19 research demonstrated the benefits that access to nature has on both physical (i.e., increased cardiovascular and respiratory health\u003csup\u003e34\u003c/sup\u003e) and mental health (i.e., lower levels of stress and anxiety\u003csup\u003e34\u003c/sup\u003e). In pregnancy the surrounding greenness and distance to outdoors space has been found to have a modifying effect on low birth weight and preterm birth, suggesting a potential physiological impact of outdoor space on pregnancy outcomes and fetal growth\u003csup\u003e35\u003c/sup\u003e. In England, the guidance during COVID-19 allowed the public to exercise outdoors once a day (within an 8km radius (or local area) from their homes\u003csup\u003e36\u003c/sup\u003e) with contact restricted to members of their household. In this context, it has been suggested that these restrictions surrounding access to outdoor space may have contributed to worse mental health outcomes\u003csup\u003e37\u003c/sup\u003e. For example, during the pandemic within a German and Swiss cohort, expectant parents' access to outdoor space was implicated as a protective factor against prenatal stress and anxiety during pregnancy\u003csup\u003e38\u003c/sup\u003e. It must be notes that Germany guidance advised a 15km radius\u003csup\u003e39\u003c/sup\u003e and in Switzerland no specific radius was given. However, research to date, has not examined the influence restriction of outdoor access had on maternal attachment and bonding to their unborn child. Furthermore, pre- COVID-19, research also highlighted the influence of socioeconomic factors on access to outdoor space and nature resources \u0026ndash; individuals with higher incomes having greater access to outdoor spaces\u003csup\u003e40\u003c/sup\u003e, whilst more vulnerable populations, especially those living in large cities, often have limited access to natural spaces such as parks. Taken together, these findings suggest that potential socioeconomic disparities could have been exacerbated by governmental guidance during the pandemic, further influencing mental health and prenatal experiences for expectant families living in deprived areas.\u003c/p\u003e \u003cp\u003eLast, in England \u0026lsquo;stay-at-home\u0026rsquo; restrictions also resulted in experiences of financial instability\u003csup\u003e6,41\u003c/sup\u003e, including worries about job loss or decreases in household income\u003csup\u003e42\u003c/sup\u003e. This is of concern, as pre-pandemic studies have associated extreme financial or housing insecurity with adverse perinatal outcomes, including low birth weight and higher likelihood of admittance to intensive care\u003csup\u003e43\u003c/sup\u003e which in turn, increases the likelihood of later developmental delay in offspring\u003csup\u003e44\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePrevious findings from the Covid in the Context of Pregnancy, Infancy and Parenting (CoCoPIP) cohort found that expectant women in England faced a number of significant changes and challenges to their healthcare\u003csup\u003e45\u003c/sup\u003e, pregnancy and expectations around giving birth\u003csup\u003e45\u003c/sup\u003e. Drawing on data from the same cohort, we aimed to explore the relationship between COVID-19-related anxiety, experiences of prenatal attachment and how factors relating to the \u0026lsquo;stay-at-home\u0026rsquo; restrictions imposed by the government (i.e., perceived healthcare support, access to outdoor space and socioeconomic factors) may have heightened pregnancy-related anxiety during the pandemic and influenced their attachment to their unborn child.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eSurvey data from the CoCoPIP study was taken from the period of July 2020 \u0026ndash; April 2021. A total of 2084 families were followed during the pandemic, including 888 expectant parents and 1196 new parents. The current study considers a sub-sample of these participants (n\u0026thinsp;=\u0026thinsp;304, see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), including participants who (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) were in their second or third trimester and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) located in England. Due to the differences in restrictions and guidance between England, Wales and Scotland this study only utilises those families residing in England at the time of their response to the survey. All participants gave informed consent to take part in the CoCoPIP online survey (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.pipkinstudy.com/covid\u003c/span\u003e\u003cspan address=\"https://www.pipkinstudy.com/covid\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e)\u003csup\u003e46\u003c/sup\u003e. Ethics approval for the survey was given by the University of Cambridge, Psychology Research Ethics Committee (PREC) (PRE.2020.077). All experiments were performed in accordance with relevant guidelines and regulations.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eThe CoCoPIP survey used a mixed-methods approach, in which both quantitative and qualitative data was collected. This survey was logic-dependent and adaptive, only showing questions relevant to the parent\u0026rsquo;s current situation (i.e., first trimester/second trimester/infant aged 0\u0026ndash;3/3\u0026ndash;6 months). For the full survey, response time was ~\u0026thinsp;30 minutes and respondents were included in a \u0026pound;100 gift card prize draw (for full survey see Aydin, Weiss, et al., 2021\u003csup\u003e46\u003c/sup\u003e). As part of this survey, parents or caregivers (including adoptive parents, same sex partners etc) were asked to complete two validated questionnaires (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R) with additional COVID-19 specific pregnancy questions, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the Antenatal Emotional Attachment Scale (AEAS) that captured the nature of the relationship between an expectant parent with their unborn baby, separate from attitudes to pregnancy or motherhood \u003csup\u003e37\u003c/sup\u003e and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) the Impact of Event Scale-Revised (IES-R) to observe anxiety related to COVID-19 at the time of participation in study. Standardised scoring for all measures was used. In addition, we assessed perceived antenatal healthcare support, social support, and access to outdoor space (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eAnalyses were carried out in SPSS v29. Hierarchical multiple regression analyses were used to assess the directional relationships between the variables of interest. For standardised questionnaires (PRAQ and AEAS), missing values of individual items were imputed with the mean of the other item responses provided by the participant, with a maximum of \u0026frac14; missing responses being acceptable for being included in the dataset.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eModerators\u003c/strong\u003e \u003cp\u003eSocial support and financial instability were explored as potential moderators within the model \u0026ndash; social support was assessed by combining responses from three questions addressing (a) support from spouse/partner, (b) support from friends and family, and (c) difficulty in separation from these loved ones due to lockdown to create a total score. Financial instability was assessed using combined responses from two questions, addressing (a) changes to financial or housing situation due to COVID-19, and (b) difficulty coping with the financial impact of COVID-19 (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for questions). Moderation analyses were performed using SPSS PROCESS macro (Hayes, 2013). The variables were mean centred (in related to total sample) prior to the moderated mediation analyses. The number of bootstrap samples for the bias-corrected bootstrap confidence intervals (CIs) was 5000. The present study used Model 21 in PROCESS to test the moderated mediation analysis.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eScoring\u003c/strong\u003e \u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) For perceived antenatal healthcare support, participants' responses were scored on a 5-point scale ranging from 1 (I do not feel supported at all) to 5 (I feel extremely supported). (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) For outdoor space, the total number of options selected gave the outside space score per participant. A greater score indicated more access to outdoor space (\u003cem\u003esee\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cem\u003efor questions\u003c/em\u003e). Scores ranged from 0 (no access) to 10 (abundant access). (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) For social support, questions (a) and (b) were reverse coded so direction of the scales became more intuitive (with a higher score relating to higher degree of social support). Scores for the three questions were summed and averaged, to give the final \u003cem\u003esocial support\u003c/em\u003e score per participant. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) For financial instability, scores from questions (a) and (b) were summed to produce the overall \u003cem\u003efinancial instability\u003c/em\u003e score, which encompassed participants\u0026rsquo; difficulty coping with the financial impact of COVID-19, as well as the number of financial aspects that had been impacted by the pandemic. In response to \u0026lsquo;(a) changes to financial or housing situation due to COVID-19\u0026rsquo;, participants were able to select multiple answers from multiple options provided, participants would be given a total score out of 9 and \u0026lsquo;(b) difficulty coping with the financial impact of COVID-19\u0026rsquo; a max score of 5 was giving in response to one question. Greater scores illustrated greater levels of financial instability, with a range of 1 (\u003cem\u003elow\u003c/em\u003e) to 14 (\u003cem\u003ehigh\u003c/em\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAdditional variables\u003c/strong\u003e \u003cp\u003eMaternal age, household income, participant education, depression diagnosis or symptoms (self-reported from the start of COVID-19 or within the last month) and event related anxiety (measures via the IERS) were used as contextual control variables within the reported analysis (\u003cem\u003esee\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSub analysis\u003c/strong\u003e \u003cp\u003eA sub-group of participants (n\u0026thinsp;=\u0026thinsp;105) disclosed their postcodes to researchers. Full postcodes were used to assign an \u0026lsquo;Indices of Multiple Deprivation\u0026rsquo; (IMD) utilising UK governmental open data sources (\u003cem\u003esee\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eNone of the identified contextual control variables were significantly related to prenatal attachment; maternal age (p\u0026thinsp;=\u0026thinsp;.41), household income (p\u0026thinsp;=\u0026thinsp;.07), participant education level (p\u0026thinsp;=\u0026thinsp;.13), experienced depression (p\u0026thinsp;=\u0026thinsp;.35) and event related stress (p\u0026thinsp;=\u0026thinsp;.20). These variables were still included within the final model as covariates and accounted for 1.9% of the variation in pregnancy-related anxiety (p\u0026thinsp;=\u0026thinsp;.37), and within all models.\u003c/p\u003e \u003cp\u003eThe main regression analysis to identify the influence of perceived healthcare support and access to outdoor space with prenatal attachment showed a nonsignificant association; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) perceived healthcare support accounted for 1.2% of the variance (B\u0026thinsp;=\u0026thinsp;.36, SE\u0026thinsp;=\u0026thinsp;.19, p\u0026thinsp;=\u0026thinsp;.06, CI 95% = \u0026minus;\u0026thinsp;.01 (upper), .73 (lower)) and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) access to outdoor space accounted for 0.1% of the variance (B=-.13, SE\u0026thinsp;=\u0026thinsp;.26, p\u0026thinsp;=\u0026thinsp;.61, CI 95% = \u0026minus;\u0026thinsp;.64 (upper), .38 (lower)). In total the final model accounted for 3.1% (Cohens \u003cem\u003ef\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.018) of the variance in prenatal attachment level. Initial correlation (\u003cem\u003esee\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) demonstrated a significant correlation between perceived healthcare support and antenatal attachment (p\u0026thinsp;=\u0026thinsp;.016), when included within the regression this significance did not remain. In addition, social support and financial instability had no moderating effect on this relationship (\u003cem\u003esee\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral identified contextual control variables were significantly related to pregnancy-related anxiety; depression experienced during the pandemic (p\u0026thinsp;=\u0026thinsp;.00), maternal age (p\u0026thinsp;=\u0026thinsp;.05), and participant education level (p\u0026thinsp;=\u0026thinsp;.04) were significantly positively related to pregnancy-related anxiety. No other variables were significantly related. These variables were still included within the final model as covariates, to observe their overall contribution to the final model, and accounted for 10.6% of the variation in pregnancy-related anxiety (p\u0026thinsp;=\u0026thinsp;.00), and within all models.\u003c/p\u003e \u003cp\u003eThe main regression analysis to explore the influence of perceived healthcare support and access to outdoor space on pregnancy-related anxiety scores revealed a significant association; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) perceived healthcare support accounted for 18.5% of the variance (B =-4.06, SE\u0026thinsp;=\u0026thinsp;1.17, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, CI 95%= -6.36 (upper), -1.76 (lower)) and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) access to outdoor space accounted for an additional 6.2% (B=-5.76, SE\u0026thinsp;=\u0026thinsp;1.55, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, CI 95% = -8.81 (upper) -2.70 (lower)). In total the final model accounted for 24.7% (Cohens \u003cem\u003ef\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.57) of the variance in pregnancy-related anxiety. Both variables, lower perceived healthcare support and less access to outdoor space, were associated with higher pregnancy-related anxiety scores. Social support had a significant moderating effect on the relationship between pregnancy-related anxiety and COVID-19 related depression (p\u0026thinsp;=\u0026thinsp;.01). Expectant women who did not report experiencing feelings of depression during COVID-19 showed a negative relationship between pregnancy related anxiety and perceived level of social support, whilst a positive association was observed between these two variables when the individual reported COVID-19-related depression (\u003cem\u003esee\u003c/em\u003e Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWithin a subsample (n\u0026thinsp;=\u0026thinsp;105) we explored the influence of Index of Multiple Depreviation (IMD) on the above-mentioned models. Whilst, IMD did not have a significant association with prenatal attachment level, IMD showed a negative correlation with pregnancy-related anxiety (p\u0026thinsp;=\u0026thinsp;.009) adding 3.8% (Cohens \u003cem\u003ef\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.61) to the variation in pregnancy-related anxiety (B = -1.28, SE\u0026thinsp;=\u0026thinsp;.57, p\u0026thinsp;=\u0026thinsp;0.026) with the final model (inc. experienced depression, perceived healthcare support, access to outdoor space and IMD) accounting for 26.8% of the variance in pregnancy-related anxiety score. This suggests that levels of pregnancy-related anxiety decreased as IMD increased (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDuring this period of global uncertainty, expectant women consistently reported higher levels of anxiety, stress, and depression\u003csup\u003e2,47\u003c/sup\u003e. We sought to identify how the impact of specific changes in public health guidance and governmental restrictions instigated during the pandemic affected pregnancy-related anxiety and prenatal attachment. Our previous qualitative analysis of participants responses highlighted how the changes to healthcare services for pregnant individuals during the pandemic increased feelings of anxiety and left women feeling inadequately supported\u003csup\u003e22,45\u003c/sup\u003e. Here we quantify these descriptions of anxiety during pregnancy, to changes in healthcare services and imposed governmental restrictions to outdoor space.\u003c/p\u003e \u003cp\u003eIncreased mental health issues were observed globally within this vulnerable population; however, the factors contributing to pregnancy-related anxiety differed across populations mainly due to differing governmental guidance and restrictions. In the USA, COVID-19-related stressors such as food availability, tension/conflict within the home, and fear of COVID-19 infection increased pregnancy-related anxiety\u003csup\u003e42\u003c/sup\u003e. Whilst in Iran predictors of pregnancy-related anxiety were related to COVID-19 practices and guidance (e.g., use of gloves and face masks outdoors and in attendance at public places) as well as social support\u003csup\u003e48\u003c/sup\u003e. Similarly, in Northern Italy\u003csup\u003e49\u003c/sup\u003e, Israel\u003csup\u003e50\u003c/sup\u003e and China\u003csup\u003e51\u003c/sup\u003e perceived social support was significantly associated with reduction in severity of antenatal and postnatal depression and anxiety. Within our UK sample the level of social support had a moderating effect on pregnancy-related anxiety, adding to this body of literature. Perceived social support, acted as a potential \u0026lsquo;protective factor\u0026rsquo; reducing pregnancy-related anxiety in expectant women who did not experience COVID-19-related depression. However, this was not reflected in individuals who reported experiencing COVID-19-related depression in which higher levels of social support were also related to high levels of pregnancy related anxiety. Overall, our findings indicate that social support alone in women experiencing COVID-19-related depression was not enough to reduce the level of pregnancy-related anxiety.\u003c/p\u003e \u003cp\u003eWe also explored financial instability related to COVID-19 as a moderating factor for pregnancy-related anxiety. In the USA, researchers found \u0026lsquo;preparedness stress\u0026rsquo; defined as feeling unprepared for the birth (i.e., changes to birth plan) was significantly related to levels of financial instability\u003csup\u003e52\u003c/sup\u003e, with COVID-19-related financial stress being associated with increased likelihood of depression in expectant women\u003csup\u003e53\u003c/sup\u003e. While financial instability was not a moderating factor within our sample, this may be due to the fact that over half our sample reported little to no financial instability. Whilst studies have reported a significant influence of household financial instability during COVID-19 on anxiety and depression\u003csup\u003e54\u003c/sup\u003e, no other studies reported financial instability influencing prenatal attachment within their cohorts.\u003c/p\u003e \u003cp\u003eOne factor consistently highlighted in studies as mitigating pregnancy-related anxiety was access to outdoor space. Cohorts from Germany and Switzerland reported access to an outdoor space as reducing anxiety, including prenatal and pandemic-related stress in expectant women\u003csup\u003e38\u003c/sup\u003e \u0026ndash; and acting as a \u0026lsquo;protective factor\u0026rsquo; for pandemic-related pregnancy stress in expectant populations in the USA\u003csup\u003e38,52\u003c/sup\u003e. We add to this body of literature showing that it was not only in relation to whether they had access to outdoor space as previously reported, but also the number of independent outdoor spaces they had access to, such that the level of pregnancy-related anxiety decreased as the individual had access to more of a range of outdoor spaces. This highlights and further supports the potential aggravating effects governmental restrictions related to outdoor accesses had on expectant populations, and the importance of research to observe and quantify the differences (i.e., urban vs rural and socioeconomic influence) to ensure that future policy addresses these issues.\u003c/p\u003e \u003cp\u003eDuring COVID-19, a number of studies identified an association between parity\u003csup\u003e50\u003c/sup\u003e, maternal age, education level and pregnancy-related anxiety. In particular a study from the USA noted expectant women with a \u0026lsquo;less than high school education\u0026rsquo; as a significant interaction term\u003csup\u003e24\u003c/sup\u003e. Similar relationships were also observed in a Turkish cohort in relation to prenatal attachment; maternal age, education, parity, and trimester of pregnancy\u003csup\u003e55\u003c/sup\u003e. While we demonstrated a significant relationship between pregnancy-related anxiety, maternal age and education level, these variables did not significantly add to our final model and were included only for clarity. Conversely, we observed a noteworthy influence of IMD on pregnancy-related anxiety. To our knowledge other studies have not explored geographic deprivation as a potential influence on pregnancy-related anxiety or prenatal attachment during COVID-19. Whilst other socio-demographic and economic factors included within the models did not relate to pregnancy-related anxiety, within our England-based population IMD may be a more accurate measure, as it is not reliant on self-report and accounts for multiple factors such as income, employment, education, living environment, health deprivation, disability, crime as well as barriers to housing and services. Our results demonstrated a negative relationship between IMD and pregnancy-related anxiety, suggesting expectant women from more deprived areas experienced higher levels of pregnancy-related anxiety.\u003c/p\u003e \u003cp\u003eLast, it is well documented that distress during pregnancy is associated with reduced mother-offspring bonding. During the pandemic various factors were attributed to reduced prenatal and mother-infant bonding. Researchers identified high COVID-19-related anxiety and increased fear of childbirth to have a negative impact on prenatal attachment\u003csup\u003e11,55,56\u003c/sup\u003e. Furthermore, in a UK based sample of 150 expectant women, Filipetti et al.\u003csup\u003e27\u003c/sup\u003e concluded that increased symptoms of depression were associated with reduced levels of attachment, with level of perceived social support serving as a \u0026lsquo;protective factor\u0026rsquo; (social support included: spouse/partner, family/friends and healthcare professionals/midwife). Within the current study we did not find any association between experienced depression and prenatal attachment. This could be related to our larger and more selective sample that included expectant women residing in England. In addition, our study began data collection three months after that of Filipetti et al\u003csup\u003e27\u003c/sup\u003e (April 2020 vs Jul 2020 respectively), and thus Filipetti et al. may have tapped in to the initial heightened feelings of depression and prenatal attachment at the start of the pandemic which then declined as the UK population adapted to the healthcare crisis and governmental guidance.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe collected data (July 2020 \u0026ndash; April 2021) reflects experiences during a period of unpredictable and fluctuating COVID-19-related government and healthcare restrictions, from the most severe national lockdown measures to a combination of severe to mild national/local restrictions. Due to the rapidly evolving nature of the governmental guidance related to the pandemic and regional variations in between national lockdowns\u003csup\u003e13\u003c/sup\u003e, it was not possible to collect equal sample sizes at each timepoint making us unable to further distinguish the effects of country-wide variance in local lockdown restrictions. Further, the introduction of \u0026ldquo;tiers\u0026rdquo; that differed geographically across England could have confounded our data relating to both outside space and social support. Furthermore, as this study was conducted as a voluntary online survey, we cannot independently confirm that all responses were actually from expectant parents or exclude bias in respondents with either positive or negative experiences of their pregnancy. Whilst we advertised this study nationally and specifically worked with national childbirth trusts (NCTs) with an emphasis on areas of low socio-economic status, the majority of participants were white (86.5%), marginally higher than the reported ethnic composition of the population (81.0%, 2021 census\u003csup\u003e47\u003c/sup\u003e); therefore, caution should be taken when generalising findings to a more ethnically diverse population. Further research is needed to explore the potential mechanisms involved, such as whether these effects are influenced by other factors such as population density or resource access.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice and research\u003c/h2\u003e \u003cp\u003eThe mitigation measures implemented by the government and the healthcare system throughout the pandemic have had a significant secondary impact on expectant women and families. It is becoming apparent that disaster planners have consistently given much less attention to the need for ongoing supportive care for childbearing aged individuals and young families during disaster recovery as compared to care effort (i.e., protecting elderly and vulnerable populations), during and in the immediate aftermath of a natural disaster\u003csup\u003e57\u003c/sup\u003e. Research consistently identifies expectant women and young families as \u0026lsquo;high risk\u0026rsquo; and in need of not only immediate social, mental, and health-care support but continued long-term care and guidance in the aftermath of such an event\u003csup\u003e58,59\u003c/sup\u003e. Going forward, the current findings along with findings from previous natural disaster research show the need for clear and consistent guidance to be in place for expectant women giving birth. This guidance should include the development of health education resources to positively influence the well-being of the pregnant population throughout their pregnancy, implemented within the healthcare policy, as well as preparing and responding to the long-term impact of such events. In addition, the present study provides initial insight into the influence of location-based deprivation and the need for governmental consideration of location when imposing guidance and restrictions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo date this is the first study to explore the influence of governmental restrictions in England on expectant parents\u0026rsquo; pregnancy-related anxiety and attachment, identifying alongside reduced healthcare support and access to outdoor spaces, that there was an increase in COVID-19 related depressive symptoms and heightened pregnancy-related anxiety. These findings should inform future policy makers in disaster planning for this vulnerable population group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors have no potential conflicts of interest to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research was funded by a Medical Research Council Programme Grant MR/T003057/1 to MJ, and a UKRI Future Leaders fellowship (grant MR/S018425/1) to SLF. T.A. is supported by the NIHR Cambridge Biomedical Research Centre (BRC), which is a partnership between Cambridge University Hospitals NHS Foundation Trust and the University of Cambridge, funded by the National Institute for Health Research (NIHR). T.A. is also supported by the NIHR HealthTech Research Centre in Brain Injury. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eEA: Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Validation, Writing - Original Draft. JF: Investigation, Data Curation, Validation. SMW: Conceptualization, Methodology, Writing - Review \u0026amp; Editing. TA: Methodology, Supervision, Writing - Review \u0026amp; Editing. JB: Supervision, Writing - Review \u0026amp; Editing. MHJ: Supervision, Funding acquisition, Writing - Review \u0026amp; Editing. SLF: Conceptualization, Methodology, Supervision, Funding acquisition, Writing - Review \u0026amp; Editing. The author(s) read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe are extremely grateful to all those families who gave their time to participate. For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) licence to any Author Accepted Manuscript version arising from this submission.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData generated and analysed during the study will not be made publicly available due to ethical and privacy restrictions, however researchers can submit a research proposal to the Data Sharing Management Committee to request access and collaboration.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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Risk factors for depression and anxiety in pregnant women during the COVID-19 pandemic: Evidence from meta-analysis. PLOS ONE 17, e0265021 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment of Gynecology, Training and Research Hospital, Van, Turkey \u003cem\u003eet al.\u003c/em\u003e The Relationship Between COVID-19 Fear and Prenatal Attachment of Pregnant Women in the Pandemic. Florence Nightingale J. Nurs. (2022) doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5152/FNJN.2022.22078\u003c/span\u003e\u003cspan address=\"10.5152/FNJN.2022.22078\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchaal, N. K. \u003cem\u003eet al.\u003c/em\u003e The influence of being pregnant during the COVID-19 pandemic on birth expectations and antenatal bonding. J. Reprod. Infant Psychol. 41, 15\u0026ndash;25 (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips, B. \u0026amp; Morrow, B. H. Women and disasters: From theory to practice. No Title (2008).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiarratano, G. P., Barcelona, V., Savage, J. \u0026amp; Harville, E. Mental health and worries of pregnant women living through disaster recovery. Health Care Women Int. 40, 259\u0026ndash;277 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKing, S., Matvienko-Sikar, K. \u0026amp; Laplante, D. P. Natural Disasters and Pregnancy: Population-Level Stressors and Interventions. in \u003cem\u003ePrenatal Stress and Child Development\u003c/em\u003e (eds. Wazana, A., Sz\u0026eacute;kely, E. \u0026amp; Oberlander, T. F.) 523\u0026ndash;564 (Springer International Publishing, Cham, 2021). doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-3-030-60159-1_18\u003c/span\u003e\u003cspan address=\"10.1007/978-3-030-60159-1_18\" 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":false,"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":"pregnancy, attachment, anxiety, COVID-19, social support, financial stability","lastPublishedDoi":"10.21203/rs.3.rs-4751681/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4751681/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLimited research has been conducted to evaluate the impact of governmental guidance during the COVID-19 pandemic on prenatal maternal anxiety and maternal-fetal attachment. Using survey data from the UK longitudinal Covid in the Context of Pregnancy, Infancy and Parenting (CoCoPIP) Study, we investigated the impact of perceived healthcare support and access to outdoor space on pregnancy-related anxiety and attachment to their unborn baby. 304 families were recruited during pregnancy (maternal age 17\u0026ndash;46 years; between July 2020 and April 2021). Anxiety and attachment in expectant women were measured using the Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R) and the Antenatal Emotional Attachment Scale (AEAS). Findings show reduced healthcare support (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and access to outdoor spaces (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) coupled with heightened COVID-related depressive symptoms (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) heightened pregnancy-related anxiety (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). In addition, results revealed that the relationship between heightened experience of depressive symptoms and pregnancy related anxiety was moderated by social support (p\u0026thinsp;\u0026lt;\u0026thinsp;.01). No significant associations were found between healthcare support and access to outdoor space in relation to attachment to the unborn baby. These findings are discussed alongside possible avenues for future research as well as recommendations with regard to the need for support for expectant families in the event of future events similar to COVID-19.\u003c/p\u003e","manuscriptTitle":"The influence of healthcare support and outdoor access on pregnancy-related anxiety and attachment to the unborn baby, during COVID-19 in England","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-12 10:41:26","doi":"10.21203/rs.3.rs-4751681/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":"4e1ed5bb-9251-40ac-9a38-147bd0a07cc8","owner":[],"postedDate":"August 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":35527706,"name":"Health sciences/Medical research/Translational research"},{"id":35527707,"name":"Health sciences/Health care/Health policy"},{"id":35527708,"name":"Health sciences/Health care/Public health"},{"id":35527709,"name":"Earth and environmental sciences/Environmental social sciences/Psychology and behaviour"}],"tags":[],"updatedAt":"2024-11-07T05:38:58+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-12 10:41:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4751681","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4751681","identity":"rs-4751681","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}