The Lived Experiences of Pregnancy and Motherhood in Bosnian Women During COVID-19
An Interpretative Phenomenological Analysis
Abstract
Abstract.Introduction: Prenatal, perinatal and postnatal period result in series of psychological, physical, relational and emotional changes and adjustments while during the pandemic pregnant women and mothers of young children must also cope with the fear of themselves, their fetuses, or children being infected. Aim: The aim of study was to explore the lived experiences of pregnant women and mothers living in Bosnia and Herzegovina during the COVID-19 outbreak. Methods: Semi-structured in-depth interviews with 30 Bosnian women, 15 of whom were pregnant and 15 who are mothers that gave birth during the COVID-19 pandemic were conducted. Participants were recruited through two local women’s associations. The data was analyzed utilized inductively using an interpretative phenomenological analysis. Results: The study results indicate that both pregnant women and mothers alike described negative and positive feelings about pregnancy and motherhood during the COVID-19 pandemic such as fear and hope. The lived experiences of anxiety and adaptation through two core concepts: trapped in the fear of the unknown and adapting and embracing uncertainty. Discussion: The main themes that emerged from the interviews reveal grounded fear but also adaptability. Even though people have amazing abilities to adapt to adverse life conditions, as women in our study demonstrate, many aspects of the pandemic’s impacts on vulnerable populations are still unexplored. Tailor-made public health strategies such as an online counseling platform should be created to accommodate specific needs and issues of this population.
Although most women jubilantly await pregnancy and motherhood, doing so during a pandemic can be both stressful and challenging. An estimated 116 million babies will be born under the shadow of the COVID-19 pandemic (United Nations International Children’s Emergency Fund – UNICEF, 2020). During the pandemic, pregnant women and mothers of young children not only had to cope with a multitude of pregnancy-related physical changes, related to their hormones or immune system adaptations (Kinsley et al., 2015, Soma-Pillay et al., 2016) and the accompanying emotional upheavals, but also with the fear for themselves, their fetuses, or their children being infected and the relevant serious healthcare issues. Even under ideal conditions, the prenatal, perinatal, and postnatal periods result in a series of psychological, physical, relational, and emotional changes and adjustments. But when perinatal and postnatal changes are combined with the impact of the COVID-19 pandemic, psychosocial outcomes are likely to be more adverse (Matvienko-Sikar et al., 2020; Davenport et al., 2020; Thapa et al., 2020). Thus, pregnant women and mothers may experience even more stress related to prenatal checkups, birthing, and postnatal care because of the overwhelming demands on healthcare, shortages of adequate supplies and equipment, and lack of sufficient birth attendants because of COVID-19 (Horsch et al., 2020; UNICEF, 2020).
Expecting mothers who experience high stress or anxiety are at risk of preterm birth, having low birth-weight infants, and infants with neurodevelopmental impairments (Beijers et al., 2014; Dunkel Schetter & Lobel, 2012; Graignic-Philippe et al., 2014; Guardino & Dunkel Schetter, 2014; Lederman, 2020). Maternal anxiety and stress adversely impact child outcomes because increased catecholamines and cortisol compromises placental functioning, maternal immune systems, and intestinal microbiota as well as impacting other maternal health behaviors (Beijers et al., 2014). The concept of maternal distress, according to Meleis’s (2007) theory on life transitions and Mercer’s (2004) theory of maternal role attainment, or a complex and multifaceted woman’s response to the transition to motherhood, “includes changes to their bodies, roles, relationships and social circumstances; birth experiences; and the demands, challenges, losses and gains associated with being a new mother” (Emmanuel & St. John, 2010, p. 2112).
The pandemic increases maternal distress since pregnant women and mothers experience increased fear of the potential risk of infection or vertical transmission, restrictions in access to routine reproductive and maternity care, or separation from families and caregivers and broader networks of support (Boekhorst et al., 2021; Diamond et al., 2020). Women who become pregnant during the pandemic are exposed to stress associated with feelings of being unprepared for childbirth (preparedness stress) and stress related to fears of perinatal COVID-19 infection (perinatal infection stress) (Preis et al., 2020). There is an urgent need to determine the mental health outcomes of perinatal women during the COVID-19 pandemic and to identify behavioral risk and protective factors to minimize potentially harmful consequences during this global public health emergency (Werchan et al., 2021).
Studies show that “increased child care needs during pre-school and school closures placed even the greater burden on working mothers with 60 percent of women reporting a significant increase in domestic, care and emotional work since the onset of, the pandemic” (UNICEF, 2020, p. 9). When pregnancy and motherhood occur in a society with lower socioeconomic status (SES), like Bosnia and Herzegovina (B&H), the impact might be even more dire. Kartsonaki (2016) described Bosnia as being in distressing “political, social and economic deadlock,” contributing to unstable political and economic environments, high unemployment rates, poverty, youth and skilled worker migration, and other adverse conditions (p. 497). Multifaceted SES and psychological consequences of the recent war in Bosnia, paired with the effects of COVID-19, makes pregnancy and motherhood particularly stressful. Also, the unfavorable economic impact of COVID-19 measures in B&H led to a noticeable rise in unemployment and a decline in GDP (Bećirović et al., 2020). Thus, the pandemic has already taken a high cost on the physical and mental health of Bosnians (Šljivo et al., 2020).
All this, just like the harm of the virus itself, lack of social contacts, waves of job losses, and the uncertain end of the COVID-19 pandemic precipitate grave stressors to people worldwide (Ruddin, 2020), including the more vulnerable people, like pregnant women and mothers. Their concerns and challenges deserve particular attention to be addressed by evidence-based interventions. During the first 9 months of 2020, there were 19,378 births in Bosnia (Federalni zavod za statistiku, 2020), while, as of 15 June 2021, Bosnia has had 204,814 confirmed cases of COVID-19, with 9,630 deaths (Ministry of Civil Affairs, 2021).
Measures to control COVID-19 were introduced in March 2020, and a full lockdown was in place from March 17 until 28 April 2020. The lockdown banned public gatherings, restricted the movement of persons over 65 and under 18, implemented a curfew from 8 p.m. until 6 a.m., mandated the wearing of masks and gloves in public, and required businesses, education, and other services to operate online.
A better understanding of pregnant and mothers’ lived experiences might help to identify COVID-19 related issues and the challenges they face, and inform both local and national efforts to strengthen the health and psychological service provision during and particularly after the pandemic. Accordingly, this study explores the lived experiences of being pregnant and/or becoming a mother in B&H during the pandemic, namely exploring the pandemic’s impact on women’s psychological well-being over time, raises awareness on possible challenges pregnant women and mothers face and coping strategies they use.
Method
Participants
We recruited a convenience sample of 30 participants through local NGO associations focused on pregnant women and mothers and breastfeeding mothers. Of the participants, 15 were pregnant (Mage = 29.00 SD = 4.70) and 15 of them were new mothers (Mage = 28.00 SD = 4.59); 17 participants were primiparous and 13 multiparous women; 11 had one child, and two participants had two children in the household. 12 of our participants were working, five were on maternity leave, 11 were unemployed, and two were still in school. Inclusion criteria included: (1) women currently pregnant (2) who delivered during COVID-19 virus outbreak (3) and who possessed the competence necessary to give consent to participate in the study. More details about participants are in Table 1.
Measures and Procedure
The associations we worked with posted recruitment materials on their official websites and social networks, and interested potential participants were instructed to contact one of the researchers to be interviewed. We opted for in-depth, semistructured interviews since we wanted to have some kind of guidance but still give enough space and flexibility for original and unexpected issues to arise (Smith, 2003), which we could best investigate in more detail with further questions. Given the ongoing COVID-19 threat, we conducted the interviews in Bosnian via Viber (an online communication tool). The interviews consisted of nine questions (see Table 2), lasting 45–70 minutes and occurring in September and October 2020.
All interviews were audio-recorded and transcribed verbatim by the research team. We anticipated that our participants would make a rather heterogeneous group, whether mothers or mothers to be, so we did not originally plan to neither conduct interviews with “two groups” nor to engage in qualitative comparison. Yet, after gaining interesting insights (differences in perceived challenges faced by mothers and pregnant women) following the first few interviews, we arbitrarily decided to set a target of up to 15 pregnant women and 15 mothers and to continue sampling beyond this number should the saturation, a “phase where no further insights emerge from the data” (Hennink et al., 2019, p. 14), not be achieved. Since the concept of data saturation is still rather controversial both in terms of its definition and application (O’Reilly & Parker, 2013), we were also guided by other qualitative standards like “the epistemological and theoretical approach, the nature of the phenomenon under investigation, the aims and scope of the study, the quality and richness of data, or the researcher’s experience and skills of conducting qualitative research, should be the primary guide in determining sample size and assessing its sufficiency” (Vasileiou et al., 2018, p. 16). No new codes, but just nuances were identified following analysis of approximately two-thirds of the interviews, although we did code all interviews in an attempt to gain more in-depth and diverse information. To truly mirror the experiences of our participants and to ensure different perspectives are represented, we constantly reread all transcripts, discussed the findings, and accounted for personal biases.
Our theoretical orientations and personal experiences affect the way we as researchers see the world and interpret different phenomena. As a mother of two young children who struggled with balancing work and homeschooling during the first 3 months of the pandemic, one author was particularly sensitive to the adverse effects of being constrained at home with children, which she found in most narratives of women with older children. Another author, a trained therapist, was focused more on examples of resilience and hardiness. These perspectives may have influenced the discussion of two distinct core concepts in explaining the phenomenon of pregnancy and motherhood during the pandemic in B&H and should be kept in mind while reading our findings.
The only sociodemographic variables taken into consideration were age, employment status, level of education, and number and age of children. The IRB Ethics Committee of the International University Sarajevo (protocol number IUS-REC-01-1919/2020) approved the research protocol. Informed consent was obtained from participants, who were also assured of confidentiality.
Data Analysis
To explore the lived experience of pregnancy and/or new motherhood during COVID-19 and better understand how our participants made sense of it, we applied an interpretative phenomenological analysis (Smith, 2017). “Phenomenological studies focus on how people perceive and discuss objects and events rather than describing phenomena according to a predetermined categorical system, conceptual and scientific criteria” (Pietkiewicz & Smith, 2014, p. 8). Reporting standards for psychological qualitative research were followed (Levitt et al., 2018).
As Alase (2016) suggested, the data were condensed and coded in three generic cycles; the steps in carrying out a phenomenological analysis of interview data were as follows: In the first cycle, two of the authors independently coded the interview transcripts and subjected them to a detailed, case-by-case, systematic qualitative analysis to become fully immersed in the data and create familiarity with the breadth and depth of the content (O’Brien et al., 2014). This cycle ended with a list of codes that were grouped, regrouped, and clustered together in the second cycle to create a smaller number of categories. The categories led to themes, and the themes were subsequently condensed into superordinate themes. Finally, in the third cycle, superordinate themes were transformed into two core concepts that illustrate the lived experience of pregnancy and motherhood during the pandemic in Bosnia and Herzegovina.
In the first cycle, we calculated interrater reliability based on the suggestions of Miles and Huberman (1994), which varied between .60 and .70 demonstrating appropriate reliability. However, throughout the entire analysis the researchers engaged in ongoing discussions about the analysis of the data until they reached an agreement on the final findings presented in this paper.
Results
In cycle one, the transcripts were read and examined several times, and with each reading, we marked the transcript with initial descriptive, linguistic, and conceptual comments. Subsequently, these comments were transformed into codes that captured the essential features and relevant meanings related to the research question. More than 50 codes (e.g., fear of the virus, loneliness because of imposed measures, restriction related feelings of isolation, unknown future and aftermaths of it all, child versus baby, careless others, hospital and health, reconnection, spirituality and religion, silver lining…) were independently identified by both coders and combined with self-reflective memos. From this point on, the researchers jointly compared, discussed, and clustered codes (units of meaning) across all interviews, and eventually reduced the codes and memos to 11 categories. Seven out of the 11 categories were related to negative cognitions and emotions: three mothers specific (explaining the new normal, running errands, reconciling different needs) and four common to first-time pregnant women and all mothers alike (restricted movements/lack of social contacts, low level of social responsibility, poor healthcare, economic worries). Four positively valenced categories were common to first-time pregnant women and to all mothers alike (finding a balance/social responsibility versus personal needs, spending quality time with family, positive self-talk/sharing and spreading optimism, and keeping the faith).
In the second generic cycle process, which served to reduce the first bulky phrases into fewer words to move closer to the “core essence” of what our participants were actually expressing, we developed connections among categories until four negatively valenced themes emerged (Am I a good enough mother, loss of enjoyment in pregnancy, loneliness and isolation, and fear of virus) and one positively valenced theme (silver lining). Irrelevant and/or overlapping themes were discarded or subsumed. We continued to make connections across interviews until a set of superordinate themes for the entire data emerged. While four themes were consolidated into two main superordinate themes: Pregnancy/motherhood concerns and challenges related to COVID-19 and General concerns and challenges related to COVID-19, one theme was transformed into a superordinate theme Active coping with COVID-19 related challenges to motherhood and pregnancy.
Finally, in the third and final generic cycle stage, we once again compared the main three superordinate themes against the original narratives and eventually transformed them into core concepts that enabled us to capture the “core essence” or the essential phenomenon as manifested in participants’ experiences. The lived experience of pregnancy and motherhood during COVID-19 is expressed through two core concepts: (I) trapped in the fear of the unknown and (II) adapting and embracing uncertainty. See Figure 1 for a graphical representation of the results of our data analysis.
Core Concept I: Trapped in the Fear of the Unknown
Pregnant women and new mothers shared many common COVID-19 related fears and concerns. Their narratives reveal that they were and still are exposed to severe stress and negative feelings, and that the pandemic has shaken their sense of reality. Pregnancy tends to be mostly a pleasant experience, yet pregnancy, childbirth, and motherhood – especially for those who gave birth or became pregnant during the first few months after the outbreak – were not experienced as something enjoyable and extraordinary, but rather something stressful and veiled in fears and uncertainty.
Fear of the unknown comprises a variety of concerns, and our women were worried about many things, from explaining “the new normal” to their children (“How am I supposed to explain to a 7-year-old boy that he is not allowed to hang out with his friends because if I let him do that he endangers me and the baby?”; DL, age 30), worrying about adverse health effects the virus may have on them and/or their babies and children (“I was so scared … we didn’t know anything about the virus at the time, so I was constantly on sedatives and I didn’t eat well, and that affected the baby’s birthweight”; ZA, age 39), to finding trusted sources of information (“So what is it [the virus]? You hear different things, people lie, conspiracy theories, which information source and who do you trust? I fear not only about me anymore [adopting protective behavior], but my baby as well”; BOR, age 23) and access to hospitals and quality of healthcare. As one young mother said: “I’m not afraid of viruses (per se), I’m afraid of our chaotic and corrupt healthcare system, what happens when you go to the hospital. If I or my baby get infected, will they treat us adequately”? (DL, age 30).
Pregnant women talked about their negative experiences during check-ups. “Because of COVID-19, regular checkups were canceled, and I was very anxious and under tremendous stress, so I completely isolated myself to stay safe and not get infected or endanger my child” (AS, age 25). “I am lying on the table and have contractions, I hear the doctor yelling at the nurse saying why she brought a COVID-19-positive pregnant women to give birth with the rest of us. Just imagine the fear I had felt” (ALM, age 26).
Lack of support following delivery was also an issue. “I was afraid restrictions would prevent my mother to be there for me after delivery, and that is exactly what happened. My mother could not come and help me with the baby. I haven’t seen anyone but my husband for almost 3 months after I gave birth (in April), it was really tough” (SI, age 28).
Mothers with more than one child were worried about the social deprivation of their children, in light of homeschooling and the aftermath of the pandemic on children. “The virus and this (social distancing and other measures) – all are awful, kids are afraid of socializing, hugs and contacts. They will be scared of life (…), and I contribute to this, because I’m worried about the pregnancy and do not take kids to the park to play anymore” (JMP, 35 age). “I did not want a cellphone to become my child’s best friend so I helped her with school, tried to spend quality time with my school-age child, and not show my COVID-19 pregnancy and labor-related anxiety and concerns in front of my children. It is tough to handle it all. With sleep deprivation because of baby and all …” (AB, age 34).
Mothers found running errands to be very challenging particularly during the first lockdown in April 2020, when children and the elderly were not allowed to leave the house. “I could not leave anyone at home with the baby so I could run errands, and I was so scared that people in the shops will try to touch the baby, so I never used a stroller just a baby carrier. So, picture this, me holding one child in one hand and carrying the baby carrier in another and running all over, paying bills for myself and my parents, doing shopping and other tasks – that was really challenging” (RT, age 32).
Economic worries were also prevalent, and almost unanimously women dreaded poverty, even the employed ones, which comes as no surprise with so many people in B&H living at the poverty line already. “The virus will come and go, but what will happen to our economy. No one seems to think about some of those struggling to make ends meet. It’s tough, and it will get tougher I think … It’s tough [the impact on the economy], people are struggling to make ends meet, even those who did not have financial issues before. I myself may not have a job when I return from maternity leave” (EGZ, age, 26). “We are used to adversities, economic hardships … but no one knows what else this pandemic will bring upon us, how hard financially it will affect us – that’s worrisome” (AHM, age, 32).
Core Concept II: Adapting and Embracing Uncertainty
Despite many adversities, the women expressed active coping strategies and resilience. It seems that responsibility and love toward children aided their self-preservation. “When she [the baby] smiles at me, she gives me the strength to endure. At first, I was paralyzed, we didn’t know anything [about the virus], but then, life goes on, you have obligations, you do not have the luxury to curl and wait for the miracle to happen” (ZS, age 23). This, often combined with faith and support from family and close friends, helped women find the inner strength to adapt. “God gives us as much burden as we can bear” (AG, age 41). Women often reported their husbands helped them, if not with household and children then by providing emotional support. “It was difficult to adapt to pregnancy and pandemic measures, but my husband was always there for me, and so were my friends. It means a lot, you know, having someone by your side in times like this” (AA, age, 30).
Continued involvement in the course of their daily lives (despite restrictions), and the subjective and objective assessments of their capacities to deal with new challenges, helped these women facilitate the necessary shift to the new normal. “We are survivors, I have explained it to myself. You cannot give up and live in fear – we have to do our best and continue with our lives fully, no matter what. You know, what does not kill us makes us stronger” (AS, age 25). “I would tell women: Don’t read the papers or watch the news and worry all the time. We have to do our best to stay healthy and sane, and ultimately everything is in God’s hands” (SV, age 32).
Clearly, women try to enjoy pregnancy and motherhood the best they can and use the pandemic to self-reflect and spend more quality time with their families. “Restricted movements and lockdown are a blessing in disguise. I spent more time with my older daughter and my husband” (AB, age 35). Women who were pregnant for the first time during the interviews reported enjoying the greater attention and help and being less stressed about the future and about transitioning to motherhood. Importantly, all the women took active steps toward self-empowerment by dealing with their own fears and insecurities about the future, among other things by volunteering to participate in this study, wanting to share their experiences with other pregnant women and new mothers, and in that way to help them cope better with the challenges of pregnancy and motherhood during the pandemic. “Most people neglect mothers and focus only on the baby, while it is important to look after mother as well, her mental and physical recovery. Women should look after support from their family and friends and find the inner strength as well” (ZA, age, 39).
Discussion
Pregnancy, giving birth, and living with a new baby are all very exciting events for a woman, but they can also be very stressful when they occur during extraordinary times such as a pandemic. Interestingly, the challenges of currently pregnant women and new mothers are somewhat different as are the challenges and concerns of mothers with one child and mothers with more than one child. Pregnant women worried not only about being infected with COVID-19 themselves but their babies, too. In addition, they were also deprived of some healthcare services, including access to routine prenatal care, which stressed them. Private gynecologists were not working during the lockdown in April 2020, and public gynecologists were postponing regular check-ups and/or reducing the number of common tests provided. Husbands and relatives were not allowed to participate in check-ups, during labor and delivery, and during first few months of the pandemic even enter the hospital. The situation, however, improved significantly at the time the interviews were conducted.
At the beginning of the pandemic, little was known about the virus, let alone its impact on pregnant women and babies, while the healthcare systems and assistance worldwide were severely strained – in Bosnia, too. B&H has free public healthcare, which in the postwar period was characterized by long wait times and a shortage of specialized medical personnel. The entire situation with healthcare got even worse during the COVID-19 pandemic. COVID-19 patients additionally overloaded the already strained healthcare services, which in turn resulted in inconsistent or no available regular healthcare service delivery to other patients in need. Our pregnant women reported not only fears related to themselves and their unborn child being exposed to the virus, but also not being able to access regular antenatal checkups, neither in the private nor the state institutions. This agrees with the study conducted by Horsch et al (2020), which states that inconsistent organizational response to COVID-19 in postnatal care and reduced access to health and support services were key psychosocial stressors among pregnant women and new mothers. Several studies, including meta-analyses and systematic reviews about perinatal women mental health during the pandemic, observe high prevalence rates of psychological problems, like anxiety, depression, and substance abuse among pregnant and postpartum women during COVID-19 (Almeida et al., 2020; Mortazavi & Ghardashi, 2021; Sahin & Kabakci, 2020; Wu et al., 2020; Yan et al., 2020; Preis et al., 2020).
Besides personal concerns about the risk of exposure to COVID-19, the new mothers and multiparous mothers in our sample were additionally worried about the exposure of their children and other family members, the impact of social deprivation on their children, and the long-term effects of the pandemic on children. Again, our results are in line with the study conducted in Northeastern Italy (Zanardo et al., 2020, p. 84), which revealed that “concerns about risk of exposure to COVID‐19, combined with quarantine measures adopted during the COVID‐19 pandemic, adversely affected the thoughts and emotions of new mothers, worsening depressive symptoms” impacting their overall psychological functioning. “As for the psychological functioning, concerning the period before quarantine, mothers reported an increasing level of emotional symptoms such as sadness and frustration, whereas they perceived their children also more undisciplined and hyperactive, with a worsening inhibitory self-control capacity” (Di Giorgio et al., 2020, p. 10).
The study did not specifically address differences in anxiety and stress levels related to age and number of children. However, our participants did raise concern regarding the COVID-19-related measures in a form of absence and ban on birth partners during delivery and visitors afterward. They were deprived of support when perhaps they needed it most. The absence of birth partners and visitors after birth, and the overall reduced social support and contacts from wider family and friends during pregnancy, resulted in increased feelings of stress and anxiety (McKinley, 2020; Thapa et al., 2020).
The transition to online schooling, home working, and stay-at-home orders during the coronavirus pandemic blurred boundaries between public and private space, and parents, particularly mothers, were and still are juggling work and family needs. These are particularly powerful sources of stress to mothers, something that is again also supported by other studies. “In addition to work and financial disruptions, during the COVID-19 pandemic, families have experienced enormous stress because of seclusion within households, social isolation, concern about the health of family and friends, disruptions to school and child care, and the need to make new health-related decisions in a context of uncertainty” (Feinberg et al., 2021, p. 2).
It is also important to note that the forced cohabitation during the pandemic reshaped interpersonal relationships in many households and impacted well-being both positively and negatively. Research shows that, for some families, the combination of economic stress and lockdown led to an increase in intimate partner violence (Barbara et al., 2020; Sacco et al, 2020), while for some others, like our participants, it actually improved and strengthened family relationships. Our participants reported having supportive relationships with their spouses and mothers. Having a supportive partner or relatives for both emotional and instrumental support helps to protect mothers from the negative impacts of stress – both normative as well as severe levels of stress exposure – during pregnancy and the postpartum period (Razurel et al., 2013, 2017). Also, having supportive families – and mothers in particular – functions as a prominent resilience factor thought to be the most effective in preventing the detrimental effects of stress on children (Roos et al., 2021).
Resilience has been extensively researched concerning adjustment, positive psychological changes, and growth following adversity (Brémault-Phillips et al., 2020; Cheadle et al., 2020; Roepke & Seligman, 2014; Schaefer et al., 2019). Adaptation and positive changes are also reported in a study with pregnant women diagnosed with CHD and type 1 diabetes mellitus (Flocco et al., 2020; Sparud-Lundin & Berg, 2011). We also noted features of positive change and resilience in our study sample in Bosnia. Our participants not only reported having supportive partners but also drew strength from their children, used collaborative coping strategies, and perceived lockdown as a chance to renew emotional bonds and reconnect with their children and spouses.
An emotional bond seems to be an important mediator in the management of stress and negative emotions. Moreover, “the COVID-19 outbreak has generated a unique situation with specific characteristics related to stress, coping strategies, and living together, creating a new multifaceted form of cohabitation” (Mari et al, 2020, p. 16). Our small and heterogeneous sample of participants seems to have adequate domestic and social support and is coping relatively well so far, but the long-term mental and physical health impacts of the pandemic on perinatal women and their children are yet to be explored.
The sociodemographic profile of our participants was rather diverse, with additional concerns being raised by unemployed mothers. So, it comes as no surprise that many of our participants also expressed their concerns about the impact of COVID-19 measures on their economic situation, and several expressed their concerns related to peoples’ lack of understanding and acting upon COVID-19 decisions and recommendations made by the local authorities. One-third of women in our sample are unemployed, which likely impacted the family’s economic status, which in turn may have also affected the women’s psychosocial well-being and coping strategies. These economic concerns are likely linked to the COVID-19-related increase in unemployment and decline in GDP (Bećirović et al., 2020).
Also, several participants, currently on maternity leave, work in the informal sector, which does not guarantee their social or economic security and might possibly impact their overall socioeconomic status. Even though we did not collect such data on our participants, SES studies reveal that women with low SES are generally at a higher risk of depression (Verbeek et al., 2019; Guintivano et al., 2018; Pham et al., 2018). Many people in B&H are accustomed to coping with the cost of living, and our participants generally complain about their socioeconomic situation irrespective of their employment status. Yet, the public measures introduced during the pandemic may have been a “game-changer” in a sense that “Many of the social and economic disparities among those living in lower SES, which likely also play a contributing role to poorer maternal health outcomes, may have been reduced as a result of imposed social restrictions” (Silverman et al., 2020, p. 782). Unfortunately, we can only speculate on the SES of our participants since it was not directly assessed.
The pregnant women and mothers in our study expressed feelings of fear and anxiety related to the ongoing COVID-19 threat and concerns about their own health or that of their children. They fear the unknown and crave more certainty. Yet, both groups demonstrated continued joy and a fighting spirit, supported by the desire to bring new life into the world and help their children thrive despite the threats of the pandemic.
Our participants reported embracing responsibility and using the restrictions to spend more quality time with family, engaging in positive self-talk, sharing and spreading optimism, and keeping their faith. The impact of adversity may have actually awakened certain qualities and skills in people, whether we attribute them to posttraumatic growth or some other phenomenon, perhaps stemming from humanistic psychology (Bosankić et al., 2019, p. 76). This study’s findings are in line with Stallard et al.’s (2021) study of the caretakers of children, suggesting evidence of posttraumatic growth in several domains including greater appreciation of life and positive spiritual change.
Many participants found peace and drew hope from their religion and spirituality. Perhaps positive religious strategies advocated by religious leaders can be applied together with other psychological techniques to improve resilience and well-being (Hashmi et al., 2020). “Religious response to the COVID-19 pandemic may have particularly important implications for well-being in vulnerable contexts where the challenges of long-standing social-structural issues (e.g., poverty) have been amplified by the public health crisis” (Counted et al., 2020, p. 12).
Despite their fears and adversities, our participants seem to remain optimistic and hopeful, and have the necessary skills needed to adequately deal with crises and challenging conditions during the outbreak. They dread the unknown, but they do not allow it to make them stagnant: They conquer it by embracing the fear. This contradiction points to people’s amazing abilities to adapt to adverse life conditions such as the COVID-19 pandemic. However, our participants are active members of the local pregnancy and motherhood support groups. So, it is also likely that their adaptability and ability to adjust to adversity are grounded in this as well as in their positive self-perceptions, previous coping experiences, and reported supportive and loving relationships.
Since research evidence indicates that stress, depression, and conflict reduce the healthy immune response to virus infections (Cohen, 2021), our findings can serve as an important resource for the local public health policymakers. Continuous efforts should be made to empower women and to generally improve their psychological well-being, so they will become more successful in coping with adversities. Our findings suggest that women with children seem to deal with more challenges than pregnant and first-time mothers. One proposition might be “offering workshops for parents on using positive parenting styles that encourage tolerance, sympathy, and positive religious coping in dealing with adversities, such as a global pandemic “(Mahamid & Bdier, 2021, p. 49).
Strengths and Limitations
To the best of our knowledge, this study is the first one on this topic in the Balkan region. It provides insight into the issues and challenges pregnant women and mothers face, and informs on both local and national efforts to strengthen the health and psychological services provided during and particularly after the pandemic. Healthcare professionals, in preparation for the current reappearance of COVID-19 and future pandemics, may also benefit from the perspectives of the recipients of their care. However, because our participants are active members of local associations, our findings are limited to that particular population of perinatal women and new mothers. Also, the sample is a small one of convenience, so that generalizability cannot be assumed. Further, participants’ overall physical and psychological health, marital quality, and total income probably also affect the well-being of these women during COVID-19. It is the voices of those women which are rarely heard – marginalized minorities, living in rural areas, uneducated, and of low SES – further studies should investigate. “Understanding the societal risk factors that make some groups particularly vulnerable is essential to ensure more effective interventions for this and future pandemics” (Mena et al., 2021, p. 327). Their COVID-19-related needs and challenges should be explored and they should be provided appropriate support.
Conclusion
This study explored the lived experiences of pregnancy and new motherhood during COVID-19 in Bosnia using an interpretative phenomenological analysis methodology. Our findings indicate that the essence of lived experiences of pregnancy and childbirth during the COVID-19 pandemic was expressed by the concepts of (a) being trapped in the fear of the unknown and (b) adapting and embracing uncertainty. The main themes that emerged from the interviews reveal grounded fear but also adaptability. The pandemic is far from over, and although people have amazing abilities to adapt to adverse life conditions, many aspects of the pandemic’s impacts on vulnerable populations remain unexplored. Our findings provide some guidance to operationalize the lived experiences of our participants into items for future mixed-method longitudinal studies that would lead to strategies to mitigate the adverse effects of the pandemic on perinatal women and new mothers.
The authors wish to thank all the amazing women who participated in the study.
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