Like most parents, I can remember – and my body can still feel – the blur of the first few months of parenting: the lack of sleep, the constant worrying and fears, and the longing for adult conversation and connection. I would always say, “I can’t imagine how much harder this would be if I were also recovering from childbirth and trying to breastfeed as well!” What has come to be called “The Fourth Trimester” has always been a challenging time for parents. It turns out, it’s made all the more so when a child is born in the middle of a pandemic.
Dr. Dani Dumitriu and her colleagues at Columbia University Irving Medical Center set out to study mothers and babies in the New York City area during COVID-19. The COVID-19 Mother Baby Outcomes (COMBO) Study was launched a year ago, during the New York City surge last spring. The study sought to understand the impact of both COVID-19 infections – and the pandemic more generally – on the developing fetus, future child health, and future maternal well-being. While the research is ongoing, and has recently expanded to additional states with support from the Centers for Disease Control, Dr. Dumitriu's preliminary results already point to a number of troubling trends.
The Pandemic is Disrupting Mother-Infant Connection and Caregiving
One important way mothers and babies can experience closeness in the first year of life is through breastfeeding. Early results from the COMBO study show a decrease in breastfeeding rates among COVID-19-positive mothers, regardless of the timing of their disease during pregnancy. Even among mothers who had COVID-19 in the spring of 2020 but gave birth in the summer, there was a decrease in breastfeeding rates. More alarmingly, decreased breastfeeding for the group was almost exclusively due to a severe drop in breastfeeding among Hispanic women (who make up nearly 75% of the COVID-19-postive mothers treated at Columbia), a stark reminder of this pandemic’s further exacerbation of existing health inequities. (Though larger test groups may not bear this out, these preliminary results also showed an increase in breastfeeding among non-Hispanic mothers, which could be a result of more mothers being able to be home with their babies due to COVID.)
Unfortunately, the effects of the pandemic extend well beyond mothers who tested positive for COVID-19, especially when it comes to the effect of masks on infants. The “still face” experiment pioneered by Dr. Edward Tronick, studies the impact of a mother’s facial expressions on an infant’s stress levels. In the experiment, the mother engages with the child normally, then looks away briefly before looking back at the child with a “still face” (no expression at all; like a mannequin), and then looks away again before returning to normal interaction. “Still face” experiments show the child’s frustration and upset when they aren’t receiving the reciprocity that they are accustomed to from the mother, and importantly, the child’s upset “spills over” into the reunion phase when mom returns her attention to the baby.
In an innovative update to the “still face” experiment, COMBO researchers conducted a “mask face” experiment, which so far seems to indicate that children react even more unfavorably to a masked face than to a still face. The current COMBO data demonstrates that over the course of the pandemic, the child’s upset about the mask decreases. While this might seem encouraging at first, it is actually quite troubling as the reactions of the babies match the results from studies of babies of depressed mothers. That means that children growing up with masked parents are learning to disconnect and reduce expectations of reciprocity and mutuality, which will lead to emotional and behavioral challenges in later years.
Feelings of loneliness and isolation among parents have increased in recent years, and the pandemic is only making it worse. Last fall, Making Caring Common at Harvard University conducted a survey of almost 1,000 Americans to gauge their feelings on social isolation and loneliness. Based on their preliminary findings, more than half of mothers with young children reported frequent loneliness. And, 22% of Millennials – the largest cohort of parents of young children – report that they have no friends.
RAPID-EC (Rapid Assessment of Pandemic Impact on Development Early Childhood Household Survey) is an early childhood family well-being survey that continues to gather essential information regarding the needs, health promoting behaviors, and well-being of U.S. children and their families during the pandemic. Last August, the RAPID-EC data showed that 63% of caregivers had lost emotional support since the start of the pandemic, although 23% said they had gained emotional support. Not surprising, given social distancing norms, there were large decreases in caregivers being able to rely on friends (35%) and co-workers (30%) for this type of support. Welcoming a new child would usually bring visits and added assistance from extended family. Isolation from loved ones during the pandemic only exacerbates the feelings of loneliness among parents.
As one might imagine, giving birth in the midst of a pandemic also brings new fears about one’s own health, the health of one’s child, and the health of others in the family. Unfortunately, these factors and others are likely contributors to a concerning finding from the COMBO study. The percentage of mother-baby pairs who displayed emotional connection was half the rate compared to the number who did so prior to COVID-19. This was equally true among mothers with prior COVID-19 disease and those with no history of the disease, implying that the stress of the pandemic was the cause of this shift in parent-child relationships. Given that four million babies have been born in the United States alone since the start of the pandemic, this could translate into catastrophic long-term consequences.
The Solution is Right Before Your Eyes (Ideally Less Than a Foot Away)
Like many in the field of child development and family health, Dr. Dumitriu already knew about the crisis of connection in this country and feared that these dynamics would only be exacerbated by COVID-19. With a deep commitment to the importance of scientific assessment, she and her colleagues at Columbia University donated their time and effort immediately at the start of the pandemic to gather data and measure the impact of COVID-19 on babies and families. The data so far demonstrates that the pandemic is exacerbating pre-existing problems of parent-child emotional connection, underscoring how important it is to take action to support families.
Emotional connection describes a mutually positive nurturing relationship between parents and children that modulates and regulates emotions, learning, and behavior. It’s that cozy synchrony that occurs when a parent and baby look at each other, respond to each other’s cues, and express joy in each other’s presence. These early relationships play a critical role in development outcomes for children, with research indicating they may account for as much as 25-50% of the variability in school readiness. Even for families where babies have multiple adverse childhood experiences, known as ACEs (e.g., violence in the home or community, parental separation due to divorce or incarceration, etc.), the presence of positive nurturing relationships can offer protection and act as a buffer to those stresses.
The RAPID-EC study is finding much the same to be true during COVID-19. For families with lower levels of emotional support, those families experienced the “chain reaction” where concerns about paying for basic needs (like food, housing, or utilities) led to increased caregiver distress, which in turn predicts child emotional difficulties. But, importantly, for families with higher levels of emotional support, there was no relationship between material hardship and subsequent caregiver distress or child emotional difficulties over time. Fortunately, the RAPID-EC data showed that the source of the greatest increase in emotional support for parents was from their own children. Once again, nurturing parent-child relationships are proving to be a buffer against stress and adversity.
Children are born seeking reciprocal reactions from their parents. The youngest of children, in the fourth trimester, can only see about a foot away, and they search for recognizable faces that express reactions in response to their cues. If parents return the bid for connection, parents and children can mutually calm each other and co-regulate. Given the COVID-19 research findings, though, it is critical that parent-facing professionals and public health leaders identify ways to support caregivers in interacting with infants without masks when safe to do so.
Research already exists that demonstrates the healing power of nurture amidst adversity, separation, and anxiety. Studies have been completed by the Nurture Science Program at Columbia University in several neonatal intensive care units (NICUs) around the effectiveness of Family Nurture Care. Outcomes showed that for families who were able to establish and maintain autonomic emotional connection, mothers had reduced depression and anxiety and the babies had fewer behavioral problems.
As leaders and policymakers look at innovation and transformation within health care systems based on the experiences of the last year, they must heed the evidence and find ways to better support early foundational relationships between parents and their children. The emotional connection and mutual support that are at the core of these relationships are important buffers at times of increased stress like the pandemic, but also during “normal” times when far too many families experience added burdens from racism, poverty, and a host of other factors.
It is near the end of “the fourth trimester” that many babies begin to smile. Like most parents, I start smiling myself as I recall the uplifting feeling of my children’s infant smiles. Relationships have the power to heal. Families that welcomed new children in the past 12 months need support in a variety of ways from basic needs to physical health to emotional support. Hopefully philanthropy and policy can work in concert to ensure these families get the reinforcement they need. In the meantime, the good news is that new parents can establish autonomic emotional connection with their babies through simple, natural acts like singing together, crying together, and smiling together. It’s reassuring to know that at least one big part of the solution is already right there in our arms.