The protective role of postpartum resilience on anxiety rates of Brazilian mothers during the COVID-19 pandemic

Objective: We evaluated the protective effect of postpartum resilience (measured before the pandemic onset) on the prevalence of moderate to severe anxiety symptoms during the coronavirus disease (COVID-19) pandemic. Methods: The sample included 589 mothers from a longitudinal study in southern Brazil. Three months after delivery we assessed maternal resilience through the Resilience Scale (RS). The Generalized Anxiety Disorders 7-item (GAD-7) was used to assess anxiety symptoms during the COVID-19 pandemic. Results: The prevalence of severe to moderate anxiety symptoms in this sample was 28.4% (95% CI: 25.0; 32.0). Resilience showed to be a protective factor against moderate to severe anxiety symptoms during the pandemic (OR: 0.98; p <0.001). Conclusions: The results showed that postpartum resilience is a factor associated with lower odds of a more intense manifestation of anxiety during pandemic periods. Thus, strengthening resilience by reinforcing appropriate coping strategies can prevent mental health problems.


INTRODUCTION
The coronavirus disease (COVID-19) pandemic has so far caused more than 630,000,000 contamination cases worldwide, leading to more than 6,590,000 deaths until early November 2022 1 .In Brazil, the impact of the pandemic has also been devastating: until the same period, more than 34,800,000 people were infected since the beginning of the pandemic and more than 680,000 people died as a result of COVID-19 1 .With high transmission, strategies for combating the spread of the virus have been applied in several countries since the first half of 2020.
The confinement measures have led families with children to face greater challenges related to managing their home office and the care and activities of their children.Being a woman, living with a partner or other people, as well as having children have been considered risk factors for anxiety in this period 2,3 .An increase in anxiety rates was observed in the Brazilian population during this period, where one study reported a 2.4-fold increase in the prevalence of anxiety among mothers 4 .
Some intrinsic factors are important to mitigate the anxiety experienced in highly anxiogenic situations, such as a pandemic.For instance, resilience is a two-dimensional "dynamic process wherein individuals display positive adaptation despite experiences of significant adversity or trauma" 5 .Based on this, resilient individuals can display adaptive behaviors in response to stressful situations, reducing the chances of developing mental disorders 6 .
Some studies revealed a direct relationship between mental health and resilience during the COVID-19 pandemic, showing that the greater the potential for resilience, the lower the scores of anxiety and stress in the general population 7,8 .Similar results were found in a few studies with pregnant and postpartum women, as well as parents of children aged 0-18 years 9,10 .Ultimately, resilience can mediate the impact of the pandemic on mental healt 7,8,11 , proving to be a possible ally in psychological treatment.
Considering the risk factors for anxiety found in previous studies and that nationals and internationals studies investigating the impact of postpartum resilience on the mental health of mothers during the COVID-19 pandemic are scarce, the main objective of this study was to evaluate the protective effect of resilience on anxiety symptoms during the pandemic in a sample of mothers in a city in southern Brazil.As a secondary aim, we described the prevalence of anxiety symptoms.

Design and participants
This is a longitudinal study nested in a larger study that followed 983 women and their children since pregnancy.In 2016, 50% of the census sectors in the urban zone of the city of Pelotas (southern Brazil) was randomly drawn.All residences located in these census sectors were visited by a research team to identify pregnant women until the 24th week of pregnancy.The participants were assessed for resilience at 90 days postpartum between 2016 and 2019.At this time there was no exposure to the COVID-19 pandemic.Then, eight months after the onset of the pandemic, all mothers who agreed to participate in a telephonic assessment of their emotional state were assessed for anxiety (N = 674; 68.6% of the women evaluated at baseline).At this moment, the children's ages ranged from 17 to 54 months (mean [M] = 34.28;standard deviation [SD] = 9.46; median [Mdn] = 34.00).In this study, we included only mothers that answered both anxiety and resilience instruments (N = 589).

Instruments
We used the Resilience Scale (RS) three months after delivery to evaluate resilience 12 .This self-report scale is composed of 25 items that evaluate resilience on a 7-point scale from 1 (disagree) to 7 (agree) points.Since this scale has no validation studies for Brazilian adult mothers, we considered it a unidimensional scale, thus being included in the statistical analysis as a continuous variable.Therefore, the higher the score the greater the potential for resilience.The Cronbach's alpha for our sample was 0.90.
Anxiety symptoms during the COVID-19 pandemic period were assessed through the Generalized Anxiety Disorders 7-item (GAD-7).This is a self-report instrument that measures the presence of anxiety symptoms in the last two weeks on a Likert scale from zero (not at all) to three (almost every day) points.We used the cut-off point of ≥ 10 points, indicating the presence of moderate to severe symptoms 13 .
We also applied a questionnaire with the following COVID-19-related variables: started working from home due to the pandemic, financial losses (got fired/had salary reduction), family income (in Reais -R$) in the last month (in tertiles), confinement duration (time without leaving home in months), number of people that live in the house, have a family member that needs to leave home to work, maternal COVID-19 diagnosis, family member COVID-19 diagnosis, death of family member due to COVID-19, follow all or almost all COVID-19 social distancing recommendations, and epidemiological weeks.

Ethical aspects
All procedures performed in our study were in accordance with the ethical standards of the Helsinki Declaration and its later amendments.The Research Ethics Committee of the Catholic University of Pelotas approved this project under protocol no.47807915.4.0000.5339.The Free and Informed Consent Form was read to all participants who gave their verbal consent.

Statistical analysis
We calculated descriptive statistics through simple and relative frequencies for categorical variables and mean and standard deviation for numerical variables.We used the Chi-square test to compare proportions.The distribution of the numeric variable was tested through the Kolmogorov-Smirnov test.After verifying that it did not follow a normal distribution, we used the t-test for independent samples with a bootstrapping procedure (1000 resampling and biascorrected and accelerated [BCa] bootstrap 95% interval) to correct distribution deviations.All variables that presented a p-value < 0.20 in bivariate analysis were conducted to multiple logistic regression.All analyses were performed using the IBM SPSS 23.0 software.We considered statistically significant the results that presented a p-value < 0.05.

RESULTS
Of the participants, 28.4% (95% CI 25.0; 32.2) had anxiety symptoms considered moderate to severe during the COVID-19 pandemic.Sample characteristics are presented in Table 1.
We conducted a post-hoc sample power analysis to verify the statistical power of our sample.Considering a 95% confidence interval and the mean differences of resilience among mothers who presented and did not present moderate to severe anxiety symptoms, we found a statistical power of 99.7% in our sample.
Concerning COVID-19-related variables, none of them presented an association with anxiety symptoms (p > 0.05).
After adjusting for COVID-19-related variables (financial losses, family income in the last month, living with a partner, having a family member that needs to leave home to work, and death of a family member) only resilience was associated with anxiety symptoms during the pandemic (OR 0.98, 95% CI 0.97; 0.99, p < 0.001), evidencing it as a protective factor for the manifestation of moderate to severe anxiety symptoms during the pandemic.(Table 2) The model was statistically significant (χ 2 (7) = 31.735,p < 0,001; Nagelkerke R 2 = 0.075).

DISCUSSION
We sought to verify the effect of resilience on prevalence of anxiety symptoms during the COVID-19 pandemic in a sample of mothers in a city in southern Brazil.The prevalence of moderate to severe anxiety symptoms in mothers found in our study is in accordance with the rates described in the literature (ranging from 25.9% to 32.7%) 4,14 .This reveals that this population is vulnerable in stressful periods, since social isolation strategies may have overloaded these women and impaired their mental health.
As the main result, we found that resilience presented a protective role in anxiety rates, being the only factor that remained associated after the adjusted analysis.Therefore, women with higher means of resilience presented lower anxiety rates during the COVID-19 pandemic.Resilience is related to the ability to overcome and cope with adverse situations, crises, or situations considered to be at risk for the development of mental disorders.For instance, the literature demonstrates that resilient individuals manage to maintain their emotional balance throughout life, with a lower probability of developing mental disorders 6 .
In this context, the COVID-19 pandemic has been considered a period of risk for mental illness in women, especially for mothers, who had to isolate themselves with their children at home and face the challenges related to routine, care, and other activities, providing higher levels of anxiety and stress.However, our results showed that resilience played a key role in reducing anxiety symptoms in these women.Thus, mothers in a resilient process seem to have been able to face the parents of 0-18 months children showed that resilience was a predictor of lower anxiety during the COVID-19 pandemic 10 .A similar result was observed in a North-American study with pregnant and 6-month postpartum women 9 .
The literature shows that resilience may also play a mediator role in the impact of COVID-19 stressors on anxiety 7,8 .An Austrian study also revealed that the association between the perceived psychological impact of the COVID-19 pandemic and anxiety symptoms was moderated by resilience 11 .However, the cross-sectional nature of the studies can lead to some bias, since the experience of stressful events can also strengthen resilience 15 .
Our findings must be interpreted in light of some limitations.First, the magnitude of the odds ratio was low, requiring further studies to confirm the results found.Second, the period of data collection may have influenced the rates of anxiety symptoms, since by the end of the second half of 2020 there was already greater knowledge about the virus, as well as studies on vaccines were already being conducted.Third, considering that resilience is not constant over time 6 , from the moment of the assessment of this construct (3 months postpartum) until the pandemic (at least 14 months of difference), the resilience capacity of the participants may have changed.And fourth, we only considered  pandemic period with less psychic suffering, showing fewer anxiety symptoms.
Resilience has been shown to be a consistent protective factor in the context of mental health in different populations.Despite studies with mothers are scarce, our findings are in conformity with the literature.A study with Australian anxiety as a measure for the participants' adaptation to the pandemic context, not including other possible negative adaptation constructs, such as depressive symptoms or substance abuse.Finally, it should be noted that resilience is not only the individuals' ability to maintain their mental health in the face of significant adversity but it is also related to their ability to recover it.Thus, during or after the moment of adversity experienced (in this case, the pandemic period), there is the possibility that some women have developed greater resilience, due to the fact that it is not a static characteristic.Thus, our study did not assess resilience in both assessments but indicated evidence of its positive role in attenuating severe manifestations of mental health problems.We should mention that there are certainly other factors related to maternal mental health that were not addressed in our study in addition to those controlled in our analyses.For instance, post-traumatic growth is a factor that should be considered.For this reason, we suggest that studies including these other variables should be conducted.

CONCLUSIONS
Despite the adversities of a pandemic, individuals with a higher potential for resilience seem to present lower levels of anxiety.This is particularly important because it shows that in situations of extreme stress, resilience makes a difference in mothers' mental health.Therefore, given the importance of this factor in highly stressful situations, such as the current pandemic, women should focus on maintaining and increasing resilience, through the implementation of strategies to reinforce adaptive behaviors and increase women's control in adverse situations.

Figure 1 .
Figure 1.Resilience scores distribution among mothers with and without moderate to severe anxiety symptoms during the COVID-19 pandemic in the city of Pelotas, Brazil, 2020-2021.GAD-7

Table 1 .
COVID-19-related variables and their association with anxiety symptoms in mothers during the pandemic in the city of Pelotas, Brazil, 2020-2021 *Variable with missing data.**Only those working before the pandemic.

Table 2 .
Logistic regression analysis of anxiety symptoms in mothers during the pandemic according to COVID-19-related variables in the city of Pelotas, Brazil, 2020-2021