Factors Associated With Changes in Pregnancy Intention Among Women Who Were Mothers of Young Children in New York City Following the COVID-19 Outbreak

Key Points Question Were there changes in pregnancy intentions among women who were mothers of young children around the peak of the first wave of COVID-19 in New York City? Findings In this cross-sectional study of 1179 women in New York City who were mothers of young children, nearly half of those who had been attempting to become pregnant and more than a third who had been thinking about trying before the COVID-19 pandemic stopped in the first few months of the outbreak. Women who responded to a survey during the lockdown were more likely to cease attempts or plans to become pregnant. Meaning The results of this study suggest that the outbreak of the COVID-19 pandemic was associated with fewer women planning or attempting to become pregnant; these findings may have long-term effects on fertility rates.

Women who responded to a survey during the lockdown were more likely to cease attempts or plans to become pregnant.

Meaning
The results of this study suggest that the outbreak of the COVID-19 pandemic was associated with fewer women planning or attempting to become pregnant; these findings may have long-term effects on fertility rates.

Introduction
Accumulating evidence suggests that, in many parts of the world, birth rates have decreased following the COVID-19 outbreak.4][5][6] Recent data suggest that, although the number of births was already decreasing in the US, the decrease between December 2019 and December 2020 was 26% greater than the average year-over-year decrease across the prior 4 months. 7VID-19-related changes in pregnancy intentions have the potential to accelerate the steady decrease in fertility rates seen since the mid-1900s in almost all regions of the world. 8On a societal level, reduced fertility rates may have both beneficial and adverse consequences by reducing the strain on the environment while increasing the dependency ratio.On an individual level, people's decision to delay or abandon childbearing may have negative ramifications across multiple domains.
Pregnancy and childbirth become riskier as women age. 9Those who delay may experience age-related infertility requiring medical intervention, which is associated with personal 10,11 and financial 12 costs, as well as potential health risks to women and children. 13In addition, relinquishing the intention to have more children altogether is associated with increased psychological distress 14 among women.
This study aimed to assess changes in pregnancy intention since the COVID-19 outbreak began among women who were mothers of young children around the peak of the first wave in New York City (NYC), which was then the epicenter of the North American outbreak.We hypothesized that women who had been planning or trying to conceive before the outbreak would report delaying their plans or attempts, and those who experienced the greatest pandemic-related increases in stress and financial strain would be more likely to delay or abandon their pregnancy intentions.

Study Population
The New York University Children's Health and Environment Study (NYU CHES) is a longitudinal pregnancy cohort that has enrolled women at less than 18 weeks' gestation since March 2016.
Women are recruited at 1 of 3 NYU-affiliated prenatal care sites and followed up through pregnancy, childbirth, and their children's early years.Questionnaire data and biospecimens are collected in each trimester, at birth, and at periodic intervals throughout infancy and early childhood.NYU CHES is a as well as their stress level during the 2 weeks preceding the questionnaire using the validated 4-item Perceived Stress Scale (score range, 0-16, with higher scores denoting greater stress). 18They were also asked about COVID-19 symptoms, diagnoses, and testing histories among household members since March 1, 2020 (the day of the first confirmed COVID-19 diagnosis in NYC), whether they or another adult in the household had lost their job due to the pandemic, and whether any adult in the household was an essential worker.The date of survey completion was dichotomized at June 1, 2020, when NYC began reopening after lockdown.

Statistical Analysis
Three groups were derived from the series of questions about pregnancy intentions.Pre-COVID-19 planners were the first group; before the pandemic, these women were thinking about becoming pregnant within the next 6 to 12 months.The second group comprised pre-COVID-19 triers: women who, before the pandemic, were actively trying to become pregnant.The third group comprised pre-COVID-19 nonplanners/nontriers; before the pandemic, these women were not thinking about becoming pregnant within the next 6 to 12 months.
Outcomes were defined as changes in the intentions of these women.The outcome groups included, among pre-COVID-19 planners, women who were no longer thinking about becoming pregnant within the next 6 to 12 months at the time of questionnaire completion; among pre-COVID-19 triers, women who were no longer trying to become pregnant at the time of questionnaire completion; and, among pre-COVID-19 nonplanners/nontriers, women who were newly thinking about or trying to become pregnant at the time of questionnaire completion.In each case, the comparison group consisted of women who did not change their intentions.

Discussion
The COVID-19 pandemic was associated with altered pregnancy intentions among women who were mothers of young children in this large, diverse NYC cohort.Nearly half of women who had been trying to become pregnant and more than a third who had been thinking about trying stopped in the first few months of the COVID-19 outbreak, and only a small proportion newly contemplated becoming pregnant.Among those who ceased trying, fewer than half were sure they would resume trying once the pandemic was over, suggesting many may be abandoning rather than delaying plans to expand their families, with potential long-term consequences for the overall fertility rate.
Our findings align with those of a national internet-based survey of 2009 sexually active cisgendered women aged 18 to 49 years conducted by the Guttmacher Institute from April 30 to May 6, 2020.Lindberg et al 6 reported that more than 40% of respondents had changed their plans about when and how many children to have, including 34% who wanted to become pregnant later or have fewer children because of the pandemic.Lower-income and non-Hispanic Black and Hispanic women were more likely to delay pregnancy or reduce their desired number of children.Although this study was larger than ours and included nulliparous as well as parous women across the reproductive life span, it was based on a convenience sample and was unable to explore in comparable depth associations with household-level or COVID-19-related factors.
In our survey we found that women who ceased to contemplate or attempt pregnancy following the outbreak tended to be less financially secure and that the opposite was true for women who were newly considering pregnancy, although results were not statistically significant, possibly because of the small sample size.This finding is similar to what was seen during the 2008 recession, when data from the US National Vital Statistics System showed that the total fertility rate precipitously decreased following 2 decades of hovering around replacement level. 19The fertility rate has since continued to decrease, reflecting changes in fertility preferences, and reached an historic low of 1.64 births per woman of reproductive age in 2020-the most recent data available.
Even as the gap between 2019 and 2020 monthly births had been widening throughout 2020, December, which was the earliest it would be reasonable to expect to see an association between COVID-19 and pregnancy intention (9 months following the first widespread outbreaks in the US), stood out, with a 7.7% decrease compared with 2019, 2 percentage points higher than the average decrease across the previous 4 months. 7Reports from both the Brookings Institution 20 and the Center for American Progress 21 highlight the many ways in which the economic effects resulting from  Pew Charitable Trusts found that, between February and August 2020, the time frame of our study, 3 times as many women who were mothers of small children lost their jobs as men who were fathers 22 ; in September, the discrepancy increased to 4 times as many. 23This level contrasts with the 2008 recession, in which more men lost jobs.Although more women who were Black lost jobs than those who were White in both the 2008 and COVID-19 downturns, the current race gap is greater, underscoring the intersectionality of race and sex when it comes to economic disadvantage. 23men who were no longer considering or trying to become pregnant tended to report higher stress levels, although findings were not statistically significant, possibly because of the small sample size.The 4-item Perceived Stress Scale asks about feelings of control, confidence, optimism, and being overwhelmed, all of which are relevant to the pressures of raising young children under pandemic restrictions, including remote schooling and insufficient childcare.Other potential sources of stress include anxiety, depression, and domestic violence, which have been shown to have increased among pregnant women and mothers since the outbreak. 24In addition, respondents' feelings may have been affected by heightened tension around racial issues prevalent throughout the spring and summer of 2020 and the intensity of Black Lives Matter protests following the death of George Floyd.Although our survey did not specifically interrogate perceived racial discrimination and anxiety around racism, the temporal coincidence of increased stress among those no longer considering pregnancy with the concurrent national focus on racial injustice suggests that this may be an avenue for future research.
Women least likely to cease contemplating or attempting pregnancy and those most likely to newly consider becoming pregnant in our study tended to be high-income, highly educated, and non-Hispanic White individuals.This finding parallels other evidence suggesting that those with financial security have continued to actively pursue pregnancy despite the pandemic, most obviously in the area of assisted reproduction, 25,26 where use rates align with income and race, especially in states where insurance coverage is not mandated. 27,28

Strengths and Limitations
The greatest strength of our study is its inclusion of data from a large, diverse group of women who were mothers of young children during and immediately following the first wave of the COVID-19 outbreak in NYC.Although our results are not generalizable to nulliparous women, they are generalizable to the population of women who had recently given birth in NYC and may be applicable to comparable populations during COVID-19 epidemic peaks.
The study also has limitations, the main one being the lack of power owing to the low prevalence of women reporting planning to become pregnant or actively trying before the pandemic.
Although this study was nested within a longitudinal cohort, we did not have a pre-COVID-19 assessment of pregnancy intention in our database.These responses may be affected by recall bias, as women were asked to recollect their pregnancy intentions up to 6 months after the outbreak and under different circumstances.We hypothesize that any recall bias would most likely lead to underreporting of pre-COVID-19 planning or trying, which would result in a reduced sample size for analyses of pre-COVID-19 planners and triers.Although we did not explicitly ask whether changes in pregnancy intention were due to the COVID-19 outbreak, the phrasing, bolding, and sequence of the survey questions suggest that it is reasonable to infer that these changes may be in large part attributable to the pandemic.Pregnancy intention questions were not asked of pregnant women or those who had given birth since the outbreak, because we assumed few, if any, women would be planning another pregnancy so soon.If they had, we have no reason to believe the change in their intentions would have differed from those of other participants.Non-Hispanic Black women were underrepresented in our study relative to their population in NYC owing to the demographics of the hospitals where NYU CHES recruits, preventing us from drawing more nuanced inferences on race.
Because we designed our study before the increased urgency of Black Lives Matter activism, we did not consider its potential relevance to our study and did not ask questions that might have

Conclusions
In our large, diverse NYC cohort of women who were mothers of young children, there were fewer women planning or attempting to become pregnant again following the outbreak of COVID-19 and there was substantial uncertainty around whether their intentions would change after the crisis passed.The stress and increased financial insecurity among mothers of young children in the early months of the pandemic could exacerbate declines in the fertility rate over the long term.Future studies might explore whether pregnancy intentions have rebounded as conditions improved and whether patterns have differed across racial and ethnic groups.
pregnancy intentions among women who were mothers of young children around the peak of the first wave of COVID-19 in New York City?Findings In this cross-sectional study of 1179 women in New York City who were mothers of young children, nearly half of those who had been attempting to become pregnant and more than a third who had been thinking about trying before the COVID-19 pandemic stopped in the first few months of the outbreak.
16ctors Associated With Changes in Pregnancy Intention Following the COVID-19 Outbreak Hispanic or married/partnered, reflects the population of pregnant women in NYC.15Beginning April 20, 2020, COVID-19 questionnaires were emailed to NYU CHES participants who were pregnant or had delivered a live infant (n = 2603).Participants could complete the survey in English, Spanish, or Mandarin, either online or on the telephone with a trained study team member fluent in their language.At the time of questionnaire completion, all participants had at least 1 child younger than 3.5 years.Survey administration closed on August 31, 2020.Response rates were calculated according to the American Association for Public Opinion Research reporting guideline for survey studies.16NYUCHES and the COVID-19 questionnaire were approved by the institutional review board of the NYU Grossman School of Medicine.All participants provided written informed consent.Participants did not receive financial compensation.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Box. COVID-19-Related Pregnancy Intention Questions, New York University Children's Health and Environment Study, 2020
across strata of pregnancy intention outcomes.Differences in categorical variables were analyzed with χ 2 tests, and t tests were used to assess differences in continuous variables.Simple logistic regression models were fit to estimate crude associations and multivariable logistic models were fit to estimate mutually adjusted associations between participant characteristics and pregnancy intention outcomes.Variables were selected according to results of bivariate analyses.Final models included covariates that, with 2-tailed testing, were significantly associated (P < .05)with the outcome (changing pregnancy intention) among at least 1 of the 3 groups and not associated with other variables.First, a model was fit among pre-COVID-19 planners and triers.These outcomes were collapsed owing to small sample size of those actively trying to become pregnant.Second, a model was fit among pre-COVID-19 nonplanners/nontriers.Sensitivity analyses were considered by fitting models among planners and triers separately and excluding women outside the NYC metropolitan area.more likely to be younger (mean [SD], 32.3 [5.8] years), have more children at home, report higher perceived stress, and have taken the survey before June 1, 2020.Among those actively trying to become pregnant before the COVID-19 pandemic, Hispanic women (19 [63.3%]), women with lower educational levels (13 [43.3%]), and women with more children living in the home (mean [SD], 1.8 [0.9]) were more likely to have stopped.Among pre-COVID-19 nonplanners/ nontriers, women who reported newly thinking about becoming pregnant were more likely to be 1. [All]: Before the COVID-19 epidemic, were you thinking about becoming pregnant in the next 6 to 12 months?A. If yes, Before the COVID-19 epidemic, were you actively trying to become pregnant?If yes, Are you still trying to become pregnant?B. If no, Do you plan to resume trying to become pregnant once the epidemic is over? 2. [All]: Are you currently thinking about becoming pregnant in the next 6 to 12 months?A. If yes, Are you actively trying to become pregnant right now? Participant demographic, COVID-19-related, stress-related, and financial/occupational characteristics were compared Results Of the 2603 women contacted, 1560 (59.9%) completed the COVID-19 questionnaire by August 31, 2020.After excluding those who were pregnant (n = 228), had recently given birth (n = 103), and were missing responses to these 2 questions (n = 40) and pregnancy intention questions (n = 10), 1179 women (75.6% of respondents) remained in the analytic sample.Mean (SD) age was 32.2 (5.6) years.Respondents were sociodemographically similar to the underlying cohort (eTable 1 in the Supplement).A total of 191 women (16.2%) reported that before the outbreak they were thinking about becoming pregnant within the next 6 to 12 months but not yet trying, 61 (5.2%) reported actively trying, and 927 (78.6%) reported not thinking about becoming pregnant within the next 6 to 12 months (eTable 2 in the Supplement).Women in the 3 groups were comparable in age and pre-COVID-19 stress levels but differed according to a number of other baseline characteristics.Women thinking about becoming pregnant within the next 6 to 12 months were most likely to be White (108 [56.5%]), whereas Hispanic women represented most of those not considering pregnancy (544 [58.7%]).Those who were actively trying to become pregnant (32 [52.5%]) or thinking about becoming pregnant (147 [77.0%]) were more likely to have private health insurance; most of those not considering pregnancy had public health insurance (552 [59.6%]).Women contemplating pregnancy were more likely to have annual household incomes greater than or equal to $100 000 (127 [66.5%]), at least a bachelor's degree (151 [79.1%]), and the highest level of financial security (116 [60.7%]) compared with other groups.Women who were not considering pregnancy had more children living in the home (mean [SD], 2.0 [1.1]) than those who were thinking about becoming pregnant (mean [SD], 1.3 [0.8]) or trying to become pregnant (mean [SD], 1.6 [0.8]).In bivariate analyses focusing on women who changed their minds after the pandemic outbreak, among pre-COVID-19 planners, a greater proportion of women with public insurance (22 [31.4%]), lower income (25 [35.2%]), lower educational level (25 [35.2%]), lower current financial security (10 [14.1%]), and COVID-19-related job loss in the household (41 [57.7%]) stopped contemplating pregnancy within the next 6 to 12 months (Table 1).Those no longer contemplating JAMA Network Open | Obstetrics and Gynecology Factors Associated With Changes in Pregnancy Intention Following the COVID-19 Outbreak JAMA Network Open.2021;4(9):e2124273.doi:10.1001/jamanetworkopen.2021.24273(Reprinted) September 15, 2021 4/11 Downloaded From: https://jamanetwork.com/ on 09/29/2023 pregnancy were also

Table 2 .
Odds Ratios From Logistic Regression Models Regarding Changing Fertility Intention Among 252 Participants

Table 3 .
Odds Ratios From Logistic Regression Models for Factors of Thinking of Becoming Pregnant Among Those Who Were Not Thinking About It Before COVID-19 Among 927 Participants Downloaded From: https://jamanetwork.com/

on 09/29/2023 the
pandemic have disproportionately affected women, especially working mothers.A survey by The