Using the Qualtrics survey platform, women were asked to provide demographic, socioeconomic, and obstetrical information, and to complete an assembly of mental health questionnaires.

Demographic and socioeconomic details included questions regarding ethnicity, religious tendencies, education, family status, work status, average household income on a 5-point scale defined in relation to the average household income in Israel (1—“Far below average”, 5—“Far above average”).

Two specific COVID-19 pandemic questionnaires were included: first regarding PPE that included two questions: (a) whether the medical staff at birth used PPE (by maternal recollection), and if so, which equipment was in use (facemasks, rubber gloves, protective goggles or shield, disposable gown, or none of the mentioned) and (b) the extent to which participants experienced difficulty as a result, on a 5-point scale (1—“not difficult at all”; 2—“a little bit difficult”; 3—” fairly difficult”; 4—” very difficult”; and 5—“extremely difficult”). We named this parameter “Impact of PPE” and evaluated it both as continuous and categorical values with score of 1–3 considered low Impact of PPE and score of 4–5 considered high Impact of PPE. This categorization was not chosen arbitrarily, it was guided by the scale, as a score of 4 or 5 refers to extensive negative impact of PPE use.

“Fear of COVID-19 Scale” was the second questionnaire. It is a novel validated questionnaire that was designed to assess different aspects of the fear of the pandemic, and was found to be associated with anxiety, stress, and depression in the general population [20]. To note, this questionnaire was also validated for the Hebrew language [21]. The questionnaire includes seven statements such as “I am afraid of losing my life because of the Coronavirus.” Participants were asked to rate their degree of agreement with the statements on a 5-point scale (total score 7–35).

To evaluate stress and anxiety that may have originated from objective potential events during pregnancy and delivery, we further defined two variables: Stress-contributing complications during pregnancy that reflect the need for a high-risk clinical follow-up during pregnancy. These that were defined as the presence of one of the following: gestational diabetes, any hypertensive disorder, fetal growth restriction or major risk of prematurity defined as need for cerclage. The second variable, Stress-contributing complications during delivery that reflect unexpected negative outcomes during delivery and include one of the following: need for an urgent cesarean delivery, explorative relaparotomy or unplanned hysterectomy, need for a blood transfusion, any anal sphincter injury or need for admission to maternal or neonatal intensive care units.

PTSD diagnosis and symptoms were evaluated using the validated City Birth Trauma Scale )City BiTS(, a self-report questionnaire aimed at assessing PTSD following childbirth, based on the DSM-5 criteria [22] that was translated to Hebrew [23]. The questionnaire consists of 29 items dealing with possible traumatic events during or immediately after birth, of them, 22 items refers to symptomology. The questionnaire is divided into diagnostic criteria, as follows: A—stressor criteria, B—re-experiencing symptoms, C—avoidance symptoms, D—negative cognition and mood, and E—hyperarousal. Participants are asked to respond on a 4-point scale (not at all, once, 2–4 times and 5 or more times). Total PTSD score was calculated as the sum of criteria B–E (total score of 22 questions). PTSD was evaluated as a continuous variable for each criterion separately and for total PTSD symptoms. Also, PTSD diagnosis was determined if participant replied any answer other than “not at all” to at least one question in criteria A–C and at least two questions for criteria D–E. PPD diagnosis and symptoms were evaluated using the validated Edinburgh Postnatal Depression Scale )EPDS(questionnaire [24]. This questionnaire is composed of 10 items, scored by using a 4-point scale (0–3). A score of ≥10 was considered as possible depression diagnosis [2426] and is commonly used in Israel as a threshold that requires further evaluation for detection of PPD symptoms. Depression was evaluated as a continuous variable to evaluate PPD symptoms [27]. Ultimately, all collected data were verified with each center’s perinatal and postnatal database.

For the Arabic version, previously translated and validated questionnaires were used, or alternatively, questionnaires were translated and back-translated by native Arabic speakers. A complete set of questionnaires is available as a Supplementary Material.

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