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Emotional wellbeing of student midwives during COVID-19

  • Author Footnotes
    1 ORCID 0000-0002-4200-0522.
    ,
    Author Footnotes
    2 @YvonneFontein.
    Yvonne Kuipers
    Correspondence
    Correspondence to: Edinburgh Napier University, School of Health and Social Care, Sighthill Campus, Edinburgh EH11 4BN, Scotland, UK.
    Footnotes
    1 ORCID 0000-0002-4200-0522.
    2 @YvonneFontein.
    Affiliations
    School of Health and Social Care, Edinburgh Napier University, Sighthill Campus, Edinburgh EH11 4BN, Scotland, UK

    School of Health and Social Care, AP University of Applied Sciences, Noorderplaats 2, 2000 Antwerp, Belgium
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  • Author Footnotes
    3 ORCID 0000-0003-0116-0738.
    Eveline Mestdagh
    Footnotes
    3 ORCID 0000-0003-0116-0738.
    Affiliations
    School of Health and Social Care, AP University of Applied Sciences, Noorderplaats 2, 2000 Antwerp, Belgium
    Search for articles by this author
  • Author Footnotes
    1 ORCID 0000-0002-4200-0522.
    2 @YvonneFontein.
    3 ORCID 0000-0003-0116-0738.
Open AccessPublished:November 29, 2022DOI:https://doi.org/10.1016/j.wombi.2022.11.012

      Abstract

      Background

      Mental health of students in higher education was affected during the COVID-19 pandemic.

      Aim

      To examine the emotional wellbeing of midwifery students in the Netherlands and Flanders (Belgium) during COVID-19.

      Methods

      A cross-sectional online-based survey with 619 Dutch and Flemish midwifery students. Sociodemographic details were obtained. Anxiety and depression were measured twice (T1, T2) during the COVID-19 pandemic.

      Findings

      Flemish students had significantly higher mean depression and anxiety scores than Dutch students during the total period of study (p < .001; p < .001). Total group mean depression and anxiety scores were significantly higher at T2 compared to T1 (p < .001; p < .001). In the Dutch student group, there was a significant increase of depression from T1 to T2 (p < .001). In the Flemish student group, both depression and anxiety scores significantly increased from T1 to T2 (p < .001; p < .001). A history of psychological problems predicted both depression and anxiety, irrespective of COVID-19 period or country (p < .001; p < .001). Being single (p.015) and having a job (p.046) predicted depression, irrespective of period or country. A history of psychological problems predicted depression (p.004; p < .001) and anxiety (p.003; p.001) during the total period of study. Being single also predicted depression during T2 (p.024).

      Conclusion

      These findings inform how emotional wellbeing of midwifery students was affected during the COVID-19 pandemic and identify those students that might need extra attention after the pandemic, during another pandemic or similar situations with social restrictions.

      Keywords

      STATEMENT OF SIGNIFICANCE
      Problem or issue
      The COVID-19 pandemic presented unique emotional challenges for midwifery students.
      What is already known
      Irrespective of the impact of COVID-19, midwifery students seem to be at risk for emotional health problems, based on age, gender, the emotional demanding and clinically and academic challenging nature of the study programme, and balancing student- and personal life.
      What this paper adds
      This study, conducted in two different countries, provides information on midwifery students’ emotional wellbeing throughout the first 15 months of the COVID-19 pandemic with successive (complete and partial) lockdown restrictions.

      Introduction

      The severe acute respiratory syndrome coronavirus (COVID-19) disease was declared as a pandemic by the World Health Organization on 11 March 2020. The COVID-19 pandemic affected higher education students due to disruptions in school and in social behaviours [
      • Rasmussen B.
      • Hutchinson A.
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      • Holton S.
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      • McTier L.
      • Kerr D.
      The impact of covid19 on psychosocial well-being and learning for Australian nursing and midwifery undergraduate students: a cross-sectional survey.
      ]. The pandemic presented unique challenges for students, of which academic work, mental health and isolation were most often reported [
      • Nieuwenhuijs W.
      • Stringa K.
      • Vancauwenbergh V.
      • Bijker K.
      The mental wellbeing of students during the COVID-19 pandemic.
      ,
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Wathelet M.
      • Duhem S.
      • Vaiva G.
      • et al.
      Factors associated with mental health disorders among university students in France confined during the COVID-19 pandemic.
      ,
      • Scott S.R.
      • Rivera K.M.
      • Rushing E.
      • Manczak E.M.
      • Rozek C.S.
      • Doom J.R.
      "I Hate This": a qualitative analysis of adolescents' self-reported challenges during the COVID-19 pandemic.
      ]. Midwifery education was greatly affected by the lockdown measures imposed by governments [
      • Bogossian F.
      • McKenna L.
      • Levett-Jones T.
      Mobilising the nursing student workforce in COVID-19: the value proposition.
      ,
      • Luyben A.
      • Fleming V.
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      Midwifery education in COVID-19- time: challenges and opportunities.
      ], causing anxiety, uncertainty, and emotional burden among students [
      • Kuliukas L.
      • Hauck Y.
      • Sweet L.
      • Vasilevski V.
      • Homer C.
      • Wynter K.
      • Wilson A.
      • Szabo R.
      • Bradfield R.
      A cross sectional study of midwifery students’ experiences of COVID-19: Uncertainty and expendability.
      ]. Theoretical education in the university context changed, adopted, and enhanced digital readiness in a rapid pace to manage student learning [
      • Ang W.H.D.
      • Shorey S.
      • Lopez V.
      • Chew H.S.J.
      • Lau Y.
      Generation Z undergraduate students’ resilience during the COVID-19 pandemic: a qualitative study.
      ].

      Mental health of midwifery students pre and peri-COVID-19

      In Europe, midwifery students are predominantly women and nearly two-third are younger than 21 years of age [
      • Ross L.
      • McSherry W.
      • Giske T.
      • et al.
      Nursing and midwifery students’ perceptions of spirituality, spiritual care, and spiritual care competency: a prospective, longitudinal, correlational European study.
      ]. Adolescent students are known to be more at risk for feeling distressed compared to other age groups [
      • Lemyre A.
      • Gauthier‐Légaré A.
      • Bélanger R.E.
      Shyness, social anxiety, social anxiety disorder, and substance use among normative adolescent populations: a systematic review.
      ,
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ], and female students are more likely to experience depression and anxiety than male peers [
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • McDonall J.
      • McTier L.
      • Hutchinson A.M.
      • Kerr D.
      • Lowe G.
      • Phillips N.N.M.
      • Rasmussen B.
      Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.
      ,
      • Chen T.
      • Lulock M.
      The mental health of university students during the COVID-19 pandemic: an online survey in the UK.
      ]. There were serious concerns about the pre-COVID mental health of student midwives because assessment of emotional health indicated that student midwives’ emotional wellbeing was not optimal [
      • Oates J.
      • Topping A.
      • Aria T.
      • Charles P.
      • Hunter C.
      • Watts K.
      The mental health and wellbeing of midwifery students: an integrative review.
      ]. Midwifery education is recognised as being stressful with the (emotional) demands of the theoretical and practical components of the study, including clinical, academic, and financial challenges [
      • Oates J.
      • Topping A.
      • Aria T.
      • Charles P.
      • Hunter C.
      • Watts K.
      The mental health and wellbeing of midwifery students: an integrative review.
      ,
      • Eaves J.L.
      • Payne N.
      Resilience, stress and burnout in student midwives.
      ,
      • Oates J.
      • Topping A.
      • Watts K.
      • Charles P.
      • Hunter C.
      • Arias T.
      ‘The rollercoaster’: a qualitative study of midwifery students’ experiences affecting their mental wellbeing.
      ]. Younger midwifery students [
      • Fenwick J.
      • Cullen D.
      • Gamble J.
      • Sidebotham M.
      Being a young midwifery student: a qualitative exploration.
      ] and students who juggle their study with other commitments, such as a job, social activities, and family life, struggle more to keep up with their academic and clinical demands and their personal commitments [
      • Carolan-Olah M G.
      • Kruger M.G.
      Final year students’ learning experiences of the Bachelor of Midwifery course.
      ]. Irrespective of the impact of COVID‐19, midwifery students seem to be more at risk for emotional health problems, based on age, gender, the demanding and challenging nature of the study programme, and balancing student- and personal life [
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Chen T.
      • Lulock M.
      The mental health of university students during the COVID-19 pandemic: an online survey in the UK.
      ,
      • Sögüt S.
      • Dolu İ.
      • Cangöl E.
      The relationship between COVID-19 knowledge levels and anxiety states of midwifery students during the outbreak: A cross-sectional web-based survey.
      ,
      • Von Soest T.
      • Kozák M.
      • Rodríguez-Cano R.
      • et al.
      Adolescents’ psychosocial well-being one year after the outbreak of the COVID-19 pandemic in Norway.
      ].
      Mental health problems of students in higher education increased during the pandemic compared to pre-pandemic prevalence rates [
      • Nieuwenhuijs W.
      • Stringa K.
      • Vancauwenbergh V.
      • Bijker K.
      The mental wellbeing of students during the COVID-19 pandemic.
      ,
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • McDonall J.
      • McTier L.
      • Hutchinson A.M.
      • Kerr D.
      • Lowe G.
      • Phillips N.N.M.
      • Rasmussen B.
      Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.
      ,
      • Chen T.
      • Lulock M.
      The mental health of university students during the COVID-19 pandemic: an online survey in the UK.
      ,
      • Hewitt R.
      Students’ views on the impact of Coronavirus on their higher education experience in 2020/2021. YouthSight. HEPI Policy Note 27.
      ,
      • Van de Velde S.
      • Buffel V.
      • Bracke P.
      • et al.
      The COVID-19 international student well-being study.
      ]. Students reported fear and worry about their own health and that of family and friends, difficulty in concentrating and disruptions to sleeping patterns. They reported worries about their course progression and assessment, increased concerns on academic performance, decreased motivation to study, and difficulties with adjusting to new online teaching methods, study strategies and the reduction of social interactions with their peers [
      • Rasmussen B.
      • Hutchinson A.
      • Lowe G.
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • Phillips N.
      • McDonall J.
      • McTier L.
      • Kerr D.
      The impact of covid19 on psychosocial well-being and learning for Australian nursing and midwifery undergraduate students: a cross-sectional survey.
      ,
      • Nieuwenhuijs W.
      • Stringa K.
      • Vancauwenbergh V.
      • Bijker K.
      The mental wellbeing of students during the COVID-19 pandemic.
      ,
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Von Soest T.
      • Kozák M.
      • Rodríguez-Cano R.
      • et al.
      Adolescents’ psychosocial well-being one year after the outbreak of the COVID-19 pandemic in Norway.
      ,
      • Hewitt R.
      Students’ views on the impact of Coronavirus on their higher education experience in 2020/2021. YouthSight. HEPI Policy Note 27.
      ]. Being younger and a higher number of years of study were positively associated with peri-pandemic depression and anxiety [
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • McDonall J.
      • McTier L.
      • Hutchinson A.M.
      • Kerr D.
      • Lowe G.
      • Phillips N.N.M.
      • Rasmussen B.
      Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.
      ].

      Midwifery research collaboration between the Netherlands and Flanders

      In a European cross-border mental health project (https://path-perinatal.eu), operational during the COVID-19 pandemic, a Dutch and a Flemish Higher Education Institution (HEI) collaborated in monitoring the peri-pandemic emotional wellbeing of Dutch and Flemish student midwives. Midwifery related research collaboration between Flanders (the northern and Dutch speaking part of Belgium) and the Netherlands, and midwifery research involving both populations is common [
      • Christiaens W.
      • Nieuwenhuijze M.
      • de Vries R.
      Trends in the medicalisation of childbirth in Flanders and the Netherlands.
      ,
      • Fontein-Kuipers Y.
      • Duivis H.
      • Schamper V.
      • Schmitz V.
      • Stam A.
      • Koster D.
      Reports of work-related traumatic events: a mixed-methods study.
      ,
      • Mestdagh E.
      • Timmermans O.
      • Colin P.J.
      • Van Rompaey B.
      A cross-sectional pilot study of student's proactive behavior in midwifery education: Validation of a developed questionnaire.
      ,
      • Mestdagh E.
      • Van Rompaey B.
      • Timmermans O.
      • Fontein-Kuipers Y.
      Proactive behaviour in midwifery practice: a qualitative overview based on midwives’ perspectives.
      ]. Approximately 48 % of the midwifery students in Flanders are Dutch, and after graduation they often start their career as a qualified midwife in a Dutch primary or secondary care setting [
      • Bleijenbergh R.
      • Mestdagh E.
      • Kuipers Y.
      Midwifery practice and education in Antwerp: forecasting its future with scenario planning.
      ,
      • Kenens R.
      • van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen. Peiling 2018.
      ,

      Vlhora. Oktobertelling 2019. Brussel. 2019. 〈http://www.vlhora.be/partners/index.html〉.

      ]. Of the current Dutch practising midwives, 20 % have been educated in Flanders [
      • Kenens R.
      • van der Velden L.
      • Vis E.
      • Batenburg R.
      Cijfers uit de registratie van verloskundigen. Peiling 2018.
      ]. In many ways Flanders and the Netherlands are similar with comparable political systems and demographic characteristics, and both countries face the same societal challenges such as ethnical diversity and socio-economic inequalities [
      • Christiaens W.
      • Nieuwenhuijze M.
      • de Vries R.
      Trends in the medicalisation of childbirth in Flanders and the Netherlands.
      ]. Flanders and the Netherlands have some vocabulary differences but overall speak the same language.

      Midwifery education in the Netherlands and Flanders

      In the Netherlands, midwifery education is a four-year programme while in Flanders it is a three-year programme, both full-time undergraduate, direct entry programmes. In both countries, professional development of student midwives occurs through theoretical learning and exposure to relevant practice learning activities. Students spend over a third of their program in the clinical area, being community practices and/or hospital settings (for further details, see Box 1). A significant difference with the Netherlands is that Flanders has a five-year combined nursing-midwifery Bachelor programme and a top-up nursing-midwifery programme at master’s level [
      • Bleijenbergh R.
      • Mestdagh E.
      • Kuipers Y.
      Midwifery practice and education in Antwerp: forecasting its future with scenario planning.
      ,

      Vlhora. Oktobertelling 2019. Brussel. 2019. 〈http://www.vlhora.be/partners/index.html〉.

      ].
      Midwifery education in Flanders and the Netherlands.
      Tabled 1
      FlandersNetherlands
      Number of HEIs*93
      Number of schools where the Bachelor midwifery programme is provided124
      Approximate number of students who enrol on the Bachelor midwifery program/year700220
      Approximate number of students graduating/year300150
      Approximate total number of midwifery students on the programme (all years)2240880
      Total number of years pre-registration midwifery programme34
      Number of European Credit Transfer and Accumulation System (ECTS) at graduation180240
      Restricted number of available programme places (Numerus Clausus)NoYes
      Entry/admission/selection testsNoYes
      Entry requirements: BiologyNot requiredRequired
      Entry requirements: ChemicsNot requiredRequired
      Entry requirements: MathematicsNot requiredRequired
      Pre-entry required number of years of formal education1211
      Clinical practice-theory ratio* *33 %−67 %35 %−65 %
      Study fees per year€1.120€2.143
      Compulsory attendance in-school educationNoNo
      Hours of face-to-face/online education theoretical education year 1a285279
      Hours of face-to-face/online education theoretical education year 2a266264
      Hours of face-to-face/online education theoretical education year 3a17280–93b
      Hours of face-to-face/online education theoretical education year 4aN/A0–58b
      *Higher Education Institution; ** Linear increase of clinical practice hours associated with year of study; a Estimated hours calculated based on various curricula of HEIs; b Minor 20 weeks (specialisation within or next to midwifery study

      Midwifery education in the Netherlands and Flanders during the COVID-19 pandemic

      In both countries the first COVID-19 pandemic wave with its concurrent lockdown, began in March 2020, easing in June 2020. A quick succession of a second wave and a third wave, both with lockdown regulations followed in October 2020 and March 2021, respectively. In each country, regulations for HEIs showed similarities in adapting the organisation of clinical placement and education up to June 2020, apart from examination and campus access [

      Ministerie van Onderwijs, Cultuur en Wetenschap. Service document HO – 2021-2022. Versie 11. Rijksoverheid: The Hague, Netherlands. 2021.

      ,

      Maenhout K. Nooddecreet Coronacrisis Hoger Onderwijs. Decr.Vl.Parl. van XXX over maatregelen in het hoger onderwijs voor het academiejaar 2019-2020 als gevolg van de coronacrisis, B.S., XX april 2020, hierna genoemd “Nooddecreet”. Gedr.st., Vl.Parl., 2019-2020, nr. 265/2. Parl.Hand., Vl.Parl., 15 april 2020.

      ,

      Vhlora. Pandemiematrix academiejaar 2020-2021. Vlaammse Hogescholenraad: Brussels, Belgium. 2020.

      ]. Exams in the Netherlands were a combination of both on-campus and online exams, opposed to the Flemish students who did all their exams online. The first three months of the pandemic, clinical placements were discontinued. In June 2020, students returned to the clinical area. There was no one-size-fits-all approach about the presence and involvement of the students. This depended on hospital and practice regulations, the situation and the woman’s preferences [

      Ministerie van Onderwijs, Cultuur en Wetenschap. Service document HO – 2021-2022. Versie 11. Rijksoverheid: The Hague, Netherlands. 2021.

      ,

      Maenhout K. Nooddecreet Coronacrisis Hoger Onderwijs. Decr.Vl.Parl. van XXX over maatregelen in het hoger onderwijs voor het academiejaar 2019-2020 als gevolg van de coronacrisis, B.S., XX april 2020, hierna genoemd “Nooddecreet”. Gedr.st., Vl.Parl., 2019-2020, nr. 265/2. Parl.Hand., Vl.Parl., 15 april 2020.

      ,

      Vhlora. Pandemiematrix academiejaar 2020-2021. Vlaammse Hogescholenraad: Brussels, Belgium. 2020.

      ,

      Ministerie van Onderwijs, Cultuur en Wetenschap. Service document HO – 2021-2022. Versie 13.2. Rijksoverheid: The Hague, Netherlands. 2022.

      ]. In both Flanders and the Netherlands, students who do not meet the minimal required European Credits (ECs) at the end of the first year of study, receive a binding recommendation that they cannot continue their study. During the pandemic, the binding recommendations were postponed to the end of the second year of study, allowing students more time to obtain the necessary ECs [

      Maenhout K. Nooddecreet Coronacrisis Hoger Onderwijs. Decr.Vl.Parl. van XXX over maatregelen in het hoger onderwijs voor het academiejaar 2019-2020 als gevolg van de coronacrisis, B.S., XX april 2020, hierna genoemd “Nooddecreet”. Gedr.st., Vl.Parl., 2019-2020, nr. 265/2. Parl.Hand., Vl.Parl., 15 april 2020.

      ,

      Vhlora. Pandemiematrix academiejaar 2020-2021. Vlaammse Hogescholenraad: Brussels, Belgium. 2020.

      ,

      Ministerie van Onderwijs, Cultuur en Wetenschap. Service document HO – 2021-2022. Versie 13.2. Rijksoverheid: The Hague, Netherlands. 2022.

      ]. In both countries, theoretical education was provided online although from June 2020 and onwards, Dutch students were allowed to come to campus for individual studying, opposed to the Flemish students. Weekly in-school skills/practical training re-started in the Netherlands in June 2020 with an adjusted group size adhering to the hygiene and social distancing rules and the square meters per classroom, while in Flanders this re-started in September 2020 with one lesson per fortnight in small groups of 15 students [

      Ministerie van Onderwijs, Cultuur en Wetenschap. Service document HO – 2021-2022. Versie 11. Rijksoverheid: The Hague, Netherlands. 2021.

      ,

      Vhlora. Pandemiematrix academiejaar 2020-2021. Vlaammse Hogescholenraad: Brussels, Belgium. 2020.

      ]. In April 2021, in-school education returned to one-day per week for the Dutch students, while there was no scale up of in-school activities for the Flemish students [

      Maenhout K. Nooddecreet Coronacrisis Hoger Onderwijs. Decr.Vl.Parl. van XXX over maatregelen in het hoger onderwijs voor het academiejaar 2019-2020 als gevolg van de coronacrisis, B.S., XX april 2020, hierna genoemd “Nooddecreet”. Gedr.st., Vl.Parl., 2019-2020, nr. 265/2. Parl.Hand., Vl.Parl., 15 april 2020.

      ,

      Ministerie van Onderwijs, Cultuur en Wetenschap. Service document HO – 2021-2022. Versie 13.2. Rijksoverheid: The Hague, Netherlands. 2022.

      ]. Belgium had a more active approach to vaccination compared to the Netherlands and the overall uptake was higher in Belgium than in the Netherlands [
      • Iftekhar E.N.
      • Prieseman V.
      • Baling R.
      • Bauer S.
      • Beutels P.
      • Calero Valdez A.
      • et al.
      A look into the future of the COVID-19 pandemic in Europe: an expert consultation.
      ]. From April 2021 and onwards, tests were freely available for students in both countries. HEIs in both countries were not allowed to ask students whether they were vaccinated or whether they had (self-) tested because both were not mandatory [

      Maenhout K. Nooddecreet Coronacrisis Hoger Onderwijs. Decr.Vl.Parl. van XXX over maatregelen in het hoger onderwijs voor het academiejaar 2019-2020 als gevolg van de coronacrisis, B.S., XX april 2020, hierna genoemd “Nooddecreet”. Gedr.st., Vl.Parl., 2019-2020, nr. 265/2. Parl.Hand., Vl.Parl., 15 april 2020.

      ,

      Ministerie van Onderwijs, Cultuur en Wetenschap. Service document HO – 2021-2022. Versie 13.2. Rijksoverheid: The Hague, Netherlands. 2022.

      ].
      Earlier studies about emotional wellbeing of midwifery students during COVID-19 did not distinguish between the pandemic waves [
      • Luyben A.
      • Fleming V.
      • Vermeulen J.
      Midwifery education in COVID-19- time: challenges and opportunities.
      ,
      • Kuliukas L.
      • Hauck Y.
      • Sweet L.
      • Vasilevski V.
      • Homer C.
      • Wynter K.
      • Wilson A.
      • Szabo R.
      • Bradfield R.
      A cross sectional study of midwifery students’ experiences of COVID-19: Uncertainty and expendability.
      ,
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Sögüt S.
      • Dolu İ.
      • Cangöl E.
      The relationship between COVID-19 knowledge levels and anxiety states of midwifery students during the outbreak: A cross-sectional web-based survey.
      ]. Being able to follow students based on common features such as country, age group, education programme, and being exposed to similar pandemic (lockdown) regulations, is of merit to make a statement whether emotional wellbeing of midwifery students changed during the pandemic and what affected their emotional wellbeing. Including several pandemic waves allows the effect of the initial shock and uncertainty of the first wave, and the adaptation to the lockdown and social distancing measures during the subsequent waves [
      • Brooks S.K.
      • Webster R.K.
      • Smith L.E.
      • Woodland L.
      • Wessely S.
      • Greenberg N.
      • Rubin G.J.
      The psychological impact of quarantine and how to reduce it: rapid review of the evidence.
      ,
      • Kuipers Y.
      • Bleijenbergh R.
      • Van den Branden L.
      • Van Gils Y.
      • Rimaux S.
      • Claerbout A.
      • Mestdagh E.
      Psychological health of pregnant and postpartum women before and during the COVID-19 pandemic.
      ]. Although the COVID-19 pandemic is a universal stressor experienced across the globe, it is likely that the psychological health impact of this event will differ among students, based on (inter)personal and contextual factors [
      • Brock R.L.
      • O’Hara M.W.
      • Hart K.J.
      • et al.
      Peritraumatic distress mediates the effect of severity of disaster exposure on perinatal depression: the Iowa flood study.
      ]. By exploring these factors, this study can contribute to the recognition of students who have been vulnerable to the adverse psychological effects of pandemic, providing suggestions for post-pandemic care [
      • Brock R.L.
      • O’Hara M.W.
      • Hart K.J.
      • et al.
      Peritraumatic distress mediates the effect of severity of disaster exposure on perinatal depression: the Iowa flood study.
      ,
      • Purdy N.
      Building back better in 2022 – with a renewed focus on pastoral care, emotional health and wellbeing for all.
      ]. Additionally, addressing this knowledge gap is important to understand the effects of a global pandemic and prepare for effective emotional support mechanisms for midwifery students during similar disruptions [
      • Dodds W.
      Disease now and potential future pandemics.
      ]. In this study we examined the emotional wellbeing of midwifery student in the Netherlands and Flanders during the first, second and third pandemic COVID-19 pandemic waves. We sought answers to the following questions:
      • What is the level of emotional wellbeing among midwifery students in the Netherlands and Flanders during the COVID-19 pandemic?
      • Are there differences in emotional wellbeing between Dutch and Flemish students during the COVID-19 pandemic?
      • Are there changes in emotional wellbeing over time within and between the groups of Dutch and Flemish students during the COVID-19 pandemic waves?
      • Are there student characteristics that predict changes in emotional wellbeing during the COVID-19 pandemic?

      Methods

      Design

      A cross-sectional online survey study was conducted with midwifery students in the Netherlands and Flanders. Eligible participants were 18 years of age or older, during any stage of their study. The data were collected between 17 March 2020–23 June 2021, using online self-completed questionnaires (Limesurvey©).

      Sampling

      The three Dutch and nine Flemish HEIs providing midwifery education were approached and informed about the study with all agreeing to recruit students. To obtain a representative sample, students were purposively recruited. To secure informed consent and confidentially requirements, we followed a procedure: A lecturer of each HEI (who was not involved in the study) distributed information about the study to the students, including the link and quick response (QR) code to the questionnaire through the HEIs’ intranet and, if available, HEI-moderated private social media platforms (Instagram©, Facebook©). The link and QR-code anonymously directed the participants to the questionnaire.

      Measures

      Sociodemographic and personal details (e.g., age, country of education, year of education, hours spent on individual study/week, clinical hours up to point of measurement, job, children, relational status and living circumstances) were collected. Two items measured the participant’s history of psychological problems (yes/no) by asking if the participant had ever experienced psychological problems pre-COVID or was still experiencing psychological problems, with or without treatment (e.g., medication, professional help). The following item included a list of several psychological issues (e.g., depression, burn out), of which one or more could be selected. Emotional wellbeing was measured with the Hospital Depression and Anxiety Scale (HADS).

      Hospital anxiety depression scale (HADS)

      The Hospital Anxiety Depression Scale (HADS) was designed to measure anxiety and depression in a general population [
      • Zigmond A.S.
      • Snaith R.P.
      The hospital anxiety and depression scale.
      ] and has shown to have good psychometric properties and to perform well in assessing anxiety and depressive disorders [
      • Bjelland I.
      • Dahl A.A.
      • Haug T.T.
      • Neckelmann D.
      The validity of the Hospital Anxiety and Depression Scale. An updated literature review.
      ]. The HADS is a 14-item self-administered measure including two 7-item subscales, one measuring anxiety and the other subscale measuring depression. Each item is rated on a scale from 0 to 3 and participants rate the response which comes closest to how they have been feeling in the past week. A subscale score between 8 and 10 identifies possible presence and a score of ≥11 the probable presence of a clinically meaningful anxiety or depressive condition [

      Pouwer F., Snoek F.J., van der Ploeg H.M. HADS-NL. Dutch translation of the hospital anxiety and depression scale. 1997. Available: 〈https://meetinstrumentenzorg.nl/instrumenten/hospital-anxiety-and-depression-scale/〉.

      ]. The HADS has been translated into Dutch [

      Pouwer F., Snoek F.J., van der Ploeg H.M. HADS-NL. Dutch translation of the hospital anxiety and depression scale. 1997. Available: 〈https://meetinstrumentenzorg.nl/instrumenten/hospital-anxiety-and-depression-scale/〉.

      ] and has been validated for use among different age groups, including a random sample of young adults [
      • Spinhoven P.H.
      • Ormel J.
      • Sloekers P.P.A.
      • Kempen G.I.J.M.
      • Speckens A.E.M.
      A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects.
      ] and undergraduate students [
      • Andrews B.
      • Heijdenberg J.
      • Wilding J.
      Student anxiety and depression: comparison of questionnaire and interview assessments.
      ]. The HADS showed an overall good sensitivity/specificity balance for the anxiety and depression subscales in adolescents and students (0.73/0.93; 0.82/0.88) [
      • Spinhoven P.H.
      • Ormel J.
      • Sloekers P.P.A.
      • Kempen G.I.J.M.
      • Speckens A.E.M.
      A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects.
      ,
      • Andrews B.
      • Heijdenberg J.
      • Wilding J.
      Student anxiety and depression: comparison of questionnaire and interview assessments.
      ].

      Statistical analysis

      The analyses were performed using the Statistical Package for the Social Sciences© (SPSS) version 28. We calculated descriptive statistics for the participants’ characteristics. The scores of the HADS depression and anxiety subscales were summed and the possible and probable presence of anxiety and depression were established using the HADS cut-off values [

      Pouwer F., Snoek F.J., van der Ploeg H.M. HADS-NL. Dutch translation of the hospital anxiety and depression scale. 1997. Available: 〈https://meetinstrumentenzorg.nl/instrumenten/hospital-anxiety-and-depression-scale/〉.

      ]. Cronbach’s alpha was calculated for the HADS total, and the depression and anxiety subscales. Normality of distribution was checked with the Kolmogorov-Smirnov test. The Mann-Whitney U test was used for continuous data and Chi-square for dichotomous data.
      The strategy for model building was as follows: based on the pandemic waves, we divided the sample in two periods. T1 included participants who completed the questionnaire between 17 March-30 September 2020 (wave 1). T2 included participants who completed the questionnaire between 1 October 2020–23 June 2021 (wave 2 and 3). We hypothesized that there would be differences in emotional wellbeing based on the initial shock about the pandemic and complete lockdown and being accustomed to the pandemic regulations during the following waves with its alternating partial and complete lockdown regulations, affecting emotional distress (i.e. wearing off or intensifying) [
      • Kuliukas L.
      • Hauck Y.
      • Sweet L.
      • Vasilevski V.
      • Homer C.
      • Wynter K.
      • Wilson A.
      • Szabo R.
      • Bradfield R.
      A cross sectional study of midwifery students’ experiences of COVID-19: Uncertainty and expendability.
      ,
      • Brooks S.K.
      • Webster R.K.
      • Smith L.E.
      • Woodland L.
      • Wessely S.
      • Greenberg N.
      • Rubin G.J.
      The psychological impact of quarantine and how to reduce it: rapid review of the evidence.
      ,
      • Kuipers Y.
      • Bleijenbergh R.
      • Van den Branden L.
      • Van Gils Y.
      • Rimaux S.
      • Claerbout A.
      • Mestdagh E.
      Psychological health of pregnant and postpartum women before and during the COVID-19 pandemic.
      ]. We calculated the differences in depression and anxiety between T1 and T2. We examined the within-group changes of the Dutch and Flemish students by comparing T1 and T2 means for HADS depression and anxiety and the proportions according to the cut-off levels. To investigate which characteristics (predictors) predict anxiety or depression (outcome measures), two dichotomous dependent outcomes variables were computed: possible depression/anxiety, scores 8–10 (yes/no) and probable depression/anxiety, scores ≥11 (yes/no). Possible and probable scores of depression and anxiety were collapsed into one dichotomous outcome variable (yes/no heightened scores). The predicting variables (students’ characteristics) were computed in dichotomous variables (yes/no) and compared with the heightened anxiety and depression scores, using two-tailed Pearson Chi-square coefficients. Binary logistic regression and Chi-square tests examined the variables predicting depression and anxiety. Predictors were chosen based on significant Pearson Chi-square coefficients. The p-value was set at <.05.

      Sample size

      A power analysis, with G*Power (3.9.1.2) indicated that a sample size of 482 would be sufficient to detect a significant small effect (Odds Ratio [OR] = 1.68) [

      Chen H., Cohen P., Chen S. How big is a big odds ration? Interpreting the magnitudes of odds ratios in epidemiological studies. Communications in Statistics - Simulation and Computation, 39:4, 860-864, DOI: 10.1080/03610911003650383.

      ], assuming a power of 0.80 and an alpha of 0.05, based on a 19 % increase of depression among student midwives pre and peri-COVID-19 [
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • McDonall J.
      • McTier L.
      • Hutchinson A.M.
      • Kerr D.
      • Lowe G.
      • Phillips N.N.M.
      • Rasmussen B.
      Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.
      ]. To draw true inferences about the population, a minimum sample of 329 Dutch students and 268 Flemish students was required (95 % Confidence Interval, p.<05).

      Ethical approval

      The study protocol was reviewed and approved by the Antwerp University Hospital Ethics Committee (Reference nr. EA_SHW_19_34). Participation was voluntary and anonymous and informed consent was obtained before the questionnaire could be completed (via box ticking).

      Results

      Of the 650 responders, 31 respondents discontinued the questionnaire after providing consent, leaving 619 completed questionnaires (95.2 % completion rate), showing no missing values. Of the 619 questionnaires (323 Dutch students and 296 Flemish students), 326 were completed between 17 March-30 September 2020 (T1), and 293 between 1 October 2020–23 June 2021 (T2). HADS total scores and the depression and anxiety subscale scores showed a non-normal distribution (D(619) = .7, p < .001; D(619) = .11, p < .001: D(619) = .07, p < .001).

      Participants

      The characteristics of the participants are shown in Table 1. Most of the respondents (64.8 %) were in their second or third year of study and most of the participants (73.3 %) indicated they spent more than 21 h per week on individual studying. The differences in study hours per week (p < .001) between Dutch and Flemish students were observed in all categories. Over a third of the participants (34.2 %) had spent more than 600 h in clinical practice. The differences in clinical hours (p.004) between Dutch and Flemish students were observed in the categories 200–400 and >600 clinical hours. There were significant more students with a study delay among Dutch midwifery students compared to Flemish students (p.014). We observed significant differences in partner status between Dutch and Flemish students (p.003). Dutch students were more often co-habiting with their partner compared to Flemish students. Also, the living circumstances of Dutch and Flemish students were significantly different (p < .001), showing variation in with whom students lived, either being with other students, parents/family, partner and/or children. More than a third of the midwifery students in both countries (69.9 %) had a job next to their study. A third of the sample reported a history of psychological problems before the COVID-19 period. Flemish students significantly more often reported a history of psychological problems (p < .001). Dutch students more often reported a history of depression, personality disorders, and Attention Deficit (Hyperactivity) Disorder compared to the Flemish students, while Flemish students more often reported a history of panic and anxiety problems.
      Table 1Characteristics student midwives.
      Total group

      N = 619 (100%)
      Dutch students

      N = 323 (52.2%%)
      Flemish students

      N = 296 (47.8%)
      P-value
      Age (in years) mean (SD±) range22.56 (±4.26)18-4922.72 (±4.59)22.38 (±3.86).812
      Age categories n (%).286
       18-21 years303 (48.9)163 (50.5)140 (47.3)
       22-25 years246 (39.7)118 (36.5)128 (43.2)
       26-30 years35 (5.7)21 (6.5)14 (4.7)
       >30 years35 (5.7)21 (6.5)14 (4.7)
      Partnership status n (%).003
       in relationship and co-habiting224 (36.2)84 (26)49 (16.5)
       in relationship but not co-habiting133 (21.5)109 (33.7)115 (38.9)
       single262 (42.3)130 (40.2)132 (44.6)
      Living circumstances n (%)<.001
       living with parents281 (45.5)134 (41.5)147 (49.7)
       (student) accommodation sharing with others131 (21.2)79 (24.5)52 (17.6)
       combination of living with others/students & parental home12 (1.9)-12 (4.1)
       living with partner and/or children128 (20.7)82 (25.4)46 (15.5)
       independent accommodation/ living alone67 (10.8)28 (8.7)39 (13.2)
      Caring for (non)biological children n (%).481
       no566 (91.4)296 (91.6)270 (91.2)
       yes53 (8.6)27 (8.4)26 (8.8)
      Job next to study n (%).375
       no186 (30.1)92 (28.5)94 (31.8)
       yes433 (69.9)231 (71.5)202 (68.2)
      on an on-call basis
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      135 (31.2)70 (30.3)65 (32.2)
      <10 hours/week
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      164 (37.9)100 (43.3)64 (31.7)
      10-20 hours a week
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      ,
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      113 (26)57 (24.7)56 (27.7)
      >20 hours/week21 (4.9)4 (1.7)17 (8.4)
      Year of education n (%)<.001
       year 1122 (19.7)71 (22)51 (17.2)
       year 2185 (29.9)80 (24.8)105 (35.5)
       year 3216 (34.9)82 (25.4)134 (45.3)
       year 477 (12.4)71 (22)-
      Extended study n (%)
       year 4 or more Flemish students/year 5 or more Dutch students25 (4)19 (5.9)6 (2).014
      Hours per week spent on study (school & personal study) n (%)<.001
       <10 hours/week64 (10.3)20 (6.2)44 (14.9)
       10-20 hours/week73 (11.8)20 (6.2)53 (17.9)
       21-30 hours/week129 (20.8)55 (17)74 (25)
       31-40 hours/week199 (32.1)117 (36.2)82 (27.7)
       41-50 hours/week126 (20.4)94 (29.1)32 (10.8)
       >50 hours/week28 (4.5)17 (5.3)11 (3.7)
      Hours of clinical practice in total n (%).004
       <200 hours144 (23.3)75 (23.2)69 (23.3)
       200-400 hours131 (21.2)54 (16.7)77 (26.0)
       401-600 hours132 (21.3)65 (20.1)67 (22.6)
       >600 hours212 (34.2)129 (39.9)83 (28)
      History of psychological problems n (0%)<.001
       none436 (70.4)256 (79.3)180 (60.9)
       yes183 (29.6)67 (20.7)116 (39.2)
      depression
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      117 (63.9)48 (71.6)69 (59.5)
      burn out
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      63 (34.4)24 (35.8)39 (33.6)
      personality disorder
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      43 (23.5)20 (29.6)23 (19.8)
      panic
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      52 (28.4)13 (19.4)39 (33.6)
      anxiety
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      88 (48.1)24 (35.8)64 (55.2)
      AD(H)D
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      4 (2.2)3 (4.5)1 (.9)
      eating disorder
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      8 (4.4)7 (10.4)1 (.9)
      post-traumatic stress
      Percentages of positive answers (‘yes’ considered as the 100 % group).
      3 (1.6)2 (3)1 (.9)
      HADS total score mean (SD±)14.7 (±8.23) 0-3811.8 (±6.86) 0-3517.8 (±8.48) 0-38<.001
      Depression scale mean (SD±)5.5 (±3.99) 0-204.1 (±3.24) 0-177 (±4.18) 0-20<.001
      U = 28385, z = −8.74, r = −.35.
      Anxiety scale mean (SD±)9.2 (±4.77) 0-217.7 (±4.24) 0-1910.7 (±4.84) 0-21<.001
      Mann-Whitney U: U = 27860, z = −9, r = −.36.
      Depression cut-off scores n (0%)<.001
       no symptoms444 (71.7)271 (83.9)173 (58.4)
       possible depression93 (15)38 (11.8)55 (18.6)
       probable presence clinically meaningful depression82 (13.2)14 (4.3)68 (23)
      Anxiety cut-off scores n (0%)<.001
       no symptoms240 (38.8)167 (51.7)73 (24.7)
       possible anxiety128 (20.7)58 (18)70 (23.6)
       probable presence clinically meaningful anxiety251 (40.5)98 (30.3)153 (51.7)
      Age was not normally distributed (D(619) = .25, p < .001).
      * Percentages of positive answers (‘yes’ considered as the 100 % group).
      a U = 28385, z = −8.74, r = −.35.
      b Mann-Whitney U: U = 27860, z = −9, r = −.36.
      The T1 sample more often included first and second year students than third year and higher (T1 45 % vs T2 58 %, X 2 8.5, p.003) and the T1 respondents more often had a study delay (T1 6 % vs T2 1 %, X 2 8.7, p.001). The students spending of <21 h on study increased from T1 to T2 (T1 8 % vs T2 47 %, X 2 123.9, p < .001). The T1 and T2 respondents showed no further differences in characteristics.

      HADS scores

      HADS scores Dutch and Flemish student groups

      The HADS showed excellent internal consistency for the total scores (α.92), and good internal consistency for the depression subscale (α.85), and the anxiety subscale (α.89). The Mann-Whitney U test showed a significant difference in the HADS depression and in the anxiety scores between Dutch and Flemish students during the total period of study (p < .001; p < .001), with significantly higher mean scores for depression and anxiety among Flemish students compared to Dutch students. The scores below and above the HADS cut-off scores for possible and the probable presence of depression and anxiety showed significant differences between the two groups (p < .001). Flemish students more often reported elevated levels of depression and anxiety compared to the Dutch students (see Table 1).

      HADS scores at T1 and T2 within and between Dutch and Flemish student groups

      We observed a significant difference in the HADS depression and in the anxiety scores between T1 and T2 (p < .001; p < .001). Among the Dutch student group, the HADS depression scores showed a significant within-group change (U = 3608, z = −3.55, r = −.20, p < .001) but not the anxiety scores (U = 4646.5, z = −1.63, r = −.09, p.102). Among the Flemish student group, both the HADS depression and anxiety scores showed a significant within-group change (U = 6607.5, z = −5.27, r = −.31, p < .001; U = 7493, z = −4.03, r = −.23, p < .001). Table 2 shows the significant increase of the mean depression and anxiety scores from T1 to T2. For both depression and anxiety there was a significant total group decrease of scores below the cut-off level ≤ 7 from T1 to T2 in both groups. However, this decrease was more evident in the Flemish student group (p < .001) compared to the Dutch student group (p < .001 vs p.06) as well as for anxiety (p < .001 vs p.3).
      Table 2Between-group and within-group HADS scores from T1 to T2.
      Total students (N = 619)Students Netherlands (N = 323)Students Flanders (N = 296)
      T1 (N = 326)T2 (N = 293)T1 (N = 212)T2 (N = 111)T1 (N = 114)T2 (N = 182)
      Mean ( ± SD)Mean ( ± SD)pMean ( ± SD)Mean ( ± SD)pMean ( ± SD)Mean ( ± SD)p
      HADS depression4.3 (3.40)7.7 (4.07)<.0013.9 (3.17)5.8 (3.28)< .0015.4 (3.74)8.1 (4.11)<.001
      Mann-Whitney U: U = 23018, z = −9.86, r = −.40.
      HADS anxiety8.1 (4.45)11.2 (4.70)<.0017.6 (4.26)8.7 (4.03).1029.2 (4.73)11.7 (4.67)<.001
      Mann-Whitney U: U = 28160, z = −7.43, r = −30.
      N (%)N (%)X2N (%)N (%)X2N (%)N (%)X2
      Depression 0–7259 (82.4)185 (64.5)59.83<.001177 (83)94 (85.6)7.75.0682 (72)91 (50)13.88<.001
      Depression 8–1048 (15.4)45 (15.6)7.67.0628 (13.2)10 (9)8.23.00420 (17.5)35 (19.2).13.717
      Depression 11–2119 (5.7)63 (19.9)54.10<.0017 (3.8)7 (6.3)7.21.0212 (10.5)56 (30.8)16.23<.001
      Anxiety 0–7154 (49.4)86 (32.2)37.57<.001113 (53.3)54 (48.7)1.08.341 (36)32 (17.6)12.75<.001
      Anxiety 8–1061 (19.6)67 (21.5)1.2.2735 (16.5)23 (20.7).15.726 (22.8)44 (24.2).07.787
      Anxiety 11–21111 (35.6)140 (46.3)26.29<.00164 (30.2)34 (30.6).66.4247 (41.2)106 (58.2)7.31.007
      a Mann-Whitney U: U = 23018, z = −9.86, r = −.40.
      b Mann-Whitney U: U = 28160, z = −7.43, r = −30.

      Correlations between predictors and outcome measures at T1 and T2

      The predicting characteristics are presented in Table 3. During both T1 and T2, heightened levels of both depression and anxiety significantly correlated with being single (T1 p.048; p.036; T2 p.054; p < .039) and having a history of psychological problems (T1 p < .001; p < .003; T2 p < .001; p < .001). During T1, depression significantly correlated with spending more than 21 h on study (p < .001), having children (p.042), having a job next to study (p.009), while living alone/independent significantly correlated with depression during T2 (p.041).
      Table 3Chi-square coefficients dichotomized students’ characteristics (both countries) correlating with heightened levels of depression and anxiety per period (T1, T2).
      T1
      CharacteristicsDepressionAnxiety
      <26 years of age or younger.084.048
      Single (yes).16*1.00*
      Living alone (yes).06.052
      Having children.075*.014
      Job next to study1.30**.06
      ≥3 years of education (yes).09.062
      Study delay (yes).061.069
      Spending >21 hours/week on study (yes)1.6***.053
      <401 hours clinical practice in total (yes).083.021
      History of psychological problems (yes)1.7***1.4**
      T2
      CharacteristicsDepressionAnxiety
      <26 years of age or younger.006.045
      Single (yes).12*.14*
      Living alone (yes).33*.011
      Having children.063.019
      Job next to study.039.047
      ≥3 years of education (yes).04.089
      Study delay (yes).008.043
      Spending >21 hours/week on study (yes).062.065
      <401 hours clinical practice in total (yes).03.065
      History of psychological problems (yes)2.7***1.8***
      Note*p <.05 (2-tailed); **p <.01 (2-tailed); ***p <.001 (2-tailed)

      Predicting depression and anxiety during COVID-19

      Table 4 shows the crude and adjusted odd ratios for the difference on the heightened anxiety and depression scores among the students per period, and per period and country. In the crude and adjusted models for anxiety, a history of psychological problems is the only predictor for anxiety, irrespective of period or country (p <.001; p <.001; p <.001). Being single (p.026; p.008; p.015), having a job (p.036; p.041; p.046), and a history of psychological problems (p <.001; p <.001; p <.001) remained as predictors for depression in the adjusted models (Table 4). An additional binary logistic regression analysis and Chi-square test for T1 and T2 (Table 5) showed that a history of psychological problems predicted depression and anxiety (p.004; p <.001). Being single also predicted depression during T2 (p.024).
      Table 4Crude and adjusted Odds Ratios (period, country) for depression and anxiety.
      DEPRESSION
      Crude
      X2 69.96, p <.001, -2 Log likelihood 673.264, Cox & Snell R2.098, Nagelkerke R2.141
      Adjusted *
      X2 97.73, p <.001, -2 Log likelihood 639.493 Cox & Snell R2.146, Nagelkerke R2.210
      Adjusted **
      X2 107.82, p <.001, -2 Log likelihood 629.412 Cox & Snell R2.160, Nagelkerke R2.230
      PredictorOR95%CIPOR95%CIPOR95%CIP
      (Constant)1.57-.313.86-.0053.94-.005
      Being single1.651.44-1.95.0261.581.44-1.09.0081.611.37-1.19.015
      Living alone.68.39–1.18.17.63.34-1.09.10.67.37-1.19.17
      Having children.76.40–1.43.40.73.38-1.39.34.71.37-1.38.32
      Having a job next to study1.521.03–2.26.0361.531.02-2.30.0411.521.01-2.29.046
      Spending >21 hours/week on study1.691.1-2.58.016.95.59-1.53.83.96.60-1.54.86
      History of psychological problems1.291.20-1.43<.0011.371.25-1.5<.0011.401.25-1.57<.001
      ANXIETY
      Crude
      X2 32.14, p <.001, -2 Log likelihood 794.49, Cox & Snell R2.051, Nagelkerke R2.069
      Adjusted *
      X2 71.74, p <.001, -2 Log likelihood 755.16, Cox & Snell R2.109, Nagelkerke R2.148
      Adjusted **
      X2 81.60, p <.001, -2 Log likelihood 745.04, Cox & Snell R2.124, Nagelkerke R2.168
      PredictorOR95%CIPOR95%CIPOR-P
      (Constant)2.55-.0311.41-.0026.36-.002
      Being single1.26.89–1.76.191.36.96-1.94.0841.32.96-1.88.13
      Living alone.75.43–1.31.32.85.49-1.50.57.70.45-1.41.44
      Having children1.34.73–2.48.351.31.70-2.47.401.34.71-2.54.37
      Having a job next to study1.33.92–1.92.131.30.89-1.91.171.31.89-1.93.17
      Spending >21 hours/week on study1.05.70-1.58.82.76.49-1.18.22.55.33-.901
      History of psychological problems1.371.25-.156<.0011.441.29-1.66<.0011.481.32-1.74<.001
      *Adjusted for period (T1, T2)
      **Adjusted for period (T1, T2) & country
      a X2 69.96, p <.001, -2 Log likelihood 673.264, Cox & Snell R2.098, Nagelkerke R2.141
      b X2 97.73, p <.001, -2 Log likelihood 639.493 Cox & Snell R2.146, Nagelkerke R2.210
      c X2 107.82, p <.001, -2 Log likelihood 629.412 Cox & Snell R2.160, Nagelkerke R2.230
      d X2 32.14, p <.001, -2 Log likelihood 794.49, Cox & Snell R2.051, Nagelkerke R2.069
      e X2 71.74, p <.001, -2 Log likelihood 755.16, Cox & Snell R2.109, Nagelkerke R2.148
      f X2 81.60, p <.001, -2 Log likelihood 745.04, Cox & Snell R2.124, Nagelkerke R2.168
      Table 5Differences Odds Ratios depression and anxiety per period (T1, T2).
      DEPRESSION
      T1
      X2 11.49, p.009, -2 Log likelihood 293.31, Cox & Snell R2.096 Nagelkerke R2.035
      T2
      X2 29.13, p <.001, -2 Log likelihood 419.73, Cox & Snell R2.084, Nagelkerke R2.113
      PredictorOR95%CIPOR95%CIP
      (Constant)1.60-.681.79-.023
      Being single1.20.82-1.76.0351.581.36-1.93.024
      Having a job next to study1.31.86-1.2.21.13.69-1.83.63
      History of psychological problems1.501.31-1.83.0041.291.29-1.83<.001
      ANXIETY
      T1T2
      X2PX2P
      History of psychological problems8.82.00310.38.001
      a X2 11.49, p.009, -2 Log likelihood 293.31, Cox & Snell R2.096 Nagelkerke R2.035
      b X2 29.13, p <.001, -2 Log likelihood 419.73, Cox & Snell R2.084, Nagelkerke R2.113

      Discussion

      This study attempted to disentangle how midwifery students’ emotional wellbeing evolved during the COVID-19 pandemic waves with different forms of lockdown (i.e. complete or partial), and which student characteristics played a role in heightened levels of depression and anxiety. This study covered a 15-month period and included three waves of the pandemic, allowing the effect of the initial shock and disruption of the first wave and the effect of adaptation to the restrictions during the two subsequent waves [
      • Kuliukas L.
      • Hauck Y.
      • Sweet L.
      • Vasilevski V.
      • Homer C.
      • Wynter K.
      • Wilson A.
      • Szabo R.
      • Bradfield R.
      A cross sectional study of midwifery students’ experiences of COVID-19: Uncertainty and expendability.
      ,
      • Brooks S.K.
      • Webster R.K.
      • Smith L.E.
      • Woodland L.
      • Wessely S.
      • Greenberg N.
      • Rubin G.J.
      The psychological impact of quarantine and how to reduce it: rapid review of the evidence.
      ,
      • Kuipers Y.
      • Bleijenbergh R.
      • Van den Branden L.
      • Van Gils Y.
      • Rimaux S.
      • Claerbout A.
      • Mestdagh E.
      Psychological health of pregnant and postpartum women before and during the COVID-19 pandemic.
      ]. Overall, depression and anxiety scores were significantly lower during the first COVID-19 wave compared to the following waves, suggesting the reoccurrence of the pandemic and lockdown to be an important factor contributing to emotional distress [
      • Brooks S.K.
      • Webster R.K.
      • Smith L.E.
      • Woodland L.
      • Wessely S.
      • Greenberg N.
      • Rubin G.J.
      The psychological impact of quarantine and how to reduce it: rapid review of the evidence.
      ]. The results acknowledge that there is variation within emotional wellbeing between countries [
      • Nieuwenhuijs W.
      • Stringa K.
      • Vancauwenbergh V.
      • Bijker K.
      The mental wellbeing of students during the COVID-19 pandemic.
      ,
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • McDonall J.
      • McTier L.
      • Hutchinson A.M.
      • Kerr D.
      • Lowe G.
      • Phillips N.N.M.
      • Rasmussen B.
      Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.
      ,
      • Chen T.
      • Lulock M.
      The mental health of university students during the COVID-19 pandemic: an online survey in the UK.
      ,
      • Hewitt R.
      Students’ views on the impact of Coronavirus on their higher education experience in 2020/2021. YouthSight. HEPI Policy Note 27.
      ,
      • Van de Velde S.
      • Buffel V.
      • Bracke P.
      • et al.
      The COVID-19 international student well-being study.
      ,
      • Auerbach R.P.
      • et al.
      WHO World Mental Health Surveys International College Student Project: prevalence and distribution of mental disorders.
      ]. This might be due to differences in organisational changes in education during the pandemic (e.g., returning to campus), as apparent in Dutch and Flemish midwifery education, but also to the extent individual students felt affected by the lockdown restrictions such as for example a curfew, closure of bars and restaurants, and number of people allowed to meet [
      • Luyben A.
      • Fleming V.
      • Vermeulen J.
      Midwifery education in COVID-19- time: challenges and opportunities.
      ,
      • Kuliukas L.
      • Hauck Y.
      • Sweet L.
      • Vasilevski V.
      • Homer C.
      • Wynter K.
      • Wilson A.
      • Szabo R.
      • Bradfield R.
      A cross sectional study of midwifery students’ experiences of COVID-19: Uncertainty and expendability.
      ,
      • Bleijenbergh R.
      • Mestdagh E.
      • Kuipers Y.
      Midwifery practice and education in Antwerp: forecasting its future with scenario planning.
      ,
      • Kuipers Y.
      • Bleijenbergh R.
      • Van den Branden L.
      • Van Gils Y.
      • Rimaux S.
      • Claerbout A.
      • Mestdagh E.
      Psychological health of pregnant and postpartum women before and during the COVID-19 pandemic.
      ].
      Having a history of psychological problems explained the vulnerability of the Dutch and Flemish midwifery students for anxiety as well as for depression during the pandemic. Having a history of psychological problems has been recognised as a pivotal factor for the heightened depression and anxiety levels during the pandemic [
      • Andersen A.J.
      • Mary-Krause M.M.
      • Bustamante J.J.
      • Héron M.
      • El Aarbaoui T.
      • Melchior M.
      Symptoms of anxiety/depression during the COVID-19 pandemic and associated lockdown in the community: longitudinal data from the TEMPO cohort in France.
      ]. In Europe, approximately 16% of adolescents have a history of or pre-existing psychological problems, usually anxiety or depression [

      UNICEF. The state of the world’s children 2021. On my mind. Promoting, protecting and caring for children’s mental health. Regional brief: Europe. United Nations Children’s Fund. 2021.

      ] - a lower number than reported by the students in our sample. Pre-pandemic research showed that pre-existing mental health problems of students are associated with experiencing emotional problems during education [
      • Yates J.
      • James D.
      • Aston I.
      Pre-existing mental health problems in medical students: a retrospective survey.
      ,
      • Sheldon E.
      • Simmonds-Buckley M.
      • Bone C.
      • et al.
      Prevalence and risk factors for mental health problems in university undergraduate students: a systematic review with meta-analysis.
      ]. Based on the students’ self-report of pre-pandemic emotional health problems, it can be assumed these intensified or reoccurred during COVID-19 [
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ], highlighting the importance of offering services to support the emotional wellbeing of midwifery students [
      • Oates J.
      • Topping A.
      • Watts K.
      • Charles P.
      • Hunter C.
      • Arias T.
      ‘The rollercoaster’: a qualitative study of midwifery students’ experiences affecting their mental wellbeing.
      ,
      • Sheldon E.
      • Simmonds-Buckley M.
      • Bone C.
      • et al.
      Prevalence and risk factors for mental health problems in university undergraduate students: a systematic review with meta-analysis.
      ], especially those with a history of/ pre-existing problem. A history of psychological problems played a significant role during the whole period of the study, while being single was only of influence on depression during the second measurement (T2). On a psychosocial level peri-pandemic loneliness carried the risk for the onset of negative feelings and emotions [
      • Andersen A.J.
      • Mary-Krause M.M.
      • Bustamante J.J.
      • Héron M.
      • El Aarbaoui T.
      • Melchior M.
      Symptoms of anxiety/depression during the COVID-19 pandemic and associated lockdown in the community: longitudinal data from the TEMPO cohort in France.
      ,
      • Wang C.
      • Pan R.
      • Wan X.
      • Tan Y.
      • Xu L.
      • Ho C.S.
      • Ho R.C.
      Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.
      ]. Being single was associated with students’ vulnerability for depression during the second period of measurement. Loneliness caused by pandemic-related contact restrictions, seemed to have affected the emotional wellbeing of student midwives while the pandemic and restrictions continued [
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Sheldon E.
      • Simmonds-Buckley M.
      • Bone C.
      • et al.
      Prevalence and risk factors for mental health problems in university undergraduate students: a systematic review with meta-analysis.
      ]. Additionally, during the pandemic midwifery students experienced being neglected by staff and women, expendable and excluded from clinical practice [
      • Bogossian F.
      • McKenna L.
      • Levett-Jones T.
      Mobilising the nursing student workforce in COVID-19: the value proposition.
      ,
      • Kuliukas L.
      • Hauck Y.
      • Sweet L.
      • Vasilevski V.
      • Homer C.
      • Wynter K.
      • Wilson A.
      • Szabo R.
      • Bradfield R.
      A cross sectional study of midwifery students’ experiences of COVID-19: Uncertainty and expendability.
      ]. It has also been suggested that relationships with parents and peers deteriorated during the pandemic [
      • Von Soest T.
      • Kozák M.
      • Rodríguez-Cano R.
      • et al.
      Adolescents’ psychosocial well-being one year after the outbreak of the COVID-19 pandemic in Norway.
      ]. All these aspects might have added to already existing feelings of loneliness caused by having no partner(relationship) and exacerbated in the context of the continuing COVID-19 pandemic [
      • Kuliukas L.
      • Hauck Y.
      • Sweet L.
      • Vasilevski V.
      • Homer C.
      • Wynter K.
      • Wilson A.
      • Szabo R.
      • Bradfield R.
      A cross sectional study of midwifery students’ experiences of COVID-19: Uncertainty and expendability.
      ], contributing to emotional fatigue, leading to stress and depression [
      • Edwards M.
      • Anderson J.
      What do you know about compassion fatigue in midwifery?.
      ].
      Midwifery students tend to develop resilience, that is, emotionally adapting to sources of stress such as COVID-19 [
      • Rasmussen B.
      • Hutchinson A.
      • Lowe G.
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • Phillips N.
      • McDonall J.
      • McTier L.
      • Kerr D.
      The impact of covid19 on psychosocial well-being and learning for Australian nursing and midwifery undergraduate students: a cross-sectional survey.
      ,
      • Ang W.H.D.
      • Shorey S.
      • Lopez V.
      • Chew H.S.J.
      • Lau Y.
      Generation Z undergraduate students’ resilience during the COVID-19 pandemic: a qualitative study.
      ,
      • Clohessy N.
      • McKellar L.
      • Fleet J.
      Bounce back – bounce forward: midwifery students experience of resilience.
      ]. As resilience has a linear association with emotional wellbeing, our findings suggest that the midwifery students in our sample were not able to build or maintain resilience during the pandemic [
      • Sood S.
      • Sharma A.
      Resilience and psychological well-being of higher education students during COVID-19: The mediating role of perceived distress.
      ]. Resilience in midwifery students involves to working out how to act in and how to respond to a situation, adopting a proactive approach [
      • Williams J.
      • Lathlean J.
      • Norman K.
      An exploration of the development of resilience in student midwives.
      ]. Associating the significant reduction of mental health during the pandemic with the assumption that resilience and thus proactive behaviour reduced, suggest that the students in our study were less able to deal with the continuing pandemic. Additionally, Dutch students are more likely to show proactive behaviour compared to Flemish students, which might explain the mental health differences between the Flemish and Dutch students in our sample, although it is unclear why this difference exists [
      • Mestdagh E.
      • Timmermans O.
      • Colin P.J.
      • Van Rompaey B.
      A cross-sectional pilot study of student's proactive behavior in midwifery education: Validation of a developed questionnaire.
      ]. Reduced peri-COVID-19 resilience should not be ignored as this might result to post-traumatic stress, emphasizing to put post-pandemic emotional support mechanisms in place for students with affected peri-pandemic emotional wellbeing [
      • Ang W.H.D.
      • Shorey S.
      • Lopez V.
      • Chew H.S.J.
      • Lau Y.
      Generation Z undergraduate students’ resilience during the COVID-19 pandemic: a qualitative study.
      ,
      • Dodds W.
      Disease now and potential future pandemics.
      ].
      Signs and symptoms of depression and anxiety were self-reported via a validated questionnaire. However, it should be taken into consideration that self-reporting questionnaires are not diagnostic instruments, and thus actual mental health problems might have been under- or overreported. A study among students showed that the high HADS anxiety scores overestimate the extent of clinical anxiety [
      • Andrews B.
      • Heijdenberg J.
      • Wilding J.
      Student anxiety and depression: comparison of questionnaire and interview assessments.
      ] as well as higher anxiety scores are associated with adolescence [
      • Lemyre A.
      • Gauthier‐Légaré A.
      • Bélanger R.E.
      Shyness, social anxiety, social anxiety disorder, and substance use among normative adolescent populations: a systematic review.
      ]. Therefore, the level of increased anxiety in this study might be overreported, but nevertheless present. Moreover, considering peri-pandemic anxiety to be higher than pre-pandemic anxiety [
      • Nieuwenhuijs W.
      • Stringa K.
      • Vancauwenbergh V.
      • Bijker K.
      The mental wellbeing of students during the COVID-19 pandemic.
      ,
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Wathelet M.
      • Duhem S.
      • Vaiva G.
      • et al.
      Factors associated with mental health disorders among university students in France confined during the COVID-19 pandemic.
      ,
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • McDonall J.
      • McTier L.
      • Hutchinson A.M.
      • Kerr D.
      • Lowe G.
      • Phillips N.N.M.
      • Rasmussen B.
      Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.
      ,
      • Chen T.
      • Lulock M.
      The mental health of university students during the COVID-19 pandemic: an online survey in the UK.
      ,
      • Hewitt R.
      Students’ views on the impact of Coronavirus on their higher education experience in 2020/2021. YouthSight. HEPI Policy Note 27.
      ,
      • Van de Velde S.
      • Buffel V.
      • Bracke P.
      • et al.
      The COVID-19 international student well-being study.
      ], the number of students with heightened levels is therefore quite worrying, particularly the Flemish students with a nearly 60% anxiety rate during the second period of measurement.
      Several study limitations warrant discussion. We did not perform a longitudinal study, allowing the follow up of the same sample of students during the different pandemic periods. Instead, our cross-sectional study, included different students during different pandemic periods, albeit there were only a few significant differences in student characteristics between T1 and T2. Additionally, due to the cross-sectional nature of this study, no causality can be established between reduced emotional wellbeing and its predictors. A further limitation of the study is that we did not measure emotional wellbeing before COVID-19. It is therefore not possible to assess possible within-group differences of pre versus peri-pandemic emotional wellbeing, although other studies suggest that emotional wellbeing decreased during COVID-19, among the general population, midwives, as well as among (midwifery) students [
      • Nieuwenhuijs W.
      • Stringa K.
      • Vancauwenbergh V.
      • Bijker K.
      The mental wellbeing of students during the COVID-19 pandemic.
      ,
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Wathelet M.
      • Duhem S.
      • Vaiva G.
      • et al.
      Factors associated with mental health disorders among university students in France confined during the COVID-19 pandemic.
      ,
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • McDonall J.
      • McTier L.
      • Hutchinson A.M.
      • Kerr D.
      • Lowe G.
      • Phillips N.N.M.
      • Rasmussen B.
      Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.
      ,
      • Chen T.
      • Lulock M.
      The mental health of university students during the COVID-19 pandemic: an online survey in the UK.
      ,
      • Hewitt R.
      Students’ views on the impact of Coronavirus on their higher education experience in 2020/2021. YouthSight. HEPI Policy Note 27.
      ,
      • Van de Velde S.
      • Buffel V.
      • Bracke P.
      • et al.
      The COVID-19 international student well-being study.
      ,
      • Wang C.
      • Pan R.
      • Wan X.
      • Tan Y.
      • Xu L.
      • Ho C.S.
      • Ho R.C.
      Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.
      ,
      • Båtsman A.
      • Fahlbeck H.
      • Hildingsson I.
      Depression, anxiety and stress in Swedish midwives: a cross-sectional survey.
      ]. Acknowledging the worrying pre-COVID mental health of student midwives [
      • Oates J.
      • Topping A.
      • Aria T.
      • Charles P.
      • Hunter C.
      • Watts K.
      The mental health and wellbeing of midwifery students: an integrative review.
      ], the further peri-pandemic poor mental health is quite alarming. Regarding the already existing concerns about the mental health of student midwives, continuous monitoring can be recommended to offer adequate support which seems necessary as midwifery students more often have a history of psychological problems or more often develop psychological problems compared to students in other than midwifery studies [
      • Charitou A.
      • Fifi P.
      • Vivlaki V.
      Is empathy an important attribute of midwives and other health professionals?: a review.
      ].
      Although we included enough respondents to allow reliable statistical inferences, we do not know which students completed the survey. Due to self-selection, we might have included students with a particular interest in the topic or maybe did not reach students who were not motivated or unable to focus or engage [
      • Rasmussen B.
      • Hutchinson A.
      • Lowe G.
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • Phillips N.
      • McDonall J.
      • McTier L.
      • Kerr D.
      The impact of covid19 on psychosocial well-being and learning for Australian nursing and midwifery undergraduate students: a cross-sectional survey.
      ]. Moreover, Flemish students were better represented than Dutch midwifery students, although the number were sufficient to draw true statistical inferences. Including or excluding certain students is likely to induce confounding and a possible over- or underreport of emotional wellbeing. A large part of the sample consisted of second- and third-year students, who are known to report higher levels of emotional exhaustion than first year students [
      • Eaves J.L.
      • Payne N.
      Resilience, stress and burnout in student midwives.
      ]. Additionally, some of the characteristics of the student midwives in both countries showed to be significantly different in addition to programme differences (e.g., hours spent-on study) - also likely to cause confounding. Flemish students had significantly higher depression and anxiety scores than Dutch students but comparing the sample’s heightened depression and anxiety to that of Australian midwifery students, the prevalence of moderate and severe depression in our sample showed to be lower, while anxiety was higher [
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • McDonall J.
      • McTier L.
      • Hutchinson A.M.
      • Kerr D.
      • Lowe G.
      • Phillips N.N.M.
      • Rasmussen B.
      Depression, anxiety and stress among Australian nursing and midwifery undergraduate students during the COVID-19 pandemic: a cross-sectional study.
      ]. Therefore, generalisation of the findings warrants some caution as our findings acknowledge that peri-pandemic emotional wellbeing of midwifery students varied between countries. Despite the differences in emotional wellbeing, the predictors for depression and anxiety during COVID-19 were similar for the Dutch and Flemish students. A history of psychological problems was also found to predict reduced peri-pandemic emotional wellbeing in a general student population [
      • Meda N.
      • Pardini S.
      • Slongo I.
      • Bodini L.
      • Zordan MA,Rigobella P.
      • et al.
      Students’ mental health problems, before, during, and after COVID-19 lockdown in Italy.
      ], although it might be that other factors play a role in other countries.
      The models with added covariates, showed higher R2 values than the models without, but it is difficult to judge whether the difference is large enough to be important as the R2 values are low. Although the prediction models were significant, it is likely that other variables predicted possible and probable depression and anxiety among midwifery students during COVID-19. We did not ask if students had been infected and/or ill due to COVID-19, whether they had lost (significant) others, how they experienced the restrictions, nor did we ask details about their study progress - which all without a doubt must have affected their emotional wellbeing [
      • Rasmussen B.
      • Hutchinson A.
      • Lowe G.
      • Wynter K.
      • Redley B.
      • Holton S.
      • Manias E.
      • Phillips N.
      • McDonall J.
      • McTier L.
      • Kerr D.
      The impact of covid19 on psychosocial well-being and learning for Australian nursing and midwifery undergraduate students: a cross-sectional survey.
      ,
      • Nieuwenhuijs W.
      • Stringa K.
      • Vancauwenbergh V.
      • Bijker K.
      The mental wellbeing of students during the COVID-19 pandemic.
      ,
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Wathelet M.
      • Duhem S.
      • Vaiva G.
      • et al.
      Factors associated with mental health disorders among university students in France confined during the COVID-19 pandemic.
      ,
      • Holm-Hadulla R.M.
      • Klimov M.
      • Juche T.
      • Möltner A.
      • Herpertz S.C.
      Well-being and mental health of students during the COVID-19 pandemic.
      ,
      • Hewitt R.
      Students’ views on the impact of Coronavirus on their higher education experience in 2020/2021. YouthSight. HEPI Policy Note 27.
      ]. Additionally, we did not have pre-pandemic prevalence rates of emotional wellbeing of the midwifery students in our sample, we would be able to examine post-COVID 19 emotional wellbeing of midwifery students to compare peri and post-pandemic figures, to better advice on post-pandemic emotional support as some scores are extremely worrying (e.g., anxiety scores Flemish students). We cannot assume that peri-pandemic emotional problems and changes just cease to exist after the pandemic and its restrictions [
      • Von Soest T.
      • Kozák M.
      • Rodríguez-Cano R.
      • et al.
      Adolescents’ psychosocial well-being one year after the outbreak of the COVID-19 pandemic in Norway.
      ,
      • Furr J.M.
      • Comer J.S.
      • Edmunds J.M.
      • Kendall P.C.
      Disasters and youth: a meta-analytical examination of posttraumatic stress.
      ] and therefore further research and post-pandemic emotional support is necessary to prevent post-traumatic stress, depression, and substance use [
      • Furr J.M.
      • Comer J.S.
      • Edmunds J.M.
      • Kendall P.C.
      Disasters and youth: a meta-analytical examination of posttraumatic stress.
      ]. We have no information about the midwifery students’ course of emotional wellbeing throughout the course without the pandemic. Therefore, further research is needed to conclude if anxiety and depression worsened because of the pandemic of whether this a phenomenon that is typical for midwifery students due to challenges and demands of the course and balancing student- and personal life [
      • Son C.
      • Hegde S.
      • Smith A.
      • Wang X.
      • Sasangohar F.
      Effects of COVID-19 on College Students' Mental Health in the United States: interview survey study.
      ,
      • Chen T.
      • Lulock M.
      The mental health of university students during the COVID-19 pandemic: an online survey in the UK.
      ,
      • Sögüt S.
      • Dolu İ.
      • Cangöl E.
      The relationship between COVID-19 knowledge levels and anxiety states of midwifery students during the outbreak: A cross-sectional web-based survey.
      ,
      • Von Soest T.
      • Kozák M.
      • Rodríguez-Cano R.
      • et al.
      Adolescents’ psychosocial well-being one year after the outbreak of the COVID-19 pandemic in Norway.
      ].

      Conclusion

      The emotional wellbeing of midwifery students in Flanders and the Netherlands during the first three waves of the COVID-19 pandemic was significantly reduced, likely to be worse than pre-pandemic prevalence rates and to have intensified while the pandemic and its restrictions continued. Certain students were more affected than others, specifically students with a history of psychological problems and students that were single. The study contributes to the knowledge of the negative effect of the pandemic on midwifery students’ emotional wellbeing, highlighting the emotional vulnerability of midwifery students - regardless of whether there is a pandemic or not. There is an urgent need for post-pandemic emotional support of student midwives. Because students’ emotional wellbeing continues to matter, we recommend that HEIs make a systematic plan for routinely regulated support of midwifery students’ emotional wellbeing, including potential other serious non-pandemic or future pandemic-related sources of stress.

      CRediT authorship contributions statement

      Yvonne Kuipers Conceptualization; Formal analysis; Funding acquisition; Investigation; Methodology; Roles/Writing – original draft; Supervision. Eveline Mestdagh Investigation; Formal analysis; Funding acquisition; Validation; Project administration; Writing – review & editing

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
      Funding
      Interreg 2 Seas Mers Zeeën https://www.interreg2seas.eu/nl [grant number 2S05-002, 2019], Province Antwerp Service for Europe, Department of Economy, Local Policies and Europe [grant number BBSPATH 1564468860780, 2019].

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