Changes in experiences with discrimination across pregnancy and postpartum: age differences and consequences for mental health

Combined effects of life course maternal psychosocial experiences on perinatal mental health

OBJECTIVES

Identifying experiences that place women at higher risk for mental health impairment is critical to inform perinatal care. This study's purpose was to identify the individual and combined association between early life adversity, discrimination, and perinatal mental health.

STUDY DESIGN

Prospective cohort study.

METHODS

The Pregnancy and Infant Development Study (PRIDE) is a prospective cohort study that follows pregnant women in Cincinnati, Ohio through 18 months postnatal. Measures of socioeconomic factors, adverse childhood experiences, discrimination, and maternal mental health were collected at home study visits. Multiple linear regression identified associations between psychosocial measures and perinatal mental health.

RESULTS

Adjusting for socioeconomic factors, early life adversity, and discrimination were significantly associated with perinatal mental health (β range from 0.20 to 1.64). The strongest association was observed for the association between emotional neglect and depression β = 2.53 (p = 0.006). The joint effect of high early adversity and high discrimination demonstrated the strongest effect.

CONCLUSION

Women who experienced early life trauma, in particular emotional neglect and discrimination, also experienced depression and distress during the perinatal period. Identification of women at risk for mental health problems should be a priority for programs that are positioned to help mitigate future consequences to mothers and their families.

Examination of Social Determinants of Health Characteristics Influencing Maternal Postpartum Symptom Experiences

Postpartum women experience multiple, co-occurring postpartum symptoms. It is unknown if social determinants of health (SDOH) influence postpartum symptom typologies. This secondary analysis used the Community and Child Health Network study data. Participants included for analysis varied depending on the availability of the SDOH data (N = 851 to 1784). Bivariate and multiple regression analyses were conducted to examine the association between SDOH and previously identified postpartum symptom typologies. Area under the receiver operating characteristics curve (AUROC) was calculated to examine if adding SDOH variables contributes to predicting postpartum symptom typologies. The adjusted odds (aOR) of being in high symptom severity or occurrence typologies were greater for participants who had less than high school education (aOR = 2.29), experienced healthcare discrimination (aOR = 2.21), used governmental aid (aOR = 2.11), or were food insecure (aOR = 2.04). AUROC improved after adding SDOH. Considering experiences of different social-economic hardships influence postpartum symptom typologies, future practice and research should address SDOH to improve postpartum symptom experiences.

Associations Among Lifetime Discrimination Typologies and Psychological Health in Black and Hispanic Women After Birth

OBJECTIVE

To identify lifetime discrimination typologies and examine their associations with psychological health outcomes among Black and Hispanic women after birth.

DESIGN

Secondary analysis of the Community and Child Health Network study data.

PARTICIPANTS

A total of 1,350 Black and 607 Hispanic women.

METHODS

We built two latent class models for Black and Hispanic women using eight indicator variables from different life domains of discrimination (childhood, family, work, police, education, housing, health care, and loans). We used bivariate and multiple regression analyses to examine the association among the identified typologies and postpartum depression and perceived stress at 6 months postpartum.

RESULTS

We selected the three-class model with best fit indices and interpretability: no lifetime discrimination (n = 1,029; 76.22%), high childhood-family racial discrimination (n = 224, 16.59%), and moderate lifetime discrimination (n = 97, 7.19%) among Black women and no lifetime discrimination (n = 493, 81.22%), high childhood-family racial discrimination (n = 93, 15.32%), and high education discrimination (n = 21, 3.46%) among Hispanic women. The adjusted postpartum depression and perceived stress scores were significantly greater in Typologies 2 and 3 than Typology 1 in Black women. The adjusted perceived stress scores were significantly greater in Typologies 2 and 3 than Typology 1 in Hispanic women.

CONCLUSION

Lifetime discrimination experiences manifested in complex patterns. Women who experienced moderate to high discrimination across all or specific life domains had worse postpartum depression and perceived stress at 6 months after birth. It is crucial to address lifetime discrimination to improve maternal mental health.

Identification of postpartum symptom informedness and preparedness typologies and their associations with psychological health: A latent class analysis

BACKGROUND

Birthing parents, defined as postpartum women and people with various gender identities who give birth, commonly experience challenging postpartum symptoms. However, many report feeling uninformed and unprepared to navigate their postpartum health.

OBJECTIVE

To identify typologies of postpartum symptom informedness and preparedness using latent class analysis (LCA) and to examine the associated patient and healthcare characteristics.

METHODS

We used survey data from a large, multi-method, longitudinal research project Postnatal Safety Learning Lab. Participants were recruited using convenience sampling and enrolled between November 2020 and June 2021. LCA was used to identify subgroups of birthing parents with different symptom informedness and preparedness using 10 binary variables (N = 148). Bivariate analysis was conducted to examine the association between characteristics and each typology.

FINDINGS

The 3-class models had better fit indices and interpretability for both informedness and preparedness typologies: High, High-moderate, and Moderate-low. The sample characteristics were different by typologies. In the modified discrimination in medical settings assessment, we found higher discrimination scores in the moderate-low informedness and preparedness typologies. The moderate-low preparedness typology had a higher percentage of birthing parents who did not have private insurance, underwent cesarean section, and planned for formula or mixed infant feeding. The median PHQ-4 scores at 4 weeks postpartum were lower among those in high informedness and preparedness typologies.

CONCLUSION

In our sample, 18 to 21 % of birthing parents were in the moderate-low informedness or preparedness typologies. Future research and practice should consider providing tailored information and anticipatory guidance as a part of more equitable and supportive care.

Feasibility and acceptability of measuring prenatal stress in daily life using smartphone-based ecological momentary assessment and wearable physiological monitors

High levels of stress during pregnancy can have lasting effects on maternal and offspring health, which disproportionately impacts families facing financial strain, systemic racism, and other forms of social oppression. Developing ways to monitor daily life stress during pregnancy is important for reducing stress-related health disparities. We evaluated the feasibility and acceptability of using mobile health (mHealth) technology (i.e., wearable biosensors, smartphone-based ecological momentary assessment) to measure prenatal stress in daily life. Fifty pregnant women (67% receiving public assistance; 70% Black, 6% Multiracial, 24% White) completed 10 days of ambulatory assessment, in which they answered smartphone-based surveys six times a day and wore a chest-band device (movisens EcgMove4) to monitor their heart rate, heart rate variability, and activity level. Feasibility and acceptability were evaluated using behavioral meta-data and participant feedback. Findings supported the feasibility and acceptability of mHealth methods: Participants answered approximately 75% of the surveys per day and wore the device for approximately 10 hours per day. Perceived burden was low. Notably, participants with higher reported stressors and financial strain reported lower burden associated with the protocol than participants with fewer life stressors, highlighting the feasibility of mHealth technology for monitoring prenatal stress among pregnant populations living with higher levels of contextual stressors. Findings support the use of mHealth technology to measure prenatal stress in real-world, daily life settings, which shows promise for informing scalable, technology-assisted interventions that may help to reduce health disparities by enabling more accessible and comprehensive care during pregnancy.

A randomized comparative-effectiveness study of two enhanced prenatal care models for low-income pregnant people: Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE)

BACKGROUND

Improving perinatal mental health and care experiences and preventing adverse maternal and infant outcomes are essential prenatal care components, yet existing services often miss the mark, particularly for low-income populations. An enhanced group prenatal care program, "Glow! Group Prenatal Care and Support," was developed in California's Central Valley in response to poor perinatal mental health, disrespectful care experiences, and high rates of adverse birth outcomes among families with low incomes.

METHODS

Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) is a pragmatic, two-arm, randomized, comparative-effectiveness study designed to assess depression (primary outcome), the experience of care (secondary outcome), and preterm birth (exploratory outcome) among Medi-Cal (California's Medicaid program)-eligible pregnant and birthing people, comparing those assigned to Glow! Group Prenatal Care and Support (Glow/GC) with those assigned to enhanced, individual prenatal care through the California Department of Public Health's Comprehensive Perinatal Services Program (CPSP/IC). Participating clinical practices offer the two comparators, alternating between comparators every 6 weeks, with the starting comparator randomized at the practice level. Participant-reported outcomes are assessed through interviewer-administered surveys at study entry, during the participant's third trimester, and at 3 months postpartum; preterm birth and other clinical outcomes are abstracted from labor and delivery records. Patient care experiences are further assessed in qualitative interviews. The protocol complies with the Standard Protocol Items for Randomized Trials.

CONCLUSIONS

This comparative-effectiveness study will be used to determine which of two forms of enhanced prenatal care is more effective, informing future decisions regarding their use.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04154423.

Intimate Partner Violence, Loss of Control, and Adolescent Perception of Birth

This secondary analysis used cross-sectional baseline data from a previous longitudinal study exploring the mental health of 303 postpartum adolescents to examine associations and predictors reflecting the perception of the birth experience among three race-ethnic groups. Analysis of two key variables, partner violence and loss of control (LOC) during labor, revealed no association. Race-ethnic differences were noted for demographic variables (marital status, birth mode, and stress level) and perception of the birth experience. Black ethnicity, multiparity, LOC, and vaginal birth were found to predict a negative perception of the birth experience. Health-care provider awareness of risk factors can guide perinatal assessments and supportive and educational interventions to promote a positive perception of birth.

Maternal Psychological Symptom Trajectories From 2 to 24 Months Postpartum: A Latent Class Growth Analysis

BACKGROUND

Postpartum women experience an array of psychological symptoms that are associated with adverse health behaviors and outcomes including postpartum suicidal ideation and long-term depression. To provide early management of postpartum psychological symptoms, it is important to understand how the symptom experiences change over time.

OBJECTIVE

The aim of this study was to examine maternal psychological symptom trajectories over 2, 6, 15, and 24 months postpartum using latent class growth analysis and to examine how each trajectory is associated with maternal depression outcome at 24 months.

METHODS

We used secondary data from the Family Life Project ( N = 1,122) and performed multitrajectory latent class growth analysis based on four observed symptom variables (depression, anxiety, somatization, and hostility). After the final model was identified, bivariate analyses were conducted to examine the association between each trajectory and (a) individual characteristics and (b) outcome (Center for Epidemiologic Studies Depression Scale [CES-D]) variables.

RESULTS

A four-class model was selected for the final model because it had better fit indices, entropy, and interpretability. The four symptom trajectories were (a) no symptoms over 24 months, (b) low symptoms over 24 months, (c) moderate symptoms increasing over 15 months, and (d) high symptoms increasing over 24 months. More postpartum women with the trajectory of high symptoms increasing over 24 months (Trajectory 4) were in low economic status (92.16%), unemployed (68.63%), or did not complete 4-year college education (98.04%). Most postpartum women (95.56%) in Trajectory 4 also had higher CES-D cutoff scores, indicating a possible clinical depression at 24 months postpartum.

DISCUSSION

Postpartum women who experience increasing symptom trajectories over 15-24 months (Trajectories 3 and 4) could benefit from tailored symptom management interventions provided earlier in the postpartum period to prevent persistent and worsening symptom experiences.

Prenatal stress and externalizing behaviors in childhood and adolescence: A systematic review and meta-analysis

Accumulating evidence suggests that psychological distress during pregnancy is linked to offspring risk for externalizing outcomes (e.g., reactive/aggressive behaviors, hyperactivity, and impulsivity). Effect sizes across studies have varied widely, however, due to differences in study design and methodology, including control for the confounding continuation of distress in the postnatal period. Clarifying these inconsistencies is necessary to guide the precision of prevention efforts and inform public health policies. A meta-analysis was conducted with 55 longitudinal studies to investigate the association between prenatal psychological distress (anxiety, depression, and perceived stress) and offspring externalizing behaviors. Results revealed a significant but small effect (r = .160) of prenatal distress on externalizing behaviors. The magnitude of the prenatal effect size remained largely unchanged after adjusting for postnatal distress (r = .159), implicating a unique effect of psychological distress during the prenatal period in the etiology of externalizing behaviors. Moderation tests showed that prenatal effects did not vary based on type and timing of psychological distress during pregnancy. Greater instability of distress from prenatal to postnatal periods predicted larger effects. Prenatal effects were comparable across most externalizing outcomes, consistent with the common comorbidity of externalizing spectrum disorders, although effects appeared smaller for nonaggressive rule-breaking (vs. aggressive) behaviors. Significant associations persisted across all developmental periods, appearing slightly larger in early childhood. We discuss these results in the context of developmental and psychobiological theories of externalizing behavior, offer preliminary clinical and public health implications, and highlight directions for future research including the need for longitudinal studies with more racially and socioeconomically diverse families. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The impact of the pandemic on mothers and children, with a focus on syndemic effects on black families: the "Prenatal to Preschool" study protocol

Introduction

Racism, a known social determinant of health, affects the mental health and well-being of pregnant and postpartum women and their children. Convincing evidence highlights the urgent need to better identify the mechanisms and the ways in which young children's development and mental health are adversely impacted by their mothers' experiences of racism. With the additional stressor of the COVID-19 pandemic, the criticality of improving knowledge of these domains has never been starker. The proposed project will address these questions and move the field forward to create targeted, culturally informed preventative interventions, thus achieving mental health equity for all children and families.

Methods

This prospective research is a cohort study that will longitudinally observe the outcomes of a cohort of mothers and their children recruited during the initial phase of the COVID-19 pandemic. Data will be parent/caregiver questionnaires assessing mental health, racism, support, and resilience at multiple time points with the first beginning at 24 months, clinical interviews with mothers, electronic medical records of mothers, and videotaped dyadic interactions at child age 24 and 48 months. A subset of Black participants will be asked to participate in qualitative interviews at child age 36 months.

Results

Analyze will be performed within and across Black and Non-Latino/a/e/x white (NLW) groups, and comparing mothers and fathers/secondary caregivers. Descriptive and multivariate analyzes will be run to better characterize how young children's development and mental health may be adversely impacted by their caregiver's experiences of racism.

Discussion

This prospective longitudinal mixed-methods study evaluates the simultaneous effects of the COVID-19 pandemic and racism on mothers and their developing children to characterize cross-racial differences, providing insight into risk and resilience factors in early development and the peripartum period.

Associations Between Direct and Indirect Forms of Racism Exposure and Stress-Induced Inflammatory Response and Health in Pregnancy

Theory and research suggest chronic direct and indirect exposures to racism impact health, and stress-responsive inflammation may play a role in these paths. This study examines links between forms of racism-related stress, salivary markers of inflammation during acute psychosocial stress, and perinatal mental and physical health in a racially heterogenous sample. Pregnant people (n = 108, 27% non-white) self-reported personal and vicarious exposure to racism (racial microaggressions, online racism, overt racial/ethnic discrimination) and racial collective self-esteem, as well as affective symptoms and general physical health. Five saliva samples collected before and after the Trier Social Stress Test were assayed for pro-inflammatory cytokines and C-reactive protein. Results revealed associations between racism-related stress and greater inflammatory reactivity/delayed recovery to acute stress, between racial collective self-esteem and lower levels of inflammation, and between profiles of inflammatory responses to stress and mental and physical symptoms. We discuss implications for understanding perinatal health disparities.

Adolescent Mothers' Psychological Wellbeing during Pregnancy and Infant Emotional Health

OBJECTIVE

Although many studies have identified risk factors for adolescent pregnancy, much less is known about factors that support pregnant adolescents' psychological wellbeing and offspring outcomes. This study drew on strength-based frameworks to investigate family and neighborhood factors linked to social connectedness that predict psychological wellbeing during adolescent pregnancy and offspring outcomes.

METHOD

Participants included 135 adolescent mothers (ages 14-21; 90% Black American) assessed annually since childhood as part of a longitudinal study. During preadolescence (ages 11-13), data on contextual stressors and neighborhood support were gathered from participants' caregivers; participants also rated their perceived trust/attachment with caregivers before and during pregnancy. To assess changes in psychological wellbeing, adolescents reported positive and depressed mood before and during pregnancy. A path analysis model tested the prospective associations between family and neighborhood factors, psychological wellbeing during pregnancy, and offspring outcomes (birth outcomes; observed infant positive/negative emotions at age 3-months).

RESULTS

Positive mood decreased from pre-pregnancy to pregnancy, whereas depressed mood remained stable. Adjusting for pre-pregnancy mood, perceived caregiver trust/attachment during pregnancy was associated with prenatal positive mood. Prenatal positive mood, in turn, reduced risk of preterm birth and indirectly predicted positive infant emotions via birth outcomes. Neighborhood support in preadolescence predicted lower prenatal depressed mood, but depressed mood did not predict infant outcomes beyond positive mood. Contextual life stress was not associated with prenatal mood after adjusting for family and neighborhood support.

CONCLUSIONS

Findings highlight changes in positive-valence emotions during adolescent pregnancy that may have unique associations with birth outcomes and offspring emotions.

The Social Determinants of Perinatal Maternal Distress

This pilot study examined associations between prenatal individual and socioenvironmental determinants of health and symptoms of perinatal maternal distress (PMD) in women enrolled in midwifery practice and living in a rural state. Pearson's correlations between prenatal predictors and PMD scores were calculated. Having experienced emotional abuse in one's lifetime, total number of past year stressors, and everyday discrimination score were all statistically significant predictors of PMD at study enrollment and follow-up. Result suggest shifting to a multi-symptom, life course assessment and intervention paradigm, tailored to the context of specific populations, may improve perinatal care and reduce disparities.

Associations between Self-Rated Health and Perinatal Depressive and Anxiety Symptoms among Latina Women

PURPOSE

The objective of this study was to determine whether decreases in or consistently low preconception to pregnancy self-rated health (SRH) were associated with perinatal depressive and anxiety symptoms among Latinas.

METHODS

This is a secondary data analysis of 153 perinatal Latinas. Three groups were created to capture SRH from preconception to pregnancy: a decline in ratings, consistently low, and good+ (i.e., good, very good, or excellent). SRH was measured using two questions about their perceived physical health before and during pregnancy. Depressive symptoms and anxiety symptoms were assessed in the third trimester and six weeks postpartum using the Edinburgh Postnatal Depression Scale and State-Trait Anxiety Inventory, respectively. Life stressors were assessed in pregnancy using a modified version of the Life Experiences Survey. Linear regressions tested the associations.

RESULTS

Women with consistently low (i.e., fair or poor) SRH reported significantly more prenatal depressive symptoms than women who reported consistently good+ SRH. Women who reported a decline in SRH to fair or poor reported more prenatal anxiety symptoms but decreased postpartum anxiety symptoms than women who reported consistently good+ ratings. Life stressors were positively associated with prenatal depressive and anxiety symptoms.

CONCLUSIONS

Healthcare practitioners should assess changes in SRH ratings to identify risks for prenatal depressive and anxiety symptoms among Latinas, who have elevated rates of depressive and anxiety symptoms compared to non-Hispanic White women. Policymakers should provide healthcare providers with mental health resources to support at-risk Latinas during the prenatal period.

Racial/ethnic disparities in subjective sleep duration, sleep quality, and sleep disturbances during pregnancy: an ECHO study

In the United States, racial/ethnic minoritized groups experience worse sleep than non-Hispanic Whites (nHW), but less is known about pregnant people. This is a key consideration since poor sleep during pregnancy is common and associated with increased risk of adverse perinatal outcomes. This study reports the prevalence of subjective sleep measures in a multi-racial/ethnic pregnant population from the Environmental influences on Child Health Outcomes (ECHO) program. Participants' self-reported race and ethnicity were grouped into: nHW, non-Hispanic Black/African American (nHB/AA), Hispanic, non-Hispanic Asian (nHA). Analyses examined trimester-specific (first (T1), second (T2), third (T3)) nocturnal sleep duration, quality, and disturbances (Pittsburgh Sleep Quality Index and ECHO maternal sleep health questionnaire). Linear or multinomial regressions estimated the associations between race/ethnicity and each sleep domain by trimester, controlling for body mass index and age, with nHW as reference group. We repeated analyses within maternal education strata. nHB/AA participants reported shorter sleep duration (T2: β = -0.55 [-0.80,-0.31]; T3: β = -0.65 [-0.99,-0.31]) and more sleep disturbances (T2: β = 1.92 [1.09,2.75]; T3: β = 1.41 [0.09,2.74]). Hispanic participants reported longer sleep duration (T1: β = 0.22 [0.00004,0.44]; T2: β = 0.61 [0.47,0.76]; T3: β = 0.46 [0.22,0.70]), better sleep quality (Reference group: Very good. Fairly good T1: OR = 0.48 [0.32,0.73], T2: OR = 0.36 [0.26,0.48], T3: OR = 0.31 [0.18,0.52]. Fairly bad T1: OR = 0.27 [0.16,0.44], T2: OR = 0.46 [0.31, 0.67], T3: OR = 0.31 [0.17,0.55]), and fewer sleep disturbances (T2: β = -0.5 [-1.0,-0.12]; T3: β = -1.21 [-2.07,-0.35]). Differences persisted within the high-SES subsample. Given the stark racial/ethnic disparities in perinatal outcomes and their associations with sleep health, further research is warranted to investigate the determinants of these disparities.

Association of Food Insecurity with Mental Health Outcomes in Parents and Children

BACKGROUND

Food insecurity affects 13.7 million US households and is linked to poor mental health. Families shield children from food insecurity by sacrificing their nutritional needs, suggesting parents and children experience food insecurity differentially.

OBJECTIVE

To identify the associations of food insecurity and mental health outcomes in parents and children DATA SOURCES: PubMed, Embase, Web of Science, and PsycInfo STUDY ELIGIBILITY CRITERIA: We included original research published in English from January 1990 to June 2020 that examined associations between food insecurity and mental health in children or parents/guardians in the United States.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers screened studies for inclusion. Data extraction was completed by one reviewer and checked by a second. Bias and confounding were assessed using the Agency for Healthcare Research and Quality RTI Item Bank. Studies were synthesized qualitatively, grouped by mental health outcome, and patterns were assessed. Meta-analyses were not performed due to high variability between studies.

RESULTS

We included 108 studies, assessing 250,553 parents and 203,822 children in total. Most studies showed a significant association between food insecurity and parental depression, anxiety, and stress, and between food insecurity and child depression, externalizing/internalizing behaviors, and hyperactivity.

LIMITATIONS

Most studies were cross-sectional and many were medium- or high-risk for bias or confounding.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Food insecurity is significantly associated with various mental health outcomes in both parents and children. The rising prevalence of food insecurity and mental health problems make it imperative that effective public health and policy interventions address both problems.

Perinatal Complications, Poor Hospital Treatment, and Positive Screen for Postpartum Depressive Symptoms Among Black Women

Though mandatory screening for depression during pregnancy and the postpartum period is recommended, postpartum depression is still underdiagnosed and overlooked among Black women. Understanding risk factors during pregnancy and delivery that may increase the risk for postpartum depression is important for Black women. Thus, the purpose of this study is to examine the relationship between perinatal complications (i.e., preterm birth, low birth weight, gestational diabetes, unplanned cesarean section, undesired pregnancy, depression during pregnancy), poor hospital treatment, and postpartum depressive symptoms (i.e., depressed mood, anhedonia, and positive screen on PHQ-2) among Black women. Using the Listening to Mothers III survey, we conducted logistic regression analyses in a nationally representative sample of 368 Black women to examine the relationship between perinatal complications, poor hospital treatment, and positive screen for postpartum depressive symptoms, measured by the Patient Health Questionnaire-2 (PHQ-2). We also examined these factors in predicting anhedonia and depressed mood. Poor hospital treatment was associated with a positive screen for postpartum depression, anhedonia, and depressed mood. Perinatal complications, when measured continuously, were associated with a positive screen for depression and depressed mood. Gestational diabetes and preterm birth were associated with depressed mood while depression during pregnancy was associated with anhedonia. Perinatal complications during pregnancy and delivery may increase the risk for postpartum depression among Black women. When screening for postpartum depression, it may also be important to inquire about poor hospital treatment and stressors emanating from these experiences.

Experiences of Discrimination and Depression Trajectories over Pregnancy

INTRODUCTION

Research on risk factors for prenatal depression is critical to improve the understanding, prevention, and treatment of women's psychopathology. The current study examines the relation between experiences of racial discrimination and trajectories of depression symptoms over the course of pregnancy.

METHOD

Participants completed standardized measures regarding symptoms of depression at four timepoints during pregnancy and reported on experiences of racial discrimination at one timepoint. Latent growth curve modeling was used to examine the relation between discrimination and initial levels (intercept) and trajectories (slope) of depression symptoms over pregnancy.

RESULTS

Participants were 129 pregnant individuals recruited from obstetric clinics and oversampled for elevated depression symptoms. Thirty-six percent of the participants were living at or below 200% of the federal poverty line. Fifty-four percent of the sample identified as non-Latinx White, 26% as Latinx, and 13% as non-Latinx Black. An unconditional latent growth curve modeling revealed a negative quadratic trajectory of depression symptoms during pregnancy. When women's report of discrimination was added as a predictor of depression trajectories, discrimination predicted the initial value (intercept) of depression symptoms, but not change over the course of pregnancy (slope). Specifically, higher levels of experiences of discrimination were associated with higher levels of depression symptoms. When sociodemographic and contextual covariates were included in the model, a low family income-to-needs ratio was also related to higher levels of depression symptoms.

CONCLUSIONS

These findings provide evidence that women's experiences of racial discrimination and family financial strain are risk factors for prenatal depression, with implications for screening, treatment, and policy.

Scoping Review of Microaggression as an Experience of Racism and Perinatal Health Outcomes

OBJECTIVE

To synthesize current knowledge and identify gaps in the literature related to microaggression as an experience of racism and its influence on perinatal health outcomes.

DATA SOURCES

We searched PubMed, Race Relations Abstracts, Academic Search Complete, CINAHL, PsycInfo, and Scopus using the keywords "micro-aggression" and "microaggression." Because microaggression is an all-encompassing term, we included articles that used keywords such as "racism," "prejudice," and/or "discrimination" because these terms are precursors to and touch on aspects of microaggression. We also included terms related to perinatal health outcomes.

STUDY SELECTION

We included articles in which researchers reported on studies conducted in the United States. Articles focused on perinatal health outcomes, referred to microaggressions or related concepts, and were published in English from January 2014 through July 2020. We chose these dates because the term microaggression became more common in the literature around 2017 and is used primarily in the United States. Following removal of duplicates, we reviewed 2,331 titles and abstracts and identified 103 articles for full-text review. Thirteen articles met inclusion for the final sample. Screening at all levels was blinded.

DATA EXTRACTION

We extracted data, including setting, study type, study design, microaggression type, results, health outcomes, and definitions of microaggression.

DATA SYNTHESIS

In the selected articles, researchers addressed microaggression as an experience of racism in relation to the following perinatal health outcomes: small-for-gestational-age newborns, hypertension, preterm birth, low birth weight, and symptoms of postpartum depression or anxiety.

CONCLUSION

In this scoping review, inconsistencies in how it was defined, measured, and controlled made it difficult to draw conclusions about the role microaggression plays in perinatal health outcomes. We recommend more research to explore, document, and understand this phenomenon.

Inconsistent Reporting of Discrimination Over Time Using the Experiences of Discrimination Scale: Potential Underestimation of Lifetime Burden

Studies documenting self-reported experiences of discrimination over the life course have been limited. Such information could be important for informing longitudinal epidemiologic studies of discrimination and health. We characterized trends in self-reports of racial, socioeconomic status, and gender discrimination over time measured using the Experiences of Discrimination Scale, with a focus on whether individuals' reports of lifetime discrimination were consistent over time. Overall experiences of discrimination and the number of settings in which discrimination was reported in 1992, 2000, and 2010 were examined among 2,774 African-American and White adults in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Reports of "ever" experiencing discrimination decreased for all forms of discrimination across the 3 study visits. Approximately one-third (30%-41%) of the sample inconsistently reported ever experiencing any discrimination over time, which contributed to the observed decreases. Depending on the form of discrimination, inconsistent reporting patterns over time were more common among African-American, younger, less educated, and lower-income individuals and women-groups who are often most exposed to and severely impacted by the health effects of discrimination. Our findings highlight the possible underestimation of the lifetime burden of discrimination when utilizing the Experiences of Discrimination Scale to capture self-reports of discrimination over time.

Associations between everyday discrimination and sleep quality and duration among African-Americans over time in the Jackson Heart Study

STUDY OBJECTIVES

African-Americans have a high burden of poor sleep, yet, psychosocial determinants (e.g. discrimination) are understudied. We investigated longitudinal associations between everyday discrimination and sleep quality and duration among African-Americans (N = 3404) in the Jackson Heart Study.

METHODS

At Exam 1 (2000-2004) and Exam 3 (2008-2013), participants completed the Everyday Discrimination Scale, rated their sleep quality (1 = poor to 5 = excellent), and self-reported hours of sleep. A subset of participants (N = 762) underwent 7-day actigraphy to objectively measure sleep duration and sleep quality (Sleep Exam 2012-2016). Changes in discrimination were defined as low stable (reference), increasing, decreasing, and high stable. Within-person changes in sleep from Exam 1 to Exam 3 were regressed on change in discrimination from Exam 1 to Exam 3 while adjusting for age, sex, education, income, employment, physical activity, smoking, body mass index, social support, and stress.

RESULTS

At Exam 1, the mean age was 54.1 (12.0) years; 64% were female, mean sleep quality was 3.0 (1.1) and 54% were short sleepers. The distribution of the discrimination change trajectories were 54.1% low stable, 13.5% increasing, 14.6% decreasing, and 17.7% were high stable. Participants who were in the increasing (vs. low stable) discrimination group had greater decrease in sleep quality. There was no association between change in discrimination and change in sleep duration. Among Sleep Exam participants, higher discrimination was cross-sectionally associated with shorter self-reported sleep duration, independent of stress.

CONCLUSION

Discrimination is a unique stressor for African-Americans; thus, future research should identify interventions to reduce the burden of discrimination on sleep quality.

Group prenatal care and improved birth outcomes: Results from a type 1 hybrid effectiveness-implementation study

To compare birth outcomes for patients receiving Expect With Me (EWM) group prenatal care or individual care only, we conducted a type 1 hybrid effectiveness-implementation trial (Detroit and Nashville, 2014-2016). Participants entered care <24 weeks gestation, had singleton pregnancy, and no prior preterm birth (N = 2402). Mean participant age was 27.1 (SD = 5.77); 49.5% were Black; 15.3% were Latina; 59.7% publicly insured. Average treatment effect of EWM compared to individual care only was estimated using augmented inverse probability weighting (AIPW). This doubly-robust analytic method produces estimates of causal association between treatment and outcome in the absence of randomization. AIPW was effective at creating equivalent groups for potential confounders. Compared to those receiving individual care only, EWM patients did significantly better on three of four primary outcomes: lower risk of infants born preterm (<37 weeks gestation; 6.4% vs. 15.1%, risk ratio (RR) 0.42, 95% Confidence Interval (CI) 0.29, 0.54), low birthweight (<2500 g; 4.3% vs. 11.6%, RR 0.37, 95% CI 0.24, 0.49), and admission to NICU (9.4% vs. 14.6%, RR 0.64, 95% CI 0.49, 0.78). There was no difference in small for gestational age (<10% percentile of weight for gestational age). EWM patients attended a mean of 5.9 group visits (SD = 2.7); 70% attended ≥5 group visits. Post-hoc analyses indicated EWM patients utilizing the integrated information technology platform had lower risk for low birthweight infants (RR 0.47, 95% CI 0.24, 0.86) than non-users. Future research is needed to understand mechanisms by which group prenatal care improves outcomes, best practices for implementation, and health systems savings. Trial registration: ClinicalTrials.govNCT02169024.

A new perspective on the maternal mortality disparity

The disparity in maternal mortality rates between ethnicities in the United States is alarming, with Black women at far higher risk of dying than women of other ethnicities. Factors typically thought of as protective in health disparity research are not necessarily protective with maternal mortality. Building upon a social justice framework by utilizing a strength-based focus is needed when addressing this issue to build upon strengths and empower Black women as a part of the solution.

Synergistic Effects of Psychological Intimate Partner Violence Exposure and Gender Discrimination on Postnatal Mental Health Trajectories

While the literature examining physical intimate partner violence (IPV) is extensive, the impact of psychological IPV on mental health during high-risk times such as the period following childbirth is not well understood. The current study examined associations between psychological IPV and the course and severity of women's postnatal mental health symptoms (depression, anxiety, and trauma symptoms). Both main effects of psychological IPV exposure and possible exacerbation by broader social victimization (i.e., gender discrimination) were considered. Participants were 76 mothers from a larger longitudinal study, who completed self-report measures of IPV, gender discrimination, and affective symptoms at 3, 6, 12, and 18 months postnatal. Hierarchical linear modeling revealed a main effect of psychological IPV on the course of trauma symptoms only. As hypothesized, gender discrimination moderated the effect of psychological IPV on all symptom trajectories in a synergistic manner. At moderate to high levels of gender discrimination only, psychological IPV predicted higher affective symptom severity and an escalating course of postnatal anxiety symptoms. These findings underscore the importance of expanding current conceptualizations of IPV impacts to incorporate relevant aspects of individuals' social-ecological context. Future directions and implications for prevention and intervention are discussed.

Perceived Stress, Resilience, and Anxiety Among Pregnant Chinese Women During the COVID-19 Pandemic: Latent Profile Analysis and Mediation Analysis

Objective: The coronavirus disease 2019 (COVID-19) pandemic has posed a major threat to pregnant women's mental health. This study aimed to characterize the patterns of perceived stress in pregnant Chinese women during the COVID-19 pandemic, to examine the profile differences on anxiety and resilience, and to investigate whether the differences in these profiles on anxiety were mediated by resilience.

Methods: From February 28, 2020 to April 26, 2020, a sample of 2,116 pregnant Chinese women who participated in online crisis interventions completed an online self-reporting questionnaire assessing their demographic characteristics, perceived stress, resilience, and anxiety.

Results: Latent profile analysis (LPA) on two stress dimensions [perceived helplessness (HEL) and perceived self-efficacy (SEL)] indicated four perceived stress profiles: adaptive (33.7% of the sample), resistant (44.6%), insensitive (19.1%), and sensitive (2.6%). The women with both adaptive and insensitive profiles had the lowest levels of anxiety, whereas those with the resistant profile had the lowest levels of resilience. Multicategorical mediation analysis showed that resilience partially mediated the differences in the pregnant women's anxiety between the adaptive/insensitive and resistant profile.

Conclusion: This study showed the heterogeneity in the perceived stress patterns of pregnant women during the COVID-19 pandemic, revealing the internal mechanisms of pregnant women's anxiety using a person-centered approach, and provided initial evidence guiding the development of differentiated stress interventions to alleviate pregnant women's anxiety during the pandemic.

Cardiac vagal control in response to acute stress during pregnancy: Associations with life stress and emotional support

Life stressors during pregnancy can disrupt maternal stress regulation and negatively impact offspring health. Despite the important role of cardiac vagal control (e.g., heart rate variability; HRV) in stress regulation, few studies have investigated how life stressors and emotional support influence vagal control during pregnancy. This study aimed to (a) characterize patterns of cardiac vagal control in response to a stressor administered in pregnancy, and (b) examine the effects of life stress and emotional support on vagal control during rest, reactivity, and recovery. Participants included 191 pregnant women (79% Black; 21% White) living in an urban U.S. city (73% receiving public assistance). Heart rate (HR) and HRV (indexed by RMSSD) were recorded continually during the preparation, task, and recovery periods of the Trier Social Stress Test (TSST). Participants reported recent life stressors (e.g., relationship problems, financial hardship) and emotional support. Piecewise growth curve modeling was used to model rates of reactivity and recovery, adjusting for gestational age at time of assessment and recent health problems. Life stress predicted greater HR and HRV reactivity to the TSST as well as greater HRV recovery (vagal rebound). However, associations were only evident for women reporting high emotional support. Results suggest that pregnant women living with frequent life stressors may exhibit more rapid autonomic responses to acute stress, including more rapid vagal rebound after stressors, potentially reflecting physiological adaptation to anticipated high-stress environments; emotional support may enhance these responses. Studies are needed to investigate long-term health outcomes related to this stress response pattern.

Associations between social determinants of health, perceived discrimination, and body mass index on symptoms of depression among young African American mothers

PURPOSE

The association between symptoms of depression and risks for cardiovascular disease (CVD) remains equivocal for African American (AA) mothers. We examined the association between social determinants of health (perceived discrimination), and cardiovascular risk (BMI) on symptoms of depression in a sample of young AA mothers.

METHODS

Secondary data from 219 adult AA mothers between the ages of 21 and 46 with an average BMI of 29.8 and yearly family income of $14,999 were analyzed using a latent growth model that evaluated four time points to assess changes in symptoms of depression.

RESULTS

Initial BMI was significantly associated with initial symptoms of depression (b = 0.12, p = .019). Perceived discrimination (unfair treatment) was associated with higher initial symptoms of depression (b = 1.14, p = .017).

CONCLUSION

The findings suggest that elevated BMI and perceived discrimination are associated with higher reported symptoms of depression among young, socioeconomically disadvantaged AA mothers. These results advance the scientific understanding of young AA mothers' risk for symptoms of depression and CVD by elucidating the impact of perceived discrimination and social experiences on mental health. Further studies of SDoH and CVD risk factors and perceived racism and depression are needed to shed light on the long-term mental health impact on AA mothers and their children.

A tale of two generations: Maternal skin color and adverse birth outcomes in Black/African American women

We examined how sociopolitical context (marked by generational cohort) and maternal skin color interacted to influence preterm delivery (PTD) rates in sample of Black women. Data were from 1410 Black women, ages 18-45 years, residing in Metropolitan Detroit, MI enrolled (2009-2011) in the Life-course Influences on Fetal Environments (LIFE) Study. Because we hypothesized that generational differences marked by changes in the sociopolitical context would influence exposure to racism, we categorized women into two cohorts by maternal birth year: a) Generation X, 1964-1983 and b) Millennial, 1984-1993. Descriptive results showed similar PTD rates by generational cohort, Generation X: 16.3% vs. Millennials: 16.1%. Yet, within each generation, PTD rates varied by women's skin tone (categorized: light, medium, and dark brown). Poisson regression models confirmed a significant interaction between generational cohort and maternal skin tone predicting PTD (P = 0.001); suggesting a salubrious association between light brown skin tone (compared to medium and dark) and PTD for Generation X. However, Millennials with medium and dark brown skin experienced lower PTD rates than their light Millennial counterparts. Research should consider sociopolitical context and the salience of skin tone bias when investigating racial health disparities, including those in perinatal health.

Gender discrimination and women's HPA activation to psychosocial stress during the postnatal period

Stress due to discrimination may contribute to physiological dysregulation and health risk during the postnatal period. This study examined longitudinal associations between gender discrimination and women's cortisol responses to subsequent stress. Mothers (N = 79) reported gender discrimination and completed mother-infant stress tasks with saliva sampling for cortisol at 6, 12, and 18 months postnatal. Multilevel modeling results indicated more overall gender discrimination was associated with higher cortisol. Changes in gender discrimination were not associated with cortisol over time. Gender discrimination may be a factor in women's postnatal stress and associated health risk via the sensitization of physiological stress responses.

Religious Discrimination Scale: Development and Initial Psychometric Evaluation

This study presents the development and initial psychometric evaluation of the Religious Discrimination Scale (RDS). This 11-item instrument identified three dimensions based on perceived discrimination experiences of members of The Church of Jesus Christ of Latter-day Saints (LDS): Perceived Prejudice, Closet Symptoms, and Negative Labels. The psychometric evaluations of the RDS indicated a strong and clear factor structure as well as good internal consistency reliability. The test of measurement and structural invariance across gender also suggested that the RDS scale is equally appropriate to be used with both men and women. Implications for practice and research as well as future directions are discussed.

Psychosocial predictors of antenatal stress in Pakistan: perspectives from a developing country

Objective

Antenatal stress is highly prevalent globally and is associated with adverse physical and psychiatric morbidities and adverse neonatal outcomes. However, the burden of antenatal stress and its psychosocial predicators have not been explored in context of the Pakistani sociocultural environment. The present study explores the prevalence of antenatal stress and its association with gender of offspring, socioeconomic background, cultural beliefs, and access to healthcare in the province of Punjab, Pakistan.

Results

There was a total of 516 pregnant women. Antenatal stress was measured by the Perceived Stress Scale (PSS). The mean score of the respondents on the Perceived Stress Scale was 7.55 (3.43). A total of 218 (42.2%) respondents reported higher stress levels. Logistic regression analysis (backward method) yielded a significant model predicting high stress levels. According to it, low family income, unplanned pregnancy, increasing number of children, less autonomy in decision making, marital problems, harassment, desire to have a male offspring, and the history of birth complications, attended by midwives were associated with high stress levels.

Social determinants as moderators of the effectiveness of health behavior change interventions: scientific gaps and opportunities

Social determinants of health (SDOH) refer to the broad range of social, economic, political, and psychosocial factors that directly or indirectly shape health outcomes and contribute to health disparities. There is a growing and concerted effort to address SDOH worldwide. However, the application of SDOH to health behavior change intervention research is unknown. We reviewed the synthesis literature on health behavior change interventions targeting self-regulation to (a) describe the sociodemographic characteristics, (b) determine which types of social determinants were tested as moderators of health behavior change interventions, (c) evaluate the methodological quality of the meta-analytic evidence, and (d) discuss scientific gaps and opportunities. Thirty (45.4%) of 66 articles examined heterogeneity of treatment effects by SDOH. There was a lack of racial/ethnic, immigrant, sexual/gender minority, and lifecourse sample diversity. Overall, 73.5% of SDOH moderator analyses tested heterogeneity of treatment effects by gender, race/ethnicity, and intervention setting; none examined neighborhood factors. Methodological quality was negatively correlated with number of SDOH analyses. Most SDOH moderator analyses were atheoretical and indicated statistically non-significant differences. We provide an integrated SDOH and science of behavior change framework and discuss scientific opportunities for intervention research on health behavior change to improve health equity.

Longitudinal associations between self-reported experiences of discrimination and depressive symptoms in young women and men post- myocardial infarction

Objectives

Research suggests that following a myocardial infarction (MI), women under the age of 60 have more elevated depressive symptoms and adverse outcomes than similarly aged men. Identifying risk factors that contribute to gender differences in depressive symptoms among this group may be critical to the development of psychosocial interventions. Experiences of discrimination may be an important correlate of depressive symptoms in this group; however, studies of this relationship have largely been cross-sectional and focused on healthy populations. This study examines longitudinal associations among gender, discrimination, and depressive symptoms in a young post-MI cohort.

Methods

Participants were 313 adults from the Myocardial Infarction and Mental Stress Ischemia Study 2 of young (≤60 yrs) post-MI patients. At baseline and 6 month follow-up, depressive symptoms were measured with the Beck Depression Inventory-II and discrimination was assessed with the 10-item version Everyday Discrimination scale. Linear regression models were used to assess the longitudinal association between reports of discrimination and depressive symptoms adjusted for sociodemographic characteristics, psychosocial factors and health status indicators and tested for gender differences.

Results

The mean age was 51.2, 49.6% were women, and 69.5% were African-American. Although the discrimination-by-gender interaction was marginally significant (p=.09) in the fully adjusted model, findings suggest that the association between changes in reports of discrimination and depressive symptoms over time may be more pronounced for women (β=.61, standard error=.15, p<.001) than men (β=.27, standard error=.13, p=.033).

Conclusion

Our findings suggest that discrimination is a risk factor for depressive symptoms in young post-MI populations over time.

Personal Versus Group Experiences of Racism and Risk of Delivering a Small-for-Gestational Age Infant in African American Women: a Life Course Perspective

The majority of studies investigating the relationship between racism/racial discrimination and birth outcomes have focused on perceived experiences of racism/racial discrimination directed at oneself (personal racism). However, evidence suggests individuals report with greater frequency racism/racial discrimination directed at friends, family members, or other members of their racial/ethnic group (group racism). We examined how much African American (AA) women report lifetime experiences of perceived racism or racial discrimination, both personal and group, varied by maternal age. We also investigated whether reports of personal and group racism/racial discrimination were associated with the risk of delivering a small-for-gestational age (SGA) infant and how much maternal age in relation to developmental life stages (adolescence [≤ 18 years], emerging adulthood [19-24 years], and adulthood [≥ 25 years]) moderated the relationship. Data stem from the Baltimore Preterm Birth Study, a hybrid prospective/retrospective cohort study that enrolled 872 women between March 2000 and July 2004 (analyzed in 2016-2017). Spline regression analyses demonstrated a statistically significant (p value for overall association < 0.001) and non-linear (p value = 0.044) relationship between maternal age and the overall racism index. Stratified analysis showed experiences of racism overall was associated with a higher odds ratio of delivering an SGA infant among AA women aged ≥ 25 years (OR = 1.45, 95% CI 1.02-2.08). The overall racism index was not associated with the SGA infant odds ratio for emerging adults (OR = 0.86, 95% CI 0.69-1.06) or adolescents (OR = 0.92, 95% CI 0.66-1.28). Multiple aspects of racism and the intersection between racism and other contextual factors need to be considered.

Racial Discrimination and Psychological Wellbeing of Pregnant Women

PURPOSE

African American women are more likely to be exposed to racial discrimination and to experience psychological distress compared with white women. Although studies have shown that social support is positively related to psychological wellbeing, little is known about the potential buffering effect of social support on the relationship between racial discrimination and psychological wellbeing of pregnant women. The purpose of this study was to determine if social support moderates effects of racial discrimination on psychological wellbeing among pregnant African American women.

STUDY DESIGN AND METHODS

Using a cross-sectional design, 107 African American women between 15 and 26 weeks gestation from an urban university-based midwifery practice completed questionnaires.

RESULTS

Women who reported more experiences of racial discrimination also reported lower levels of social support and psychological wellbeing (p <.05).

CLINICAL IMPLICATIONS

Maternal child nurses should be aware that experiences of racial discrimination have negative effects on psychological wellbeing of pregnant African American women regardless of their levels of social support. However, social support can reduce psychological distress and improve wellbeing of pregnant women. Therefore, nurses need to provide pregnant women with positive and supportive experiences that may improve their psychological wellbeing.

Intergenerational Consequences: Women's Experiences of Discrimination in Pregnancy Predict Infant Social-Emotional Development at 6 Months and 1 Year

OBJECTIVE

Racial/ethnic and socioeconomic disparities in infant development in the United States have lifelong consequences. Discrimination predicts poorer health and academic outcomes. This study explored for the first time intergenerational consequences of women's experiences of discrimination reported during pregnancy for their infants' social-emotional development in the first year of life.

METHODS

Data come from a longitudinal study with predominantly Black and Latina, socioeconomically disadvantaged, urban young women (N = 704, Mage = 18.53) across pregnancy through 1 year postpartum. Women were recruited from community hospitals and health centers in a Northeastern US city. Linear regression analyses examined whether women's experiences of everyday discrimination reported during pregnancy predicted social-emotional development outcomes among their infants at 6 months and 1 year of age, controlling for potentially confounding medical and sociodemographic factors. Path analyses tested if pregnancy distress, anxiety, or depressive symptoms mediated significant associations.

RESULTS

Everyday discrimination reported during pregnancy prospectively predicted greater inhibition/separation problems and greater negative emotionality, but did not predict attention skills or positive emotionality, at 6 months and 1 year. Depressive symptoms mediated the association of discrimination with negative emotionality at 6 months, and pregnancy distress, anxiety, and depressive symptoms mediated the association of discrimination with negative emotionality at 1 year.

CONCLUSION

Findings support that there are intergenerational consequences of discrimination, extending past findings to infant social-emotional development outcomes in the first year of life. It may be important to address discrimination before and during pregnancy and enhance support to mothers and infants exposed to discrimination to promote health equity across the life span.

Health care experiences of pregnant, birthing and postnatal women of color at risk for preterm birth

BACKGROUND

Chronic stress is a known risk factor for preterm birth, yet little is known about how healthcare experiences add to or mitigate perceived stress. In this study, we described the pregnancy-related healthcare experiences of 54 women of color from Fresno, Oakland, and San Francisco, California, with social and/or medical risk factors for preterm birth.

METHODS

This study was a secondary analysis of focus group data generated as part of a larger project focused on patient and community involvement in preterm birth research. English and Spanish speaking women, age 18 or greater with social and/or medical risk factors for preterm birth participated in two focus groups, six weeks apart. Data from the first focus groups are included in this analysis.

RESULTS

Five themes emerged from thematic analysis of the transcripts. Participants described disrespect during healthcare encounters, including experiences of racism and discrimination; stressful interactions with all levels of staff; unmet information needs; and inconsistent social support. Despite these adverse experiences, women felt confidence in parenting and newborn care. Participant recommendations for healthcare systems improvement included: greater attention to birth plans, better communication among multiple healthcare providers, more careful listening to patients during clinical encounters, increased support for social programs such as California's Black Infant Health, and less reliance on past carceral history and/or child protective services involvement.

DISCUSSION

The women in this study perceived their prenatal healthcare as a largely disrespectful and stressful experience. Our findings add to the growing literature that women of color experience discrimination, racism and disrespect in healthcare encounters and that they believe this affects their health and that of their infants.

Characterizing non-monosexual women at risk for poor mental health outcomes: A mixed methods study

OBJECTIVES

Non-monosexual women - those who report attraction to or sexual relationships with individuals of more than one gender - have elevated risk for poor mental health outcomes. We aimed to examine which elements of non-monosexual experience are associated with this elevated risk.

METHODS

We conducted a sequential exploratory mixed methods analysis of qualitative interview and survey data from 39 non-monosexual women recruited consecutively through prenatal care providers. Qualitative analyses identified distinguishing features, and quantitative analyses tested associations between these features and mental health symptoms.

RESULTS

Nine qualitative themes were identified to describe distinguishing features of non-monosexual women. Of these, current and past five years partner gender, lack of LGBTQ community connection, and low centrality of sexual minority identity were associated with anxiety symptoms. Latent class analysis revealed significantly higher levels of anxiety symptoms among non-monosexual women partnered with men relative to those partnered with women.

CONCLUSION

Sexual minority women who partner with men may be particularly at risk for poor mental health. Considering this group's invisibility in public health research and practice, interventions are needed to address this disparity.

Acculturation and Adverse Birth Outcomes in a Predominantly Puerto Rican Population

Introduction Latinas in the United States on average have poorer birth outcomes than Whites, yet considerable heterogeneity exists within Latinas. Puerto Ricans have some of the highest rates of adverse outcomes and are understudied. The goal of this study was to determine if acculturation was associated with adverse birth outcomes in a predominantly Puerto Rican population. Methods We conducted a secondary analysis of Proyecto Buena Salud, a prospective cohort study conducted from 2006 to 2011. A convenience sample of pregnant Latina women were recruited from a tertiary care hospital in Massachusetts. Acculturation was measured in early pregnancy; directly via the Psychological Acculturation Scale, and via proxies of language preference and generation in the United States. Birth outcomes (gestational age and birthweight) were abstracted from medical records (n = 1362). Results After adjustment, psychological acculturation, language preference, and generation was not associated with odds of preterm birth. However, every unit increase in psychological acculturation score was associated with an increase in gestational age of 0.22 weeks (SE = 0.1, p = 0.04) among all births. Women who preferred to speak Spanish (β = -0.39, SE = 0.2, p = 0.02) and who were first generation in the US (β = -0.33, SE = 0.1, p = 0.02) had significantly lower gestational ages than women who preferred English or who were later generation, respectively. Similarly, women who were first generation had babies who weighed 76.11 g less (SE = 35.2, p = 0.03) than women who were later generation. Discussion We observed a small, but statistically significant adverse impact of low acculturation on gestational age and birthweight in this predominantly Puerto Rican population.

The prevalence of antenatal and postnatal co-morbid anxiety and depression: a meta-analysis

To date, the precise prevalence of co-morbidity of anxiety and depression in the perinatal period is not well known. We aimed to estimate the prevalence of co-morbid anxiety and depression in the antenatal and postnatal periods. Systematic searches of multiple electronic databases were conducted for studies published between January 1950 and January 2016. We included 66 (24 published and 42 unpublished) studies incorporating 162 120 women from 30 countries. Prevalence of self-reported antenatal anxiety symptoms and mild to severe depressive symptoms was 9.5% [95% confidence interval (CI) 7.8-11.2, 17 studies, n = 25 592] and of co-morbid anxiety symptoms and moderate/severe depressive symptoms was 6.3% (95% CI 4.8-7.7, 17 studies, n = 27 270). Prevalence of a clinical diagnosis of any antenatal anxiety disorder and depression was 9.3% (95% CI 4.0-14.7, 10 studies, n = 3918) and of co-morbid generalized anxiety disorder and depression was 1.7% (95% CI 0.2-3.1, three studies, n = 3085). Postnatally between 1 and 24 weeks postpartum, the prevalence of co-morbid anxiety symptoms and mild to severe depressive symptoms was 8.2% (95% CI 6.5-9.9, 15 studies, n = 14 731), while co-morbid anxiety symptoms and moderate/severe depressive symptoms was 5.7% (95% CI 4.3-7.1, 13 studies, n = 20 849). The prevalence of a clinical diagnosis of co-morbid anxiety and depression was 4.2% (95% CI 1.9-6.6, eight studies, n = 3251). Prevalence rates did not differ with regard to year of publication, country income, selection bias and attrition bias. The results suggest that co-morbid perinatal anxiety and depression are prevalent and warrant clinical attention given the potential negative child developmental consequences if left untreated. Further research is warranted to develop evidence-based interventions for prevention, identification and treatment of this co-morbidity.

Perceived Racial/Ethnic Discrimination and Mental Health: a Review and Future Directions for Social Epidemiology

PURPOSE OF REVIEW

Recent literature on racial or ethnic discrimination and mental health was reviewed to assess the current science and identify key areas of emphasis for social epidemiology. Objectives of this review were to: 1) Determine whether there have been advancements in the measurement and analysis of perceived discrimination; 2) Identify the use of theories and/or frameworks in perceived discrimination and mental health research; and 3) Assess the extent to which stress buffers are being considered and evaluated in the existing literature.

RECENT FINDINGS

Metrics and analytic approaches used to assess discrimination remain largely unchanged. Theory and/or frameworks such as the stress and coping framework continue to be underused in majority of the studies. Adolescents and young adults experiencing racial/ethnic discrimination were at greater risk of adverse mental health outcomes, and the accumulation of stressors over the life course may have an aggregate impact on mental health. Some growth seems evident in studies examining the mediation and moderation of stress buffers and other key factors with the findings suggesting a reduction in the effects of discrimination on mental health.

SUMMARY

Discrimination scales should consider the multiple social identities of a person, the context where the exposure occurs, how the stressor manifests specifically in adolescents, the historical traumas, and cumulative exposure. Life course theory and intersectionality may help guide future work. Despite existing research, gaps remain in in elucidating the effects of racial and ethnic discrimination on mental health, signaling an opportunity and a call to social epidemiologists to engage in interdisciplinary research to speed research progress.

Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis

BackgroundMaternal anxiety negatively influences child outcomes. Reliable estimates have not been established because of varying published prevalence rates.AimsTo establish summary estimates for the prevalence of maternal anxiety in the antenatal and postnatal periods.MethodWe searched multiple databases including MEDLINE, Embase, and PsycINFO to identify studies published up to January 2016 with data on the prevalence of antenatal or postnatal anxiety. Data were extracted from published reports and any missing information was requested from investigators. Estimates were pooled using random-effects meta-analyses.ResultsWe reviewed 23 468 abstracts, retrieved 783 articles and included 102 studies incorporating 221 974 women from 34 countries. The prevalence for self-reported anxiety symptoms was 18.2% (95% CI 13.6-22.8) in the first trimester, 19.1% (95% CI 15.9-22.4) in the second trimester and 24.6% (95% CI 21.2-28.0) in the third trimester. The overall prevalence for a clinical diagnosis of any anxiety disorder was 15.2% (95% CI 9.0-21.4) and 4.1% (95% CI 1.9-6.2) for a generalised anxiety disorder. Postnatally, the prevalence for anxiety symptoms overall at 1-24 weeks was 15.0% (95% CI 13.7-16.4). The prevalence for any anxiety disorder over the same period was 9.9% (95% CI 6.1-13.8), and 5.7% (95% CI 2.3-9.2) for a generalised anxiety disorder. Rates were higher in low- to middle-income countries.ConclusionsResults suggest perinatal anxiety is highly prevalent and merits clinical attention. Research is warranted to develop evidence-based interventions.

Explaining racial and ethnic inequalities in postpartum allostatic load: Results from a multisite study of low to middle income woment

BACKGROUND

Racial and ethnic inequalities in women's health are widely documented, but not for the postpartum period, and few studies examine whether neighborhood, psychosocial, and biological factors explain these gaps in women's health.

METHODS

Using prospective longitudinal data collected from 1766 low to middle income women between 2008 and 2012 by the Community Child Health Network (CCHN), we tested the extent to which adjustment for neighborhood, economic, psychological, and medical conditions following a birth explained differences between African American, Latina, and White women in an indicator of physiological dysregulation allostatic load (AL), at one year postpartum as measured by 10 biomarkers: Body Mass Index, Waist Hip Ratio, systolic and diastolic blood pressure, high sensitivity C-reactive protein, Hemoglobin A1c, high-density lipoprotein and cholesterol ratio, and diurnal cortisol.

RESULTS

Mean postpartum AL scores were 4.65 for African American, 4.57 for Latina and 3.86 for White women. Unadjusted regression estimates for high AL for African American women (with White as the reference) were 0.80 (SD = 0.11) and 0.53 (SD = 0.15) for Latina women. Adjustment for household poverty, neighborhood, stress, and resilience variables resulted in a reduction of 36% of the excess risk in high AL for African Americans versus Whites and 42% of the excess risk for Latinas compared to Whites.

CONCLUSIONS

Racial and ethnic inequalities in AL were accounted for largely by household poverty with additional contributions by psychological, economic, neighbourhood and medical variables. There remained a significant inequality between African American, and Latina women as compared to Whites even after adjustment for this set of variables. Future research into health inequalities among women should include a fuller consideration of the social determinants of health including employment, housing and prepregnancy medical conditions.

The association between maternal and partner experienced racial discrimination and prenatal perceived stress, prenatal and postnatal depression: findings from the growing up in New Zealand cohort study

BACKGROUND

A growing number of studies document the association between maternal experiences of racial discrimination and adverse children's outcomes, but our understanding of how experiences of racial discrimination are associated with pre- and post-natal maternal mental health, is limited. In addition, existent literature rarely takes into consideration racial discrimination experienced by the partner.

METHODS

We analysed data from the Growing Up in New Zealand study to examine the burden of lifetime and past year experiences of racial discrimination on prenatal and postnatal mental health among Māori, Pacific, and Asian women in New Zealand (NZ), and to study the individual and joint contribution of mother's and partner's experiences of lifetime and past year racial discrimination to women's prenatal and postnatal mental health.

RESULTS

Our findings show strong associations between lifetime and past year experiences of ethnically-motivated interpersonal attacks and unfair treatment on mother's mental health. Māori, Pacific, and Asian women who had experienced unfair treatment by a health professional in their lifetime were 66 % more likely to suffer from postnatal depression, compared to women who did not report these experiences. We found a cumulative effect of lifetime experiences of ethnically-motivated personal attacks on poor maternal mental health if both the mother and the partner had experienced a racist attack.

CONCLUSIONS

Experiences of racial discrimination have severe direct consequences for the mother's mental health. Given the importance of mother's mental health for the basic human needs of a healthy child, racism and racial discrimination should be addressed.

Stereotypes of Black American Women Related to Sexuality and Motherhood

Intersectionality theorists and researchers suggest the importance of examining unique stereotypes associated with intersecting group identities. We focus on the unique stereotypes of Black women in the United States related to sexuality and motherhood. In an online experimental study, 435 undergraduates from a Northeastern U.S. university were randomly assigned to one of the four conditions in which they viewed a photograph and read a description of a target young woman. The target's race (Black vs. White) and pregnancy status (pregnant vs. no pregnancy information) were varied. A Black female target (pregnant or not) was perceived more negatively on items related to historically rooted societal stereotypes about sexual activity, sexual risk, motherhood status, and socioeconomic status than was a White female target, but there were no differences on items unrelated to societal stereotypes. A Black target described as pregnant was also perceived as more likely to be a single mother and to need public assistance than was a White target described as pregnant. Current findings, along with evidence that societal stereotypes have damaging effects, underscore the importance of diversifying images of Black women and increasing awareness of how stereotypes affect perceptions of Black women. Findings also highlight the value of research employing intersectionality to understand stereotypes.

Cumulative Effect of Racial Discrimination on the Mental Health of Ethnic Minorities in the United Kingdom

OBJECTIVES

To examine the longitudinal association between cumulative exposure to racial discrimination and changes in the mental health of ethnic minority people.

METHODS

We used data from 4 waves (2009-2013) of the UK Household Longitudinal Study, a longitudinal household panel survey of approximately 40 000 households, including an ethnic minority boost sample of approximately 4000 households.

RESULTS

Ethnic minority people who reported exposure to racial discrimination at 1 time point had 12-Item Short Form Health Survey (SF-12) mental component scores 1.93 (95% confidence interval [CI] = -3.31, -0.56) points lower than did those who reported no exposure to racial discrimination, whereas those who had been exposed to 2 or more domains of racial discrimination, at 2 different time points, had SF-12 mental component scores 8.26 (95% CI = -13.33, -3.18) points lower than did those who reported no experiences of racial discrimination. Controlling for racial discrimination and other socioeconomic factors reduced ethnic inequalities in mental health.

CONCLUSIONS

Cumulative exposure to racial discrimination has incremental negative long-term effects on the mental health of ethnic minority people in the United Kingdom. Studies that examine exposure to racial discrimination at 1 point in time may underestimate the contribution of racism to poor health.

Discrimination and excessive weight gain during pregnancy among Black and Latina young women

RATIONALE

Excessive weight gain during pregnancy is a major determinant of later life obesity among both Black and Latina women and their offspring. However, psychosocial determinants of this risk, including everyday discrimination, and potential moderators of such effects remain unexplored.

OBJECTIVE

We examined the influence of discrimination, a culturally relevant stressor, on odds of gaining weight beyond Institute of Medicine recommendations during pregnancy. Whether the effect was moderated by race/ethnicity, age, or depressive symptoms was also examined.

METHOD

Participants were 413 Black and Latina pregnant young women, ages 14-21 years. Experience with discrimination and all moderators were assessed in the second trimester. Last weight recorded in the third trimester was abstracted from medical records and used to determine excessive weight gain.

RESULTS

Ever experiencing discrimination was associated with a 71% increase in the odds of excessive weight gain. The effect of discrimination was primarily present among women who attributed this treatment to membership in a historically oppressed group (e.g., ethnic minority, female) or to membership in other stigmatized groups (e.g., overweight). The effect of ever experiencing discrimination was not moderated by race/ethnicity or age but was moderated by depressive symptoms. Supporting the perspective of the environmental affordances model, discrimination strongly predicted excessive weight gain when women were low in depressive symptoms but had no effect when women were high in depressive symptoms. The moderating role of depressive symptoms was equivalent for Black and Latina women.

CONCLUSION

Results highlight the role of discrimination in perpetuating weight-related health disparities and suggest opportunities for improving health outcomes among young pregnant women.

Exploring Group Composition among Young, Urban Women of Color in Prenatal Care: Implications for Satisfaction, Engagement, and Group Attendance

PURPOSE

Group models of prenatal care continue to grow in popularity. However, little is known about how group composition (similarity or diversity between members of groups) relates to care-related outcomes. The current investigation aimed to explore associations between prenatal care group composition with patient satisfaction, engagement, and group attendance among young, urban women of color.

METHODS

Data were drawn from two studies conducted in New Haven and Atlanta (2001-2004; n = 557) and New York City (2008-2011; n = 375) designed to evaluate group prenatal care among young, urban women of color. Women aged 14 to 25 were assigned to group prenatal care and completed surveys during their second and third trimesters of pregnancy. Group attendance was recorded. Data were merged and analyzed guided by the Group Actor-Partner Interdependence Model using multilevel regression. Analyses explored composition in terms of age, race, ethnicity, and language.

MAIN FINDINGS

Women in groups with others more diverse in age reported greater patient engagement and, in turn, attended more group sessions, b(se) = -0.01(0.01); p = .04.

CONCLUSION

The composition of prenatal care groups seems to be associated with young women's engagement in care, ultimately relating to the number of group prenatal care sessions they attend. Creating groups diverse in age may be particularly beneficial for young, urban women of color, who have unique pregnancy needs and experiences. Future research is needed to test the generalizability of these exploratory findings.