Associations Between Adverse Childhood Experiences and Stressful Life Events and Health Outcomes in Pregnant and Breastfeeding Women from Diverse Racial and Ethnic Groups

Abstract

Background:

This study sought to understand the characteristics of racially/ethnically diverse pregnant and breastfeeding women who have experienced adverse childhood experiences (ACEs) and stressful life events (SLEs) and the relationship among ACEs, SLEs, and health outcomes in this population.

Materials and Methods:

This was a secondary analysis of cross-sectional data from the Family Matters study. The participants in this study were families with children ages 5–9 (N = 1,307) recruited from Minneapolis–St. Paul primary care clinics representing six racial/ethnic backgrounds (White, Black, Native American, Hmong, Somali, Latino). Primary caregivers completed surveys about personal health, parenting styles, resilience, ACEs, and SLEs. Linear and logistic regression models were used to examine the associations between ACEs and SLEs with health outcomes of pregnant and breastfeeding women at the individual level.

Results:

A total of 123 racially/ethnically diverse women in this study reported being pregnant or currently breastfeeding. Eighty-eight (72%) reported a history of ACEs or SLEs. Those with both ACEs/SLEs reported more depression, economic strain, and a shorter duration of living in the United States. An increase in one reported ACE or SLE was positively associated with self-reported stress, number of reported medical conditions, substance use, self-efficacy, and permissive parenting (all β coefficients p < 0.05). SLEs independently demonstrated increased predictive probability of severe mental health distress (6.7 percentage points, confidence interval [95% CI: 0.02–0.11; p < 0.01]) and moderate or severe anxiety (7.5 percentage points [95% CI: 0.04–0.11; p < 0.001]).

Conclusion:

Exposure to ACEs and SLEs appear to have significant impacts on physical health, mental health, and substance use in pregnant racially/ethnically diverse women.

Introduction

Personal health and wellbeing can be adversely impacted by negative events throughout the life course. These are categorized as Adverse Childhood Experiences (ACEs) and Stressful Life Events (SLEs). By definition, ACEs are stressful and potentially traumatizing events that occur during childhood (<age 18) and include events such as family member abuse and/or neglect, parent in jail/prison, parental mental illness/substance use, and parental loss (through divorce, separation, or death).¹ While similarly defined, SLEs can occur at any point across the life course. Some examples include job loss, divorce, death of a loved one, trauma, abuse, or legal concerns. Exposure to ACEs and SLEs is known to have cumulative adverse effects on adult physical, mental, and relational health. As the number of exposures to ACEs and SLEs increases, so does risk for poor health outcomes such as addiction, depression, and heart disease^1,2

ACEs and SLEs can trigger chronic stress responses and provoke maladaptive coping mechanisms, which have deleterious impacts on health outcomes.^2,3 While ACEs and SLEs are associated with negative health outcomes across the life course, pregnancy and the early postpartum period may be a time when ACEs and SLEs have an even more detrimental outcome on women's health and wellbeing.^{4

–13}

Prior research examining the influence of ACEs and SLEs on pregnant women has examined maternal physical and mental health and substance use outcomes.^{4

–13} Physical health studies have focused on associations between ACEs and SLEs and the risk of chronic health conditions, inflammation levels, and risk of preterm labor. Studies indicate that women who experienced physical and emotional abuse in childhood were significantly more likely to enter pregnancy with a chronic health condition, especially those who reported low social support in pregnancy.^4,5 Exposure to ACEs is also associated with increased inflammation during pregnancy, as measured by serum levels of cortisol, C-reactive protein, and interleukin-6.^6,7,14 Increased levels of inflammation have implications for immune dysregulation, somatic symptoms, and depression during pregnancy^6,7 Lastly, a smaller body of literature indicates that women with ACEs and SLEs are at greater risk for preterm labor, independent of other risk factors such as previous miscarriage, smoking status, and maternal age.^15,16

ACEs and SLEs also influence maternal substance use during the perinatal period. ACEs are associated with alcohol consumption, smoking, and drug use in pregnancy.⁷ Exposure to ACEs resulted in a two- to three-fold increase in the odds of binge drinking during pregnancy,⁸ and SLEs predicted dependence on and consumption of alcohol in pregnant women.⁹ Additionally, mothers who reported two to four ACEs were more likely to report marijuana use during pregnancy compared with those who reported zero, and SLEs were associated with increased odds of continued cannabis use during pregnancy.^17,18

Finally, in recent years the disease burden of mental health conditions in pregnant and postpartum women has gained more widespread attention. Women with ACEs are at an elevated risk of developing postpartum depression (PPD), post-traumatic stress disorder (PTSD), and anxiety.^10,11 Women who have experienced cumulative childhood trauma are 4.95 times more at risk of presenting comorbid psychiatric problems during pregnancy than nonexposed women,¹¹ and this risk increases with the number of ACEs experienced.¹² The specific type of ACE may also play a role. Women exposed to child maltreatment reported more anxiety, depression, and PTSD than women exposed to household dysfunction.^19,20 In addition, women who have recently experienced SLEs are at a higher risk of developing PPD^21,22 as well as anxiety.²³

While attention has been paid to the influence of SLEs on pregnant women from racially/ethnically diverse groups, few studies have focused on the impact of ACEs in these groups. Environmental and social factors that often disproportionately impact racially/ethnically diverse groups such as neighborhood safety, violence, or economic strain, are related to preterm labor and low birthweight.^24,25 More recent research indicates that SLEs in racially/ethnically diverse groups during pregnancy are often related to symptoms of depression, anxiety, and poor physical health/chronic disease.^26,27 There is less information on ACEs.

The available literature has examined PPD in low-income groups, which often include racial/ethnic minorities.^28,29 This group appears to be at a particularly high risk for both ACEs and PPD. However, information regarding racial variability in ACEs and PPD is limited. One study found that Black women were significantly more likely to have experienced ACEs than White women. The team utilized both conventional and expanded³⁰ definitions of ACEs, including experiencing racism, witnessing violence, and environmental trauma.³¹ Because of inconsistencies in the types of stressors (ACEs vs. SLEs) and populations (specific focus on racially/ethnically diverse groups vs. non), we sought to examine the physical and mental health, and substance use outcomes in these diverse groups.

Theoretical/conceptual frameworks

A biopsychosocial-cultural (BPS-C) framework allows for an examination of how cultural variables (e.g., gender identity, sexual orientation, race/ethnicity, immigration status, socioeconomic status) are relevant and influential on health outcomes.^32,33 A BPS-C framework also aligns with a social determinants of health (SDOH) framework that posits factors such as economic strain, community violence, and toxic stress, such as ACEs and SLEs, are associated with poor health outcomes,³⁴ including maternal health. Thus, with the BPS-C conceptual framework along with the SDOH framework guiding our research, the following questions were assessed: (1) In a racially/ethnically diverse sample, what are the characteristics of pregnant and breastfeeding women who have experienced ACEs/SLEs? (2) What is the relationship between ACEs/SLEs and maternal mental and physical health and substance use? We hypothesized that ACEs and SLEs would be related to increased mental health distress, physical health concerns, and substance use.

Findings from this study will have potential to provide a better understanding of the impact of ACEs/SLEs in a racially/ethnically diverse pregnant population and guide maternity care practitioners regarding how to best support these patients.

Materials and Methods

This study was a secondary analysis of cross-sectional data from the Family Matters study (R01HL125171).³⁵ The Family Matters study is a longitudinal observational cohort study examining childhood obesity disparities and the corresponding risks and/or protective factors. Recruitment for the study involved enrolling children from primary care clinics in Minneapolis–St. Paul, Minnesota. The eligibility requirements for parents/guardians into Family Matters study were having a child between 5 and 9 years old, residing in Minneapolis–St. Paul, and the ability to read English, Spanish, Hmong, or Somali. The exclusion criteria included children with dietary restrictions (e.g., feeding tubes), BMI <5th percentile, and diagnosis of serious and persistent mental illness. The Family Matters study recruited children across six racial/ethnic groups (White, Black, Native American, Hmong, Somali, and Latino) for diverse population and subpopulation analyses. For the current analysis, we excluded the White participants to focus specifically on racially/ethnically diverse groups.

Any non-White participant who was currently pregnant or breastfeeding (n = 123) was part of the analytic sample. The University of Minnesota Institutional Review Board approved all components of the study. All parents provided informed consent to participate in accordance with the Declaration of Helsinki.

The outcomes of interest in this analysis were measures of maternal mental and physical health, substance use, resilience, and parenting abilities. Measures of mental health included self-esteem, stress, ability to manage stress, role overload, social activity, daily activity, mental health distress, anxiety, and resilience. Measures of physical health included the number of health conditions reported and how much the parent sleeps during the week and on the weekend. Self-efficacy and parenting abilities were measured, including permissive, authoritative, and authoritarian styles. Substance use was measured by self-reported substance use. The predictors were ACEs and SLEs. Table 1 contains descriptions of all predictor and outcome variables, details on how the variables were operationalized, and the respective validated surveys from which the questions were taken.^{36

–52} Survey instrument collection was done around validated scales. All surveys underwent culturally appropriate translation by members of the respective racial/ethnic subgroups included in this study.

Table 1.

Predictor and Outcome Variable Measures and Operationalization Methods

Outcomes		Survey measure name
Substance use	Substance use was reported through survey on a five-point Likert scale: “1. Never,” “2. A few times”, “3. Monthly,” “4. Weekly,” and “5. Daily.” Participants provided a response across three domains: cigarettes, beer/wine/hard liquor, and marijuana. This scale was recoded zero to four where never was coded as zero. The mean across the three domains was calculated for each participant. The mean value for this sample was 0.31 (SD = 0.54).	Project EAT Survey³⁵
Self esteem	Self-esteem was reported through survey based on a four-point Likert scale: “1. Strongly disagree,” “2. Disagree,” “3. Agree,” and “4. Strongly agree.” Participants provided responses across five domains: on the whole, I am satisfied with myself, I feel that I have a number of good qualities, at times I think I am no good at all, I am able to do things as well as most other people, and I wish I could have more respect for myself. The variables representing feeling no good at all and respect for self were reverse coded. A sum was calculated of the answers to the five domains. The mean value of self-esteem in this sample was 3.23 (SD = 0.56).	Rosenberg Self-esteem Scale³⁶
Stress	Stress was reported through survey based on a scale of zero to 10. A value of zero being not stressed at all and 10 being very stressed. The mean reported stress level for this sample was 3.76 (SD = 2.52).	Perceived Stress Scale³⁷
Manage stress	Ability to manage stress was reported through survey based on a scale of 0 to 10. A value of 0 being ineffective and a 10 being effective. The mean reported ability to manage stress for this sample was 6.11 (SD = 3.08).	Perceived Stress Scale³⁷
Role overload	Role overload was reported through survey based on a four-point Likert scale: “1. Strongly Disagree,” “2. Disagree,” “3. Agree,” and “4. Strongly Agree.” Participants provided responses across four domains: I have to do things that I do not really have the time and energy for, I need more hours in the day to do all the things that are expected of me, I do not ever seem to have any time for myself, and there are times when I cannot meet everyone's expectations. The number of times participants responded with agree or strongly agree were summed. The mean role overload score was 2.16 (SD = 1.46).	Reilly's Role Overload Scale³⁸
Social activity	Social activity was reported through survey on a five-point Likert scale adapted from the SF-36 survey: “1. Not at all,” “2. Very little,” “3. Somewhat,” “4. Quite a lot,” “5. Could not do social activities.” Participants provided a response to the following question, During the past month, how much did your emotional problems limit your usual social activities with family or friends? The mean social activity value for this sample was 1.78 (SD = 0.99).	Short-form 36 Questionnaire³⁹
Daily activities	Daily Activity was reported through survey on a five-point Likert scale modified from the SF-36 survey: “1. Not at all,” “2. Very little,” “3. Somewhat,” “4. Quite a lot,” and “5. Could not do social activities.” Participants provided a response to the following question, during the past month how much did your emotional problems limit you from doing your usual work, school, or other daily activities? The mean daily activity value for this sample was 1.73 (SD = 0.91).	Short-form 36 Questionnaire³⁹
Mental health distress symptomology (depression)	Mental health distress was reported through survey on a five-point Likert scale: “1. All of the time,” “2. Most of the time,” “3. Some of the time,” “4. A little of the time,” “5. None of the time.” Participants provided response across six domains: nervousness, hopelessness, feeling restless or fidgety, feeling so depressed nothing could cheer you up, that everything was effort, worthlessness. The variables representing the six domains were all reverse scored. Mental health distress was coded as a dichotomous variable using the K6 scale. Participants with a K6 higher than 13 were coded as having severe mental health distress symptomology, those with a score greater than five were classified as having moderate or severe mental health distress symptomology. Approximately 8% of the sample reported severe mental health distress symptomology and 38% reported moderate or severe mental health distress symptomology.	Kessler 6 Psychological Distress Scale⁴⁰
Anxiety	Anxiety was reported through survey and participants answered based on a five-point Likert scale: “1. All of the time,” “2. Most of the time,” “3. Some of the time,” “4. A little of the time,” and “5. None of the time.” Participants provided responses across four domains: not being able to stop or control worrying, trouble relaxing, becoming easily annoyed or irritable, and feeling afraid as if something awful might happen. The variables representing the four domains were reverse scored. Anxiety was coded as a dichotomous variable using the GAD7 scale. Participants with a score of nine or higher were coded as having severe anxiety. Participants with a score greater than six were classified as having moderate or severe anxiety. Approximately 6% of the sample reported severe anxiety and 13% reported moderate or severe anxiety.	General Anxiety Disorder-7⁴¹
Resilience	Resilience was reported through survey based on a five-point Likert scale based on the Brief Resiliency Score: “1. Strongly disagree,” “2. Disagree,” “3. Neutral,” “4. Agree,” and “5. Strongly agree.” Participants provided responses across four domains: I tend to bounce back quickly after hard times, I have a hard time making it through stressful events, I usually come through difficult times with little trouble, I tend to take a long time to get over setbacks in my life. The variables for having a hard time making it through stressful events and taking a long time to get over setbacks were reverse scored. This outcome was then dichotomized, and a row mean was calculated. Participants with a mean score of less than three were classified as having low resilience. The mean resilience score for this sample was 3.56 (SD = 0.70). Approximately 11% of the sample was classified as having low resilience.	Brief Resilience Scale⁴²
Parent sleep week	The number of hours that study participants slept during the week was obtained through survey. Participants were asked how many hours they sleep per night between Monday and Friday. Response options were 1–10 and 10+.⁴¹ The mean sleep hours during the week reported in this sample was 6.71 (SD = 1.31).	Adapted from Night Eating Diagnostic Scale⁴³
Parent sleep weekend	The number of hours that study participants slept on the weekend was obtained through survey. Participants were asked how many hours they sleep per night between Saturday and Sunday. Response options were 1–10 and 10+. The mean sleep hours on the weekend reported in this sample was 7.20 (SD = 1.49).	Adapted from Night Eating Diagnostic Scale⁴³
Permissive	Permissive parenting style was reported through survey on a five-point Likert scale based on the Parenting Practices Questionnaire: “1. Never,” “2. Once in a while,” “3. About half of the time,” “4. Very often,” and “5. Always.” Participants provided responses across three domains: I threaten [child_name] with punishment more often than actually giving it, I give into [child_name] when he/she causes a commotion, I find it difficult to discipline [child_name]. The responses were summed for each participant. The mean permissive parenting style score was 1.80 (SD = 0.74).	Parenting Practices Questionnaire⁴⁴
Authoritative	Authoritative parenting style was reported through survey on a five-point Likert scale based on the Parenting Practices Questionnaire: “1. Never,” “2. Once in a while,” “3. About half of the time,” “4. Very often,” and “5. Always.” Participants provided responses across three domains: I encourage [child_name] to talk about his/her problems, I give [child_name] reasons why rules should be obeyed, I encourage [child_name] to freely express him/herself even when disagreeing with me. The responses were summed for each participant. The mean authoritative parenting style score was 4.35 (SD = 0.84).	Parenting Practices Questionnaire⁴⁴
Authoritarian	Authoritarian parenting style was reported through survey on a five-point Likert scale based on the Parenting Practices Questionnaire: “1. Never,” “2. Once in a while,” “3. About half of the time,” “4. Very often,” and “5. Always.” Participants provided responses across three domains: I use physical punishment as a way of disciplining [child_name] (e.g., spank, slap, grab) I yell or shout when [child_name] misbehaves When [child_name] asks why he/she has to obey, I state: because I said so, or I am your parent and I want you to. The responses were summed for each participant. The mean authoritarian parenting style score was 1.88 (SD = 0.58).	Parenting Practices Questionnaire⁴⁴
Self-efficacy	Self-efficacy was reported through survey based on a four-point Likert scale: “1. Strongly disagree,” “2. Disagree,” “3. Agree,” and “4. Strongly agree.” Participants provided responses across six domains: even a good parent may not have much impact on whether a child feels good about himself or herself, the amount that a young child will learn is mostly due to family background, the neighborhood, and school, rather than their parents, on most days, I can handle the ups and downs of being a parent, being a parent makes me tense and anxious, schools and the Public Education System should be responsible for educating children, rather than their parents, no matter how hard I try, it seems that I just cannot find a way to get the services that my child and family needs. All domains were reverse scored, except for handling ups and downs. The response values were summed for each participant. The mean resilience score for this sample was 3.00 (SD = 0.46).	Early Intervention Parenting Self-Efficacy Scale⁴⁵
Disease total	The total number of diseases that participants listed as having were reported through survey adapted from the Project EAT Survey. Participants reported whether they had the following conditions: type one diabetes, type two diabetes, heart disease, hypertension, food allergies, asthma, anorexia, bulimia, binge eating disorder, depression, gastrointestinal disorder, or other. The number of conditions each participant reported were summed. Approximately 23% of the sample reported two or more conditions. The most reported condition in this sample was depression (18%).	Project EAT Survey^46 –48
Predictors
ACES	ACEs were reported through survey where participants answered yes or no to the following questions: Were your parents ever separated or divorced? Was a household member depressed or mentally ill, or did a household member attempt suicide? Did a household member go to prison (including yourself)? Did you often or very often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? Did you often or very often feel that your family didn't look out for each other, feel close to each other, or support each other? Did you often or very often feel that your parents were too drunk or high to take care of you? Was your mother or stepmother often or very often pushed, grabbed, slapped, or had something thrown at her? Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you? Were you physically abused by a parent or guardian? Were you sexually abused by a parent or guardian? Were you sexually abused by someone who was not a parent or guardian? The number of yes responses were totaled and multiplied by 10 so in this analysis the associations are in 10% units. Respondents most reported that their parents were separated or divorced (61%). The mean ACE score for this study was 1.86 (SD = 2.07).	ACEs Questionnaire¹
SLEs	SLEs were reported through survey and participants answered “No,” “Yes, in the past year,” or “Yes, more than a year ago” to the following questions: Had a serious illness; Were fired from your job; Had a major financial crisis; Had problems with the police or a court appearance; Had a separation due to marital difficulties or broke off a steady relationship; Had a parent, child, spouse/significant other, close relative or close friend die; Been in a serious car accident or another kind of accident at work or somewhere else; Been involved in a dating or marital relationship where you felt controlled, intimidated, or threatened; Been hit, shoved, held down, or had some other physical force used against you by a spouse/significant other or someone you were dating; Been attacked, beaten, or mugged; Had a close family member or friend die violently, for example in a serious car crash, mugging, homicide, or suicide; Witnessed a situation in which someone was seriously injured or killed, or in which you feared someone would be seriously injured or killed? For this analysis, the number of yes responses were totaled and multiplied by 10 so in this analysis the associations are in 10% units. Respondents most reported (40%) that they had been unemployed or looking for work unsuccessfully for more than one month. The mean SLE score for this study was 1.59 (SD = 1.61).	List of Threatening Experiences⁴⁹
Exposure to community violence	Exposure to community violence was reported through survey based on a four-point Likert scale: “1. Never,” “2. Once or twice,” “3. A few times,” and “4. Many times.” Participants provided responses as to whether they experienced these four domains within the past year: been awakened to the noise of police, ambulance, or gunshots, seen someone get arrested, seen drug deals, and seen someone beaten, stabbed, or shot. A mean score across all of the responses was calculated for each participant. The mean resilience score for this sample was 3.00 (SD = 0.46).	Modified from Richters and Martinez’ “Children's Exposure to Violence” Scale⁵⁰
Ability to live on income	How difficult it is for respondents to live on total household income was reported through survey on a four-point Likert scale: “1. Not at all difficult,” “2. Somewhat difficult,” “3. Very difficult or can barely get by,” and “4. Extremely difficult or impossible.” Approximately 26% of the sample reported not at all difficult, 45% reported somewhat difficult, 24% reported very difficult or can barely get by, and 5% reported extremely difficult or impossible.	Project EAT Survey⁵¹

ACEs, Adverse Childhood Experiences; EAT, Project EAT Survey; SLEs, stressful life events.

Statistical analyses

Bivariate analyses, specifically the t-test for continuous variables and Pearson's chi-square test for categorical variables, were conducted to compare the demographic characteristics between the sample of pregnant or breastfeeding women without ACEs or SLEs (n = 35) and the sample of women with at least one ACE or SLE (n = 88). Linear regression models were used to assess the association between ACEs and SLEs and the continuous outcome variables, such as mental and physical health, substance use, resilience, and parenting ability categories. Logistic regression models were performed on the dichotomous outcome variables, which included severe mental health distress, anxiety, and resilience.

Both the linear and logistic regression models controlled for the sex of the child, age of the child, parental education, household income, age of the parent, ability to live on income (economic strain), and exposure to community violence. We selected these variables from categories of SDOH and culture that were assessed in the larger Family Matters study while being careful to not overfit our model due to its sample size. Data management and analysis were conducted in Stata 17.0 MP (College Station, TX).

Results

Sample demographics and differences between full sample and subsample

In this analysis, 123 women (Table 2) reported either being pregnant or currently breastfeeding. A subsample of 88 (72%) women reported a history of at least one ACE or SLE. Of these, 57% experienced one to three ACEs and 43% experienced four or more. The most common ACEs were parental divorce (61%), low family support (25%), and mentally ill family members (21%). The most common SLEs were unemployment (40%), major financial crisis (33%), and family member who died violently (33%).

Table 2.

Demographic Characteristics of Pregnant or Breastfeeding Women with a History of Adverse Childhood Experiences or Stressful Life Events (Excluding White Race)

	n = 123
	Pregnant or breastfeeding women without ACEs or SLEs	Pregnant or breastfeeding women reporting at least one ACE or SLE
	n = 35	n = 88
Child age in years (SD)	6.76 (1.3)	7.18 (1.5)
Parent age in years (SD)	31.97 (5.3)	30.70 (4.8)
Parent born in the United States	8 (23%)	49 (56%)
Parent race/ethnicity^* (Pearson chi-square = 16.33, p = 0.012)
Black or African American	14	25
Hispanic or Latino	8	18
Asian American	8	21
Native Hawaiian or other Pacific Islander	1	1
American Indian or Native American	0	13
Other	3	0
Multiracial	1	10
Parent educational attainment
Some high school	5	23
High school or associates	18	30
Some college or bachelors	11	29
Graduate degree	1	6
Relationship status
Married	20	43
Committed dating relationship or engaged	4	19
Separated/divorced	3	6
Widowed	0	1
Single	8	19
Total medical conditions reported
0	31	62
1	4	20
2	0	6
3	0	0
Top 3 ACEs
		Parents divorced (54/88) 61.4%
		No family support (22/87) 25.3%
		Family member mentally ill (18/87) 20.7%
Top 3 SLEs
		Unemployment (34/86) 39.5%
		Financial crisis (29/87) 33.3%
		Family member die violently (28/86) 32.6%
Depression^* (Pearson chi-square = 7.32, p = 0.007)
No	35	72
Yes	0	16
Live on income^* (Pearson chi-square = 16.20, p = 0.001)
Not at all difficult	21	23
Somewhat difficult	2	40
Very difficult or can barely get by	3	21
Extremely difficult or impossible	0	4
Hours currently worked per week for pay
0 hours	19	43
1–9 hours	0	4
10–19 hours	2	6
20–29 hours	3	6
30–39 hours	5	5
40 hours	5	18
More than 40 hours	0	6
Parent immigrant time living in the United States^* (Pearson chi-square = 9.24, p = 0.010)
Less than 1 year	0	0
1 to <5 years	1	11
5–10 years	6	2
10+ years	20	26
Household income
Less than $20,000	12	35
$20,000–$34,999	8	21
$35,000–$49,999	8	21
$50,000–$74,999	6	8
$75,000–$99,999	0	1
$100,000 or more	0	1
Not reported	1	1

p < 0.05.

The average age of women with a history of ACEs or SLEs was 31 (SD = 4.8). Approximately 56% reported being born in the United States with 30% of immigrants reported having lived in the United States for >10 years. In terms of income, 64% of the women who reported a history of ACEs or SLEs had a household income of less than $34,999. Just under half of this sample (49%) reported a high school or associates degree education or less. About one-third (33%) of the sample reported some college or a bachelor's degree and 7% reported a graduate degree. Just under half of the sample (49%) reported being married and approximately one-fifth of the sample (22%) reported being single.

Bivariate analyses comparing the demographics of pregnant or breastfeeding women without a history of ACEs or SLEs to pregnant or breastfeeding women with a history of at least one reported ACE or SLE found that these groups differed significantly across depression prevalence, economic strain, race/ethnicity, and duration of living in the United States (Table 2). All women with a history of depression reported at least one ACE or SLE (χ ² = 6.05, p = 0.01). There was a greater proportion of women who had lived in the United States for 1 to 5 years among those with at least one ACE or SLE than those without (χ ² = 7.32, p = 0.007). All Native American women in the sample reported at least one ACE or SLE (χ ² = 16.33, p = 0.012). Approximately 95% of women who reported that it was somewhat difficult to get by on their income had a history of at least one ACE or SLE, 88% of women who reported that it was very difficult to get by on their income had a history of at least one ACE or SLE, and 100% of women who reported that it was extremely difficult to get by on their income had a history of at least one ACE or SLE (χ ² = 16.2, p = 0.001).

RQ1—what is the relationship between ACEs/SLEs and maternal mental health, physical health, substance use, resilience, parenting abilities?

The results of the linear regression analysis (Table 3) examining the association between ACEs and SLEs and maternal mental and physical health, substance use, resilience, and parenting abilities showed that an increase in one ACE was significantly positively associated with stress (β = 0.302 confidence interval [95% CI]: 0.05–0.56; p < 0.05) and the number of reported medical conditions (β = 0.10, 95% CI: 0.03–0.17; p < 0.05). An increase in one SLE was significantly positively associated with substance use (β = 0.07 95% CI: 0.02–0.13; p < 0.05), self-efficacy (β = 0.07 95% CI: 0.01–0.14; p < 0.05), and permissive parenting style (β = 0.13 95% CI: 0.03–0.23; p < 0.05).

Table 3.

Linear Associations Between Adverse Childhood Experiences, Stressful Life Events, and Pregnant/Breastfeeding Women's Mental and Physical Health, Substance Use, Resilience, and Parenting Style

Variables	ACEs				SLEs
Variables	Β	95% CI	p	Standardized effect size	β	95% CI	p	Standardized effect size
Substance use	0.032	−0.018 to 0.083	0.206		0.074	0.016 to 0.133	0.014	0.14
Self esteem	0.004	−0.063 to 0.070	0.910		0.016	−0.061 to 0.093	0.685
Stress	0.302	0.045 to 0.558	0.022	0.12	0.047	−0.250 to 0.343	0.754
Ability to manage stress	0.372	−0.026 to 0.770	0.067		−0.053	−0.513 to 0.408	0.820
Role overload	0.094	−0.075 to 0.263	0.271		0.160	−0.036 to 0.355	0.109
Social activity	0.062	−0.049 to 0.172	0.271		0.047	−0.081 to 0.175	0.465
Daily activity	0.061	−0.044 to 0.165	0.250		0.001	−0.120 to 0.122	0.983
Medical conditions reported	0.100	0.033 to 0.168	0.004	0.15	0.051	−0.027 to 0.128	0.195
Parent reported sleep during the week	−0.003	−0.170 to 0.165	0.973		0.004	−0.190 to 0.197	0.970
Parent reported sleep during the weekend	0.014	−0.176 to 0.204	0.881		0.114	−0.105 to 0.334	0.303
Self-efficacy	0.042	−0.013 to 0.097	0.135		0.072	0.008 to 0.136	0.027	0.16
Permissive parenting	0.081	−0.006 to 0.168	0.067		0.133	0.033 to 0.234	0.010	0.19
Authoritative parenting	0.070	−0.038 to 0.179	0.202		−0.051	−0.176 to 0.075	0.425
Authoritarian parenting	0.041	−0.030 to 0.113	0.255		0.061	−0.023 to 0.144	0.147

Controlling for the sex of the child, age of the child, sex of the parent, parent education, household income, age of the parent, ability to live on income, and exposure to community violence.

Sample Interpretation: These are linear regression results, the row with stress is showing that for an increase in one ACE, parent reported stress on a scale of 1 to 10 increases 0.30. This has an effect size of 0.12 and is statistically significant with a p-value of 0.022.

The results of the logistic regression analyses (Table 4), demonstrate that the effect within ACEs indicates that the predicted probability difference of severe mental health distress increased 2.3 percentage points for an increase in one ACE (95% CI: 0.003–0.04; p < 0.05) and the predicted probability difference of moderate or severe parental anxiety increased 4.4 percentage points for an increase in one ACE (95% CI: 0.01–0.08; p < 0.05). The effect within SLEs indicates that for an increase in one SLE, the predicted probability difference of severe mental health distress symptomology increased by 6.7 percentage points (95% CI: 0.02–0.11; p < 0.05), the predicted probability difference of moderate or severe mental health distress symptomology increased by 8.5 percentage points (95% CI: 0.02–0.15; p < 0.05), and the predicted probability difference of moderate or severe anxiety increased 7.5 percentage points (95% CI: 0.04–0.11; p < 0.05).

Table 4.

Predicted Probabilities of Mental Health Outcomes and Resilience Among Pregnant or Breastfeeding Women with Adverse Childhood Experiences or Stressful Life Events

	ACEs			SLEs
	Predicted probability difference	95% CI	p	Predicted probability difference	95% CI	p	Obs
Severe Parental Distress	0.023	0.003 to 0.044	0.026	0.067	0.021 to 0.113	0.004	69
Moderate or Severe Parental Distress	−0.006	−0.060 to 0.048	0.820	0.085	0.022 to 0.148	0.008	84
Severe Parental Anxiety	Not estimable based on small sample size			Not estimable based on small sample size
Moderate or Severe Parental Anxiety	0.044	0.010 to 0.079	0.012	0.075	0.037 to 0.113	<0.001	73
Low Resilience	−0.017	−0.065 to 0.031	0.486	0.022	−0.070 to 0.113	0.647	47

Controlling for the sex of the child, age of the child, sex of the parent, parent education, household income, age of the parent, ability to live on income, and exposure to community violence.

Sample Interpretation: These are predicted probabilities resulting from logistic regression models. In the SLE column, we see a predicted probability value of 0.067 for severe parental distress. This means that for an increase in one SLE, the probability of developing severe parental distress increases by 6.7 percentage points. This is significant with a p-value of 0.004.

Discussion

This study examined the characteristics of pregnant and breastfeeding women from a racially/ethnically diverse sample and how their exposure to ACEs and SLEs was associated with various health outcomes. Our sample was predominantly married, low-income, working part-time or less, had more than one child, some degree of post-high school education, difficulty living on their income, and received government assistance. Of those not born in the United States, the majority immigrated 10+ years ago, whereas a smaller group immigrated 1–5 years ago.

Overall, results indicated that women who reported no ACEs or SLEs reported lower stress, felt moderately comfortable managing their stress, experienced lower difficulties with social and daily activities, moderate self-esteem and self-efficacy, and largely considered themselves to use authoritative parenting practices. In comparison to those without a history of ACEs or SLEs, those with at least one ACE/SLE were more likely to report struggles with depression and inability to live on their income, had lived in the United States for the least amount of time, and were of Native American heritage. Both groups reported similar levels of stress, self-esteem and self-efficacy, parenting practices, and engagement in daily and social activities. Among those with ACEs/SLEs, the frequency of adverse events was high. In our sample, 72% of the participants reported at least one ACE or SLE and 43% experienced at least four or more (ACE and/or SLE). This is similar to the frequency of ACEs reported by Atzlet al.¹⁹ in their study of pregnant women from predominantly racially/ethnically diverse groups.

By comparison, recent data indicate that 60.9% of adults report at least one ACE and 15.6% experience four or more ACEs.⁵³ Our findings are consistent with data indicating that female sex, younger age, and diverse racial/ethnic groups are at risk of experiencing a higher number of ACEs/SLEs.⁵³

To account for potential confounding variables, we took into consideration participants' cultural aspects and SDOH. It is well known that factors related to access to education and health care, economic stability, social, relational and community context, and neighborhood environment play a role in a range of health outcomes and can be associated with ACEs and SLEs.^34,54 However, we were not able to account for all of these potential confounders because of small sample size and concerns with overfitting. This is addressed further in our limitations. Therefore, our findings indicate that ACEs and SLEs, independent of economic strain, community violence, and participant age and education, were associated with different health outcomes as discussed below.

Our data indicated that ACEs were independently associated with measures of stress and number of chronic health conditions (e.g., asthma, gastrointestinal conditions, type 2 diabetes) during pregnancy/early postpartum. This supports previous research suggesting that women with a history of ACEs are at greater risk for chronic health conditions during pregnancy.^6,7 While the effect sizes for these findings were small and our participants reported feeling relatively low stress, the impact of ACEs has a graded effect. For example, those with ≥4 ACEs have a 4- to 12-fold increased risk of drug abuse and depression and a 2- to 4-fold increase in poor health and smoking compared with those who have none.¹ Therefore, even with a smaller effect size, an increase of one ACE in our sample is indicative of meaningful increases in stress and chronic disease and dysfunction during pregnancy and early postpartum in low-income racially/ethnically diverse groups.

This study also found that SLEs were positively associated with substance use, self-efficacy, and permissive parenting style. Although the baseline scores in these areas indicate lower prevalence of these factors, findings suggest that the presence of SLEs is associated with greater substance use, self-efficacy, and a tendency toward permissive parenting. This supports previous research showing that stress is related to substance use in pregnancy.^8,9 It additionally suggests that with increased stressors, mothers are more likely to report a greater sense of self-efficacy. Self-efficacy is defined as a personal evaluation of competency to perform tasks and trust one's abilities to effectively manage challenges.^55,56 Higher levels of self-efficacy decrease chances of experiencing stress in light of stressful events.^56,57 Therefore, it has been suggested that increases in the sense of control someone has over a situation may be seen as a way to manage stress.⁵⁵

While it may seem counterintuitive, our study findings may indicate that as mothers experience increases in stressful events, they exert more control over the situation as a coping skill, which in turn, increases their sense of self efficacy and ability to manage stress. Indeed, our results did not show any relationship between stress levels or challenges managing stress.

Lastly, mothers tend to engage in more permissive parenting than the authoritative parenting participants reported at baseline. Research on parental stress often examines stress in relationship to child-level variables such as temperament, mental or behavioral concerns, or developmental delay.^58,59 These studies suggest that parenting style becomes more authoritative, punitive, or abusive. Our study may suggest stress has different impacts on parenting style depending on the source of stress (e.g., child vs. other family or community-level variable).

When examining psychological measures, both ACEs and SLEs appeared to independently increase the risk of severe mental health concerns and anxiety during pregnancy in this group, with more associations among SLEs and mental health outcomes. This supports previous research in these areas^12,21
–23 and expands the literature by specifically examining a diverse sample. It is also of note that SLE scores had more significant findings than ACEs in our sample, but previous research on SLEs alone demonstrate their relationship with mental health outcomes in racially/ethnically diverse groups.^26,27

Recent research suggests that toxic stress is the underlying mechanism responsible for the physiological and psychological outcomes related to ACE exposure.³⁴ It also accounts for poor health outcomes when significant stressful events are experienced in adulthood.³⁴ When someone is repeatedly exposed to stress both because of the event and the aftermath of the event (e.g., parental separation and ongoing stress related to dysfunction in separated parents, or loss of a family member and ongoing stress related to shifts in family roles and dynamics), their stress response system becomes chronically activated. This has implications across various organ systems, and can affect areas such as executive functioning, problem solving, reward pathways, and lifespan stress response.^58,60

Our study findings have several important clinical implications. First, it would be important for practitioners to consider universally screening for ACEs/SLEs, while taking into account this group may be at higher risk. We caution practitioners to be aware of this risk while also being mindful of tendencies toward bias and reinforcing stereotypes in this population. Screening could be done through formal screening during an intake process or discussion during an initial prenatal appointment or an infant's well check if the mother does not have a doctor at the same clinic as her child.

Second, if these stressors are present, practitioners should pay attention to the patients' potentially increased risk for severe mental health distress, overall stress levels, substance use/abuse, and presence of or care for chronic health conditions that could be complicated by pregnancy. Knowing that this group may struggle more with these concerns if they have more than one ACE or SLE, early intervention and support throughout the pregnancy and postpartum period is important. Patients from low-income and racially/ethnically diverse groups are often under-resourced and have limited access to care.

Therefore, it is important to create close connections with community agencies/resources related to mental health, substance use, and stress management, help connect patients to these agencies through a clinical social worker, and, ideally, in-house behavioral health. Lastly, a clinician can ask patients about what a typical day looks like, interactions with their other children, general stress levels, who offers help and how useful that help is, and what other resources could help them.

This study has both strengths and limitations. While our sample was highly racially/ethnically diverse, it was a small sample, which limited our ability to perform more advanced statistical modeling, examine interactions among variables, and post hoc analyses. A larger sample size would allow for a more specific and targeted understanding of this population. We acknowledge that other cultural and racial/ethnic (e.g., acculturation, discrimination), relational (e.g., intimate partner violence), and SDOH variables may be important to examine to better understand the relationships between ACES, SLEs, and maternal mental and physical health and should be examined in future research. Our sample demographics were also specific. The findings are not generalizable to larger populations, but they offer important insight into working with low-income racially/ethnically diverse women.

While another strength of our study was the inclusion of both ACEs and SLEs, all measures were self-report, which can be susceptible to desirability bias- especially since parts of the larger study involved an intervention with their children. In addition, social desirability may have occurred as participants may have wanted to be perceived as having higher functioning to avoid raising suspicions among the study staff.

Conclusion

This study examined the characteristics of low-income, racially and ethnically diverse pregnant and breastfeeding women and sought to understand the associations between ACEs and SLEs with measures of physical and mental wellbeing and substance use. Our primary hypothesis that ACES and SLEs would be positively associated with challenges in these three areas was partially supported. It appears that while ACEs may be associated with increased stress and health problems, SLEs have stronger associations with substance use, parenting practices, and self-efficacy. Both ACEs and SLEs are each separately associated with more severe mental health outcomes. This highlights the need to take into consideration the impact of both ACEs and SLEs early in pregnancy or the postpartum period when providing care to offer targeted support and resources. It also demonstrates the importance of further research to understand and examine additional contextual factors such as culture and SDOH in this population.

Footnotes

Acknowledgments

This study was possible, thanks to the willingness of 1,307 families from St. Paul and Minneapolis, Minnesota who shared their lived experiences through a survey. The authors additionally acknowledge and thank their Family Matters study team who collected this information. Additionally, the University of Minnesota Medical School's Department of Family Medicine and Community Health support for the Family Matters Study allowed for project planning, respondent recruitment, and data analysis.

Authors' Contributions

L.Z.-H.: conceptualized this article from the larger Family Matters study, assisted with data analysis and interpretation, wrote all drafts of the article, approved the final article for submission, and agrees to be accountable for all aspects of the work regarding the accuracy or integrity of any part of the work. C.P.C.: conducted data analysis, assisted with data interpretation, and drafted the Materials/Methods and sections. He also critically reviewed the article, gave final approval of this version to be published, and agrees to be accountable for all aspects of the work regarding the accuracy or integrity of any part of the work. A.T.: conducted and assisted with the data analysis and assisted with data interpretation. He critically reviewed the article, gave final approval of this version to be published, and agrees to be accountable for all aspects of the work regarding the accuracy or integrity of any part of the work. A.B.: assisted with the literature search, drafting of the introduction, assisted with data analysis interpretation and implications, reference management, and critically reviewed the article. She gave final approval of this version to be published and agrees to be accountable for all aspects of the work regarding the accuracy or integrity of any part of the work. K.M.: assisted with the literature search, drafting of the introduction, assisted with data analysis interpretation and implications, reference management, and critically reviewed the article. She gave final approval of this version to be published and agrees to be accountable for all aspects of the work regarding the accuracy or integrity of any part of the work.

J.M.B.: is the primary investigator for the larger Family Matters study, obtained funding for the study, and oversaw its conceptualization, design, and data collection. She assisted with the conceptualization of this article. She critically reviewed the article, gave final approval of this version to be published, and agrees to be accountable for all aspects of the work regarding the accuracy or integrity of any part of the work.

Data Access Statement

Deidentified individual participant data will not be made available.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Research is supported by grant number R01HL126171 and R01HL156994 from the National Heart, Lung, and Blood Institute (PI: J.M.B.).

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