What is prenatal stress? A scoping review of how prenatal stress is defined and measured within the context of food insecurity,housing instability,and immigration in the United States

Abstract

Background:

Stress during pregnancy can lead to significant adverse outcomes for maternal mental health. Early evaluation of prenatal stress can help identify treatment needs and appropriate interventions. Disparities in the social determinants of health can contribute to stress, but what constitutes stress during pregnancy within the social determinants of health framework is poorly understood.

Objective:

To scope how prenatal stress is defined and measured among pregnant people exposed to three prominent social stressors in the United States: insecurity pertaining to food, housing, and immigration.

Eligibility Criteria:

We included all studies that focused on stress during pregnancy in the context of food insecurity, housing instability, and immigration, given their recent policy focus due to the COVID-19 pandemic and ongoing political discourse, in addition to their importance in American College of Obstetricians and Gynecologists (ACOG’s) social determinants of health screening tool.

Sources of Evidence:

We searched PubMed, Scopus, and Web of Science for articles published between January 2012 and January 2022.

Charting Methods:

Using a piloted charting tool, we extracted relevant study information from the selected articles and analyzed the content pertaining to stress.

Results:

An initial search identified 1,023 articles, of which 24 met our inclusion criteria. None of the studies defined prenatal stress, and only one used the Prenatal Distress Questionnaire, a prenatal stress-specific tool to measure it. The Perceived Stress Scale was the most common instrument used in seven studies. Fifteen studies measured over 25 alternative exposures that researchers theorized were associated with stress, and 4 of the 15 studies did not explain the association between the measure and stress.

Conclusions:

Our findings demonstrate a fundamental inconsistency in how prenatal stress is defined and measured in the context of social determinants of health, limiting the comparison of results across studies and the potential development of effective interventions to promote better maternal mental health.

Keywords

definition measurement pregnant people pregnant women prenatal stress social determinants of health

Introduction

Two in five people in the US experience a stressful life event the year before pregnancy, and 10%–20% suffer from mental health problems during the perinatal period.^1,2 People who experience stress during pregnancy are at a greater risk for maternal mental health disorders and adverse maternal and birth outcomes, including preterm birth, fetal growth restriction, maternal mood disorders, and infant developmental delays.^2
–16 Maternal mental health conditions, including depression, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, bipolar illness, and substance use disorders, are the most common complications of pregnancy and childbirth in the United States, affecting 1 in 5 or 800,000 people each year.^17
–19 Screening for stress during pregnancy may help identify people who can benefit from stress-reduction interventions to mitigate prenatal stress and associated maternal and fetal outcomes.

Nearly 30 years ago, Lobel³ called attention to the importance of “a robust, conceptually and methodologically powerful operational definition of prenatal stress,”^20,21 and developed the Prenatal Distress Questionnaire (PDQ) and its successor, the Revised Prenatal Distress Questionnaire (NuPDQ). However, what constitutes prenatal stress remains broadly described in the social sciences literature, potentially impeding interventions to prevent adverse outcomes. Some researchers have operationally defined prenatal stress as the number of major life events or daily hassles during pregnancy.^21
–23 In contrast, others have defined it as emotional states, particularly anxiety, without attention to what elicits these emotions.^21,24 Most maternal health research assesses general stress that is nonspecific to pregnancy.^{3,10,15,25,26} Some commonly used measures of stress during pregnancy have included perceived stress to capture life event changes, daily hassles, and chronic stress; emotional stress to capture anxiety, sadness, and general tension; and psychosocial stress to capture caregiver burden, job strain, and discrimination.^{2
–9,11
–16,27
–31} The variation in stress constructs and the multitude of tools used to measure it impedes the comparability of research results to the detriment of maternal mental health promotion.

The American College of Obstetricians and Gynecologists (ACOG) emphasizes the importance of addressing social and structural determinants, including food insecurity, housing, and immigration, as part of patient-centered care to decrease inequities in reproductive healthcare.³² Unmet social needs, often called the social determinants of health (SDOH), can contribute to adverse perinatal outcomes for low-income mothers and their newborns.³³ The Center for Disease Control and Prevention (CDC) asserts that social determinants have a much greater influence on health than genetic or healthcare access factors, which have traditionally been the focus of health research and interventions.³⁴ However, there is a significant gap in maternal health literature regarding the role of social determinants in impacting maternal morbidity and mortality, including mental health conditions – and especially the underlying mechanisms for these associations.³⁵

Recent Behavioral Risk Factor Surveillance System (BRFSS) data show that lack of money for adequate food and a balanced meal was the most common unmet need affecting two-thirds of low-income adults in 12 states.³⁶ One in five individuals reported being unable to pay for housing and experiencing constant stress, and those with multiple needs were more likely to miss medical appointments. In interviews conducted with prenatal care providers and patients, we documented similar experiences where pregnant and postpartum people faced multiple needs, any of which could be exacerbated on any given day. These challenges compromised their ability to work, buy food, take care of their children, go to medical appointments, continue with substance use disorder treatment, or feel safe in their relationship.³⁷ Furthermore, current immigration policies limit access to obstetric and gynecologic care while in custody, target pregnant people at points of entry for immigrant-enforcement actions, separate parents and children, and restrict access to asylum for victims of gender-based violence.³⁸ Highly racialized rhetoric and promises of punitive, anti-immigrant policies made during the 2016 election were associated with a significant increase in preterm births; low birth weight newborns; self-reported sadness, anxiety, and nervousness; and decreased healthcare utilization by US immigrants.^38,39

Given the persistence of maternal health disparities and in light of the stress imposed by social and material adversity on pregnant people and associated maternal and infant health outcomes, we examined how researchers and interventionists conceptualize and measure prenatal stress in groups experiencing these social disadvantages in the United States.⁴⁰ To investigate this question, we conducted a scoping review to assess how researchers are defining and measuring prenatal stress in the context of food insecurity, housing instability, and immigration in the United States. Our rationale for excluding non-U.S. studies was to optimize comparability of the overall sociopolitical context in which these stressors were experienced. Our primary aim was to assess the definition and measurement of prenatal stress in research focusing on pregnant people exposed to food insecurity, housing, and immigration to identify research gaps and opportunities to develop effective mental health interventions.

Methods

Conceptual framework

We adapted two frameworks to develop our conceptual model of stress during pregnancy as a possible result of three social stressors with consequences for maternal, fetal, and infant health. The SDOH framework illustrates how structural or “upstream” social, economic, and political factors, such as income, education, occupation, gender, race, and ethnicity, contribute to a person’s intermediate or “midstream” living and working conditions, which ultimately impacts their health status.⁴¹ These midstream factors include a person’s housing quality, employment opportunities, access to healthy food, and overall ability to lead a healthy life. In the second framework by Kramer et al.,⁴² a pregnant person is situated at the intersection of her social and health life course trajectory and the multilevel causes of morbidity and mortality, ranging from biomedical conditions to the health service, transportation, social support, and community environments. We adapted these frameworks to highlight the demands of pregnancy (illustrated by a “top-down” arrow of biomedical needs) and the underlying social conditions that produce stress (illustrated by a “bottom up” arrow of the conditions of life in general that induce stress); the two arrows capture the coexistence of two sets of demands on a single pregnant body. Figure 1 below illustrates our conceptual model for this approach. We posit that while social determinants produce stressors in any stage of life, the demands of pregnancy exacerbate the immediacy of their effect, resulting in a combined form of stress that is best captured as prenatal stress due to its timing and overlap with pregnancy-related needs.

Figure 1.

Conceptual model for prenatal stress and the social determinants of health.

Approach

Scoping reviews aim to map key concepts supporting a research area rapidly and are recommended when the field of interest is complex or has not been comprehensively reviewed.⁴³ We conducted a scoping review to identify gaps in the existing literature concerning the current definitions and measurements of prenatal stress and to highlight opportunities for integrating validated measures of prenatal stress in research on social determinants of maternal health.⁴³ We used Arksey and O’Malley’s⁴³ framework for conducting scoping reviews and reported our results using the PRISMA extension for scoping reviews.⁴⁴

Study eligibility criteria

We created study eligibility criteria to ensure that a broad range of articles could be included in this review. We identified all articles within our search timeline that included stress as a variable of interest during pregnancy among individuals subjected to food insecurity, housing instability, or immigration. We chose these stressors to focus on the key elements of the ACOG social determinants of health screening tool and the recent policy focus on these issues given the COVID-19 pandemic and ongoing political discourse on immigration.^{32,37,45
–49} The definition of food insecurity, housing instability, or immigration was unrestricted, i.e. we relied on the study authors’ operationalization of these factors and did not specify a particular aspect of any of these three stressors. Therefore, as long as the study population was described as experiencing one of these conditions, we considered the article for inclusion. Next, we reviewed these studies for their focus on stress during pregnancy and excluded those that did not include stress as a variable in maternal health assessments. In addition, we omitted studies conducted outside of the United States and those that examined the impact of stress during the postpartum phase. Studies not written in English were excluded because of the cost and time involved in translation. Articles focusing on biological and oxidative stress were also excluded as this was outside the scope of this review. A detailed inclusion criteria table with justifications and explanations can be found in Supplemental Appendix 1.

Databases, search terms, and limits

We searched PubMed, Scopus, and Web of Science to assess how prenatal stress was defined and measured in literature from January 2012 to January 2022 to capture contemporary contexts for social adversity in the United States. Studies were limited to those published in these 10 years to focus our search and highlight the possible inconsistencies in the way prenatal stress is defined and measured in recent literature to limit the influence of large variations in U.S. social and immigration policy over time. We completed this preliminary search in three parts, exploring keywords such as “food insecurity,” “housing instability,” “immigration,” “pregnancy,” “prenatal,” and “stress.” We utilized the Boolean operator “AND” to combine themes and “OR” within themes for all three searches, optimizing the search process and ensuring comprehensive results. No other limitations were applied. Supplemental Appendix 2 includes a detailed breakdown of our search strategies for each database searched.

Study selection

I.P. and A.D. screened all the articles identified via electronic searches for eligibility using Rayyan.⁵⁰ We were blinded during the screening process and applied the inclusion and exclusion criteria to all abstracts. If the relevance of a study or its relation to the concept of stress was unclear from the abstract, we scanned the full article. Once both researchers had made their selections, we unblinded the first review and included all studies for which both I.P. and A.D. agreed on the assessment. In the case of disagreement, both reviewers discussed the article and made a final decision. We read each of the included studies and discussed them to determine whether they should be included in the review.

Charting the data

Using a standardized data collection form, IP extracted data from all included studies, including the definition of prenatal stress (if any), how it was measured, and when it was measured during the pregnancy. The data collection form is included in Supplemental Appendix 3.

Collating, summarizing, and reporting the results

IP and AD tabulated and summarized the extracted data. Both reviewers created independent descriptive narratives to illustrate findings concerning the definitions of and measurement approaches for prenatal stress in the included studies and then compared the narratives. Through conversation and consensus, we developed a combined narrative. Both reviewers re-reviewed the tabulated and summarized data to ensure we had not missed any important points.

Results

Included studies

The study selection process is presented in Figure 2 below. Our initial search identified 1,023 articles. After removing 70 duplicates, IP and AD independently screened the remaining 953 articles and excluded another 909 based on the title and abstract. Of the 44 articles that underwent a full-text review, 20 were excluded because they either had incorrect or missing stress indicators (n = 16) or studied the wrong population (n = 4). Twenty-four articles met all inclusion criteria.

Figure 2.

Study selection flow diagram.

Study characteristics

Of the 24 articles that assessed stress during pregnancy in the context of food insecurity, housing instability, and immigration, six studied the relationship between stress and food insecurity, three studied the relationship between stress and housing instability, and 15 examined the relationship between stress and immigration.^51
–74 Study designs included prospective birth cohort studies (n = 10), retrospective studies (n = 4), case-control studies (n = 3), mixed methods research studies (n = 2), retrospective cross-sectional studies (n = 2), a qualitative study (n = 1), and quasi-experimental studies (pre-post) (n = 2).^51
–74 A summary of the characteristics of the included studies is presented in Table 1 below.

Table 1.

Included study characteristics.

Author	Study design	Study location	Study population	Study aim and stress variable
Housing instability
Mendez et al.⁷²	Retrospective cohort study	North Carolina	4652 diverse pregnant women with a singleton gestation of < 20 weeks (average 14.8 weeks), who had an intrauterine pregnancy and were either English- or Spanish-speaking	Effect of institutional racism in the form of residential redlining and segregation on self-reported stress
Novick et al.⁷³	Qualitative study	Northeast America	39 mostly low-income African American or Hispanic women with a mean age of 21.6 years	Effect of group prenatal care on circumstances that create personal stress and generate challenges for women receiving prenatal care
Shaw et al.⁷¹	Retrospective cross-sectional study	All US except California, Idaho, and Ohio	70,757 live births from 2012 to 2013	Effect of co-occurring medical and psychosocial factors, including dichotomized cumulative stress (high/low), on preterm birth and low birthweight
Food insecurity
Eick et al.⁵⁵	Prospective birth cohort study	California	510 economically diverse group of pregnant women > 18 years of age with a singleton pregnancy in the second trimester and were either English- or Spanish-speaking	Effect of psychosocial stressors including neighborhood quality, stressful life events, caregiving for an ill family member, discrimination, job strain, food insecurity, financial strain, and unplanned pregnancy on responses to psychosocial stress, including perceived stress, depression, and perceived community status
Goin et al.⁵⁴	Prospective birth cohort study	California	510 economically diverse group of pregnant women > 18 years of age with a singleton pregnancy in the second trimester and were either English- or Spanish-speaking	Relationship between self-reported hardships and birthweight for gestational age z-scores
Heberlein et al.⁵¹	Prospective birth cohort study	South-eastern United States	248 racially diverse, medically low risk, English speaking pregnant women who entered prenatal care prior to 17 weeks’ gestation	Effect of ‘Centering Pregnancy’ group prenatal care versus traditional individual prenatal care on maternal health psychosocial outcomes including prenatal distress, prenatal coping, general and perceived stress, depression, affective states, empowerment, maternal functioning, and postnatal attachment.
Laraia et al.⁵²	Prospective longitudinal study	North Carolina	526 women > 16 years of age at the time of conception with a singleton pregnancy and were English speaking	Effect of marginal food security and food insecurity measured during pregnancy and postpartum on perceived stress, disordered eating behavior, percentage of calories from fat, and postpartum weight status at 3 and 12 months
Izano et al.⁷⁴	Prospective birth cohort study	California	355 diverse pregnant women between 18–40 years of age with singleton pregnancies in their second trimester	Associations between newborn telomere length and maternal chronic and psychosocial stress during pregnancy
Testa and Fahmy⁵³	Prospective birth cohort study	Washington, Oregon, and Iowa	Annual sample size from each state ranges between 1000–3000 women	Effect of exposure to incarceration and the role of social support on maternal food insecurity during pregnancy using Pearlin’s Process of Stress model.
Immigration
Bandoli et al.⁶²	Case-control study	California	1193 pregnant women were selected. Cases included low birth weight (<2500 g) or preterm birth (< 37 completed weeks gestation), and controls had a weight of ⩾ 2500g and were full term	Effect of prenatal psychosocial stressors (pregnancy anxiety, acute stress from negative life events, chronic stress) on wheeze in young offspring
Cabeza de Baca et al.⁷⁰	Prospective birth cohort study	California	201 low-income Latina women with a mean age of 34.6 who primarily spoke Spanish (93.5%; English, 6.5%) and were mostly first-time mothers	Effect of unplanned pregnancy and pregnancy relationship status on prenatal maternal depression
Coller et al.⁶⁷	Retrospective cohort study	California	1214 low-income pregnant women of Mexican descent who were either US-born or immigrants aged between 18 and 44 years and spoke English, Spanish, or a combination of the two	Effect of duration of residence and sociodemographic and psychosocial correlates (general functional social support from others, partner support, depressive symptoms, and stress) on unintended birth
D’Anna-Hernandez et al.⁵⁷	Prospective birth cohort study	California	98 women of Mexican descent between 18 and 45 years of age who were 10–15 weeks pregnant and did not smoke or currently use illicit drugs	Influence of acculturation, acculturative stress and perceived discrimination independent from general stress as well as with general perceived stress on maternal mental health
Dodgson et al.⁶⁸	Case-control study	Hawaii	146 low-income, high-risk Native Hawaiian/Pacific Islander pregnant women who were > 20 years of age and gave birth to a live, healthy newborn at 36 weeks’ gestation or later	Effect of post-traumatic stress disorder (PTSD) on pregnancy outcomes
Fleuriet and Sunil⁶⁵	Retrospective cross-sectional study	Texas	300 low-income pregnant Mexican immigrant and Mexican American women who were 18 years or older with a singleton pregnancy and were at low medical risk for having low birthweight infants	Effect of subjective social status (SSS) on variation in birth weight
Fleuriet and Sunil⁶⁴	Mixed methods research study	Texas	36 pregnant immigrant women from northern Mexico and Mexican Americans living in South Texas	Effect of length of time immigrant Mexican women live in the United States on how meanings of pregnancy and motherhood increasingly integrate notions of stress
Hoggatt et al.⁶⁶	Retrospective cohort study	California	2543 Hispanic/Latina women with a singleton pregnancy	Effect of environmental and behavioral risk factors, including chronic stress, among US-born Latinas’, foreign born Latinas’, and non-Latina Whites’ prevalence of low birth weight (LBW)
Little et al.⁶⁹	Quasi-experimental (pre-post) study	Michigan	96 Japanese women between 15–25 weeks of gestation	Effect of level of concern that Japanese women have during the prenatal period on postpartum satisfaction with the same variables after birth
Madeira et al.⁵⁹	Quasi-experimental (pre-post) study	Midwestern Region	50 Somali women > 20 weeks pregnant with a mean age of 29.8 years and a median number of pregnancies per woman of six (range = 1–11)	Effect of group prenatal care (GPC) on maternal anxiety and stress as part of participants’ satisfaction, knowledge, and prenatal care engagement
Osman et al.⁵⁸	Prospective birth cohort study	California	197 pregnant women of Mexican descent between 18 and 45 years of age who were non-smoking and non-illicit drug users	Relationship between the connection between religiosity and perinatal anxiety and how it may protect against the effects of sociocultural stressors such as acculturative stress
Preciado et al.⁵⁶	Prospective birth cohort study	California	151 Mexican American women > 18 years of age who were < 15 weeks pregnant, had a singleton pregnancy, and did not smoke or currently use tobacco, illicit, or prescription drugs	Effect of sociocultural stressors on prenatal anxiety
Stanhope et al.⁶¹	Mixed methods research study	Georgia	111 Spanish-speaking, uninsured immigrant women ⩾ 18 years old who had < 24 completed weeks gestation (median age was 15 weeks) and enrolled in prenatal care	Effect of external stressors and coping strategies on women’s narratives about their lives through an ecosocial framework
Toledo-Corral et al.⁶³	Retrospective cohort study	California	442 Hispanic and Black women > 18 years of age who spoke either English or Spanish and were < 20 weeks of gestation	Effect of role of race, ethnicity, and immigration status on perceived stress and depressive symptomatology trends
Tsai et al.⁶⁰	Case-control study	Massachusetts	1121 pregnant African American women (628 U.S. born and 493 immigrant Black women). Cases included preterm birth mothers who delivered singleton, live births < 37 weeks of gestation, and controls included mothers who delivered ⩾ 37 weeks of gestation	Effect of genetic ancestry and stress on preterm birth (PTB) and related adverse outcomes on U.S. born and immigrant Black women

PTSD: post-traumatic stress disorder; SSS: subjective social status; GPC: group prenatal care; LBW: low birth weight; PTB: preterm birth.

Thirteen studies measured stress during the second or third trimester of pregnancy (14–40 weeks gestation).^{51,52,54,55,59
–63,69,70,72,74} Three studies measured stress during the first trimester of pregnancy (1–12 weeks gestation).^56
–58 Eight studies did not mention when they measured stress during pregnancy.^{53,64
–68,71,73} Of the 24 studies included in this scoping review, one studied Japanese American women, one studied Hawaiian/Pacific Islander women, one studied Somali women, one studied Black women, nine studied Latinx women, and 11 studied a racially diverse cohort of women.^51
–74 All women who participated in the selected studies were 18 years or older, and most were low-income with singleton pregnancies.^51
–74

Defining prenatal stress

Although each included study focused on stress during pregnancy, only five studies named prenatal stress specifically, and none of them defined it.^{51,69
–71,73} None of these studies described whether prenatal stress was unique or how it might differ from general stress in the context of adverse social determinants of health. Seven other studies identified a particular form of stress that had an associated definition, including post-traumatic stress (n = 1),⁶⁸ acculturative stress (n = 3),^56
–58 and self-reported stress (n = 2).^55,72 See Table 2 below.

Table 2.

Types of stress and their definitions in selected studies.

Author	Stressor/social determinant	Type of stress reported	Definition of stress used in the study
D’Anna-Hernandez et al.⁵⁷	Immigration	Acculturative stress	“Acculturative stress refers to the stress associated with acculturative experiences and cultural adaptation. Acculturative stress draws on an individual’s resources necessary for the adjustment to a new culture.”⁵⁷
Dodgson et al.⁶⁸	Immigration	Post-traumatic stress (defined through PTSD)	“. . . a multidimensional trauma and stress-related disorder that includes (1) having a personal history of exposure to an experienced or witnessed traumatic event that involved actual or threatened death or serious injury to self or others; (2) eliciting a response of intense fear, helplessness, or horror that continues for more than one month; and (3) having symptoms from each of 4 symptom clusters (i.e., re-experiencing, avoidance, persistent negative alterations in cognitions and mood, and alterations in arousal and reactivity).”⁶⁸
Eick et al.⁵⁵	Food insecurity	Self-reported stress	“Psychosocial stressors and responses to stress were derived from the theory of allostasis, which has been previously adapted in an effort to better understand and evaluate the effects of pregnancy-related stress, coping, and physiologic changes that may lead to adverse perinatal health outcomes. The theory of allostasis allows us to understand how individuals regulate body systems when they experience expected or unexpected events that are stressful or may be perceived as stressful.”⁵⁵
Mendez et al.⁷²	Housing instability	Self-reported stress	“Stress is a dynamic and multifaceted phenomenon that has been associated with poor health . . . However, perceptions of stress may depend on the source of stress, and physiological responses to stress may be related to an individual’s ability or willingness to appraise or report stress.”⁷²
Osman et al.⁵⁸	Immigration	Acculturative stress	“The psychological distress associated with the process of adapting to a new culture.”⁵⁸
Preciado et al.⁵⁶	Immigration	Acculturative stress	“The stress associated with the process of acculturation.” Acculturation was defined as “the multidimensional process of psychological and cultural changes when interacting between two or more cultures.”⁵⁶
Testa and Fahmy⁵³	Food insecurity	Process of stress	“The process of social stress can be seen as combining three major conceptual domains: the courses of stress, the mediators of stress, and the manifestations of stress.”⁵³

PTSD: post-traumatic stress disorder.

Measuring prenatal stress

While we screened for studies that measured some form of stress, only 13 used a validated instrument.^{51,52,56
–59,62
–65,68,72,74} Seven studies used the Perceived Social Stress Scale (PSS),^{51,56,57,59,62,64,65} two studies used Cohen’s 10-item Perceived Stress Scale (PSS-10),^52,63 one study used Cohen’s 4-item Perceived Stress Scale (PSS-4),⁷⁴ and one study used Cohen’s 14-item Perceived Stress Scale (PSS-14) to measure psychosocial and perceived stress.⁷² Bandoli et al.⁶² measured chronic stress using a validated tool and acute stress using a non-validated questionnaire. In addition to the PSS-4, Izano et al.⁷⁴ also measured psychosocial stress using questions from the literature on factors related to psychosocial stress, work, social and physical environments that had been previously validated in other study populations and were pilot tested on a subset of women in the Chemicals in Our Body (CIOB) study. Eight studies used non-validated surveys and questionnaires constructed by the research team to measure stress.^{53,60,66,67,69
–71,73} Three studies mentioned that they used a validated tool to measure paradigms of stress but did not specify which tool they used.^54,55,61

Five studies specifically measured life events commonly understood to cause stress among individuals^{54,55,67,68,74}; however, of these five studies, only one specified which validated tool they used to measure it: the Life Events Checklist (LEC).⁶⁸ Three studies measured acculturative stress using a combination of the Social Attitudinal Familial and Environmental Stress Scale (SAFE) and the Acculturation Rating Scale for Mexican-Americans-Revised (ARMSA-II).^56
–58 Of the five studies that mentioned prenatal stress, only one used a validated tool, the PDQ, to measure it.^51,74 Tsai et al.⁶⁰ measured stress during pregnancy using a non-validated, standardized questionnaire. Brief descriptions of the validated instruments are included in Table 3 below.

Table 3.

Stress measurement instruments.

Validated stress measurement tool	Description of tool
Perceived social stress scale (PSS)	All four variations of this tool aim to measure personal stress by evaluating the degree to which situations in one’s life are appraised as stressful.⁷⁵
Cohen’s 10-item perceived stress scale (PSS-10)
Cohen’s 14-item perceived stress scale (PSS-14)
Cohen’s 4-item perceived stress scale (PSS-4)
Life events checklist (LEC)	Assesses traumatic exposure, particularly when evaluating consistency of events that actually happened to a respondent.⁷⁶
Social attitudinal familial and environmental stress scale (SAFE)	Measures stress associated with the acculturative process among immigrants.⁷⁷
Acculturation rating scale for Mexican Americans-revised (ARMSA-II)	Quantifies the construct of acculturation along three primary factors: language, ethnic identity, and ethnic interaction.⁷⁸
Prenatal distress questionnaire (PDQ)	Assesses specific worries and concerns during pregnancy.⁷⁹
Center for epidemiological studies depression scale	Assesses degrees of depressive symptoms and detects at-risk individuals for depression in the general population.⁸⁰
Discrimination stress scale (DSS)	Assesses perceived racial/ethnic discrimination in everyday life due to ethnic minority status.⁸¹

Fifteen studies measured over 25 common stressors that were included as stress indicators.^{51
–58,60
–62,67
–71,74} These included caregiver burden (n = 3),^54,55,74 unplanned pregnancy (n = 3),^54,70,74 change in marital status (n = 2),^70,71 incarceration (n = 2),^53,71 violence and abuse (n = 1),⁶⁸ discrimination (n = 2),^56,57 and poor neighborhood environment (n = 2).^54,74 Four studies measured financial strain, and three studies measured job strain.^54,55,71,74 Two studies measured depression, and another two measured pregnancy-related anxiety.^51,58,62 While some studies measured food insecurity as a construct that is separate from stress (n = 5),^{51,52,54,55,74} Laraia et al.⁵² write that “the household food insecurity scale can be viewed as a crude measure that captures psychosocial stress, poor diet quality, and economic hardship.” Of the 15 studies that measured a stress paradigm, four studies did not explain the association between the stress paradigm and stress during pregnancy.^51,60,67,69 In addition, 10 studies measured a series of measures and compiled the data without clarifying which measures were used to measure stress specifically.^{51
–54,56
–58,67,68,70} See Table 4 for a breakdown of how prenatal stress and general stress were measured in the included studies.

Table 4.

Measurement of prenatal stress and general stress.

Author	How was stress conceptualized?	Did they explain the relationship between the measure and stress?	Did they utilize validated measurement tools to measure stress?	Which stress measurement instruments did they use?
Housing instability
Mendez et al.⁷²	Perceived stress	—	Yes	PSS-14
Novick et al.⁷³	Perceived stress	—	No	—
Shaw et al.⁷¹	Stressors such as financial concerns, divorce, incarceration, death of someone close, and moving	Yes	No	—
Food insecurity
Eick et al.⁵⁵	Psychosocial stressors: stressful life events, caregiving, job strain, discrimination, food insecurity, financial strain, and unplanned pregnancy	Yes	Yes	Not specified
Goin et al.⁵⁴	Financial hardship, food insecurity, job strain, poor neighborhood environment, low community standing, caregiving, high burden of stressful life events, and unplanned pregnancy	Yes	Yes	Not specified
Heberlein et al.⁵¹	Food Insecurity, psychosocial well-being, depression, and pregnancy-related distress	No	Yes	PSS, Center for Epidemiological Studies Depression Scale, and PDQ
Laraia et al.⁵²	Perceived stress	—	Yes	PSS-10
Izano et al.⁷⁴	Psychosocial stressors: financial strain, food insecurity, high job strain, poor neighborhood quality, low community standing, perceived stress, caregiving for a dependent family member, stressful life events, and unplanned pregnancy	Yes	Yes	PSS-4, Tool developed by study team
Testa and Fahmy⁵³	Incarceration exposure	Yes	No	—
Immigration
Bandoli et al.⁶²	Pregnancy anxiety, acute stress, and chronic stress	Yes	Yes	PSS
Cabeza de Baca et al.⁷⁰	Maternal relationship status and planned pregnancy status	Yes	No	—
Coller et al.⁶⁷	Not specified: Used a modified index adapted from the Life Events List for acute stressors during pregnancy (e.g., loss of a loved one, worries about money, family troubles)	No	No	—
D’Anna-Hernandez et al.⁵⁷	Maternal acculturative stress, discrimination, perceived stress	Yes	Yes	ARMSA-II, SAFE, DSS, and PSS
Dodgson et al.⁶⁸	Family-level variables (e.g., family support, father of the infant actively involved, family stress), violence, and life events	Yes	Yes	LEC
Fleuriet and Sunil⁶⁵	Psychosocial stress	—	Yes	PSS
Fleuriet and Sunil⁶⁴	Psychosocial stress	—	Yes	PSS
Hoggatt et al.⁶⁶	Chronic stress	—	No	—
Little et al.⁶⁹	Pregnancy readiness	No	No	—
Madeira et al.⁵⁹	Perceived stress	—	Yes	PSS
Osman et al.⁵⁸	Maternal acculturative stress, pregnancy anxiety	Yes	Yes	ARMSA-II and SAFE
Preciado et al.⁵⁶	Maternal acculturative stress, discrimination, and perceived stress	Yes	Yes	ARMSA-II, SAFE, DSS, and PSS
Stanhope et al.⁶¹	Chronic stress	—	Yes	Not specified
Toledo-Corral et al.⁶³	Perceived Stress	—	Yes	PSS-10
Tsai et al.⁶⁰	Lifetime stress and stress during pregnancy	No	No	—

PSS: perceived social stress scale; PDQ: prenatal distress questionnaire; ARMSA-II: acculturation rating scale for Mexican Americans-revised II; SAFE: social attitudinal familial and environmental stress scale; DSS: discrimination stress scale; LEC: life events checklist.

Four of the five studies using more than one tool or scale to measure stress presented a correlation matrix of these measures. Izano et al.⁷⁴ found a strong association between food insecurity and financial strain, as well as between food insecurity and poor neighborhood quality. In addition, high job strain was highly correlated with financial strain. Among women of Mexican descent in southern California, acculturative stress was highly correlated with anxiety symptoms during all stages of pregnancy and postpartum.⁵⁸ Similarly, in another sample of Mexican-American women in southern California, acculturative stress was associated with prenatal anxiety symptoms in every trimester, although the anxiety declined by the last three months of pregnancy. Perceived discrimination was not found to be associated with anxiety.⁵⁶ D’Anna-Hernandez et al.,⁵⁷ however, found that acculturative stress measures were highly correlated with perceived discrimination but not cultural stressors of acculturation and that acculturative stress and perceived stress were highly correlated with maternal depressive symptoms, which was an outcome in their study but also used as a measure of stress in others.

Discussion

Of the 24 articles we reviewed, none defined prenatal stress, and only one used a prenatal stress-specific tool to measure it.^51
–74 While we screened for US studies that measured some form of stress during pregnancy, we found a large variation in the tools used to measure prenatal stress and the related constructs that are measured as stress indicators. Furthermore, we question whether an association between two concepts, e.g. food insecurity and stress, is sufficient to use the one to approximate the other. Therefore, our study found that within the past 10 years in the United States, there has been little consistency in the definition and measurement of prenatal stress in the context of three common social determinants of health.

Three decades ago, Lobel¹⁵ raised concerns about the conceptual equivalence of three measures of prenatal stress, including stressful life events, women’s emotional responses (state anxiety), and their predisposition toward anxiety (trait anxiety) in pregnancy literature. We investigated whether prenatal stress is defined and measured as a validated measure in contemporary research on psychosocial risk factors associated with pregnancy and birth outcomes and found that this lack of conceptual equivalence persists.³² In their review of literature from 1999 to 2009 on ways prenatal stress was being measured, Nast et al.²⁵ identified 43 different psychometric instruments used to measure maternal psychosocial stress across seven constructs, with anxiety being most frequent and stress related to pregnancy and parenting being least. While we focused our study on the measurement of prenatal stress in relation to adverse social conditions, we still identified 10 different instruments that measured over 25 different constructs; of the tools that directly measured stress, perceived stress was measured most frequently, and prenatal stress was measured the least.^{51,52,56
–59,62
–65,68,72,74} While using multiple measures (proxies) for prenatal stress should have helped to reduce problems of measurement error, we observed a lack of evidence showing the conceptual equivalence of these proxies and prenatal stress.

Within food insecurity, housing instability, and immigration, we found no uniform definition or measure of prenatal stress. Although several studies used validated instruments, most of them did not consider the specific demands resulting from social adversity and pregnancy, as we had conceptualized in our model. Among the measures related to particular social determinants, acculturative stress related to immigration status was the most frequently used measure, capturing a particular aspect of immigration. However, other than the PDQ, all other instruments were designed for use at any stage in one’s life, disregarding the physical, psychosocial, and financial demands of pregnancy. When measuring stress, it is important to differentiate between measuring stressful events, such as being food insecure, which can be measured discretely, and the cognitive, emotional, and biological response to these stressors.⁸² Social scientists, such as those working within the SDOH framework, may use the term “stress” loosely,⁸³ either failing to define it or using it to refer to a multitude of experiences, and this lack of specificity can impede any clear assessment or comparisons of stress during pregnancy, especially when harmful exposures can have detrimental consequences for mothers and their infants.⁸⁴

Certain studies centered on the three SDOHs mentioned in this paper drew attention to the heightened vulnerability of pregnant individuals impacted by our selected determinants. However, despite this focus, these studies failed to meet our selection criteria and were not included in our analysis. An example includes a study of linked administrative data for women who received shelter through an Emergency Assistance program in Massachusetts.⁸⁵ While this study measured the effect of unstable housing during pregnancy on pregnancy complications, it excluded data on mental health disorders among the study population. Similarly, another study measured household food insecurity and elevated antenatal depression symptoms (EADS) but did not equate EADS with stress, and therefore, it did not meet our study inclusion criteria.⁸⁶ An immigration and stress study investigated the health profiles and use of healthcare services among newly arrived migrant women in Canada.⁸⁷ Although the study indicated potential stress during pregnancy and focused on depression, anxiety, somatization, and post-traumatic stress disorder (PTSD) in an immigrant population, it did not meet our country selection criteria.

Strengths and limitations

A strength of our review was our particular focus on three salient aspects of the SDOH framework, given its relevance to contemporary research on maternal health inequities. By focusing on three different social determinants, we were able to question and answer how their psychological impact is being conceptualized in current literature. Another strength was having two researchers independently screen, select, and extract data. This minimized bias and increased the validity of the data reported. A limitation of our study was that we limited the scope of research to the United States to focus on how food insecurity, housing instability, and immigration impact stress among pregnant people in the sociopolitical context of one country. While this allowed us to compare findings without needing to account for country-specific factors, such as housing policy, we also had to exclude international studies that specifically attempted to define and measure prenatal stress. As this was a scoping review, we did not formally evaluate study quality and the risk of bias.

Future implications

Having a consistent definition and set of measures for prenatal stress is important for research and policy development. Currently, the differences in the conceptualization of prenatal stress impede comparisons across populations, settings, and stressors and, thus, fail to build compelling evidence for the importance of prenatal stress for maternal and child health outcomes. The inability to effectively conceptualize prenatal stress in the context of social determinants of health hinders our ability to understand the degree to which addressing the source of stress, such as food insecurity, housing instability, or immigration, reduces prenatal stress across different populations and geographies. Choosing and documenting appropriate measures of stress should be based on theoretical and empirical examinations of the uniqueness of the population, windows of sensitivity, types of stress responses, characteristics of the stressor, and the best scales available to accommodate the intended measure.⁸² We encourage social scientists working within the SDOH framework to consider greater specificity in their definition of stress and in the tools they choose to measure it, including a clear presentation of their conceptual approach to do so.

As healthcare stakeholders seek to assess and address social determinants of health-related needs, it is imperative that they can turn to credible data in the literature that accurately defines and measures prenatal stress. In addition, increasing the reliability and validity of pregnancy-specific stress measures over time could benefit clinical care, aiding healthcare workers in identifying pregnant people at greatest risk of delivering early or engaging in behaviors, such as smoking, and subsequently offering additional support that aims to reduce prenatal stress and adverse maternal and infant health outcomes.^{3,26,88
–90}

Conclusions

Research with concise and consistent definitions of prenatal stress during adverse social conditions is sparse in the United States. We encourage the accurate definition and measurement of prenatal stress so that conclusions made in the literature are applicable across studies and to other policy and community-based maternal health initiatives. We recommend identifying a consistent, well-supported multidimensional approach to defining and measuring prenatal stress in the context of adverse social conditions to provide consistent evidence on how the relationship between prenatal stress and social determinants of health can influence adverse maternal and child health outcomes. Improving the definition of prenatal stress and standardizing the tools used to measure it will allow us to build effective interventions and policies that can aid those facing stress-related pregnancy complications.

Supplemental Material

sj-docx-1-whe-10.1177_17455057231191091 – Supplemental material for What is prenatal stress? A scoping review of how prenatal stress is defined and measured within the context of food insecurity, housing instability, and immigration in the United States

Supplemental material, sj-docx-1-whe-10.1177_17455057231191091 for What is prenatal stress? A scoping review of how prenatal stress is defined and measured within the context of food insecurity, housing instability, and immigration in the United States by Ishani Patel and Alka Dev in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057231191091 – Supplemental material for What is prenatal stress? A scoping review of how prenatal stress is defined and measured within the context of food insecurity, housing instability, and immigration in the United States

Supplemental material, sj-docx-2-whe-10.1177_17455057231191091 for What is prenatal stress? A scoping review of how prenatal stress is defined and measured within the context of food insecurity, housing instability, and immigration in the United States by Ishani Patel and Alka Dev in Women’s Health

Footnotes

Acknowledgements

The authors thank the professors at The Dartmouth Institute for Health Policy and Clinical Practice that provided their guidance and expertise during this study: Dr. Catherine Saunders and Dr. Rebecca Emeny. Three high school students assisted with the initial search as a summer project: Richa Vaid, Liana Lansigan, and Diya Kochhar.

Declarations

ORCID iD

Ishani Patel

Supplemental material

Supplemental material for this article is available online.

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