Psychological Needs Fulfillment and Perinatal Well-being Among Low-SES Individuals: A Mixed Methods Investigation

Abstract

Poor perinatal mental health is associated with deleterious effects and individuals with low socioeconomic status (SES) are at elevated risk. Fortifying multi-level resources of low-SES pregnant individuals to boost their well-being is a crucial step towards achieving equity in perinatal health. The purpose of this project was to explore what patterns of resources supported well-being among low-SES pregnant individuals in Colorado. In a prospective mixed methods cohort study, 23 low-SES pregnant individuals completed surveys and interviews. Participants were separated into 3 subgroups based on their overall Warwick-Edinburgh Mental Well-being Scale (WEMWBS) score and interviewed to identify multi-level resources that supported their well-being. Our analysis was framed by Self-Determination Theory which contends that three universal basic psychological needs are required for individuals to function in a healthy manner: autonomy, competence, and relatedness. We extrapolated resources that promoted perinatal competence, autonomy, and relatedness from the high well-being group. Perinatal-related knowledge (construct related to competence); mindfulness and intended pregnancy (constructs related to autonomy); and emotional, informational, and friend support, social capital, and connection to nature (constructs related to relatedness) were identified as the resources more frequently endorsed in the high well-being group. Targeting interventions to fortify specific multi-level resources that support the autonomy, competence, and relatedness of pregnant individuals facing socioeconomic disadvantage is a crucial step towards achieving equity in perinatal health.

Introduction

The perinatal period (i.e. pregnancy through one year postpartum) is characterized by profound changes that can pose a challenge to mothers’ mental health and well-being as they face a combination of physical, social, financial, and emotional transitions. About 17% of mothers experience prenatal depression, 20% experience prenatal anxiety, and 35% perceive heightened stress during pregnancy (Fawcett et al., 2019; Papapetrou et al., 2023; Underwood et al., 2016). Poor mental health and well-being has serious implications on pregnancy and birth outcomes as well as the long-term health of mothers and their children. For example, prenatal depression is associated with preterm birth, childbirth by caesarean section, pre-eclampsia, and peripartum cardiomyopathy (Jacovides et al., 2024; Nicholson et al., 2016).

Conversely, good perinatal mental health has salutary effects. Positive maternal affect during pregnancy is linked to longer gestational length and higher birth weight and is thus protective against health complications associated with preterm birth and low birth weight (Estinfort et al., 2022; Pesonen et al., 2016). Research demonstrates that having good mental health in the prenatal period predicts postpartum flourishing (Montiero et al., 2021). The World Health Organization conceptualizes a “positive pregnancy experience” as one that not only encompasses the treatment of disease, but also includes health education and promotion (WHO, 2016). Well-being is not merely the lack of poor mental health, but rather a state of thriving in which individuals realize their full potential and adaptively cope with everyday stressors (WHO, 2016). For the purposes of this study, well-being is defined as mental well-being which encompassing both eudemonic and hedonic well-being as well as psychological functioning and subjective well-being (Tennant et al., 2007).

Individuals who have the opportunity to cultivate and retain certain psychological (e.g., mindfulness) (Corno et al., 2019), social (e.g., emotional support) (Byrd-Craven & Massey, 2013), and community-level (e.g., neighborhood connection) (Giurgescu et al., 2015) resources may be favorably situated to thrive and be well (Luthans & Youssef-Morgan, 2017; Youssef-Morgan & Luthans, 2015).

Unfortunately, these multi-level resources tend to be differentially distributed by socioeconomic status (SES) such that individuals with lower SES have fewer psychosocial- (e.g., financial support) and community-level (e.g., work-related support and maternity leave) resources at their disposal (Taylor & Seeman, 1999). Social determinants of health including experiences of discrimination may worsen perinatal mental health and well-being and subsequent outcomes. Experiencing adverse social determinants increases one’s risk of poor perinatal mental health (Endres et al., 2023). For example, people living in poverty tend to lack the resources to meet basic human needs such as food, housing, and high-quality healthcare; These stressful living conditions are a burden to their mental health, and many become entrapped in a feedback loop of poverty increasing the risk of poor mental health and poor mental health increasing the risk of poverty (WHO, 2022).

According to Self-Determination Theory (SDT), multi-level resources may be particularly protective among low-SES pregnant samples by bolstering three universal basic psychological needs required for individuals to function in a healthy manner: autonomy, competence, and relatedness (Ryan & Deci, 2000; Schultz & Ryan, 2015). Autonomy refers to feeling unrestrained and having a sense that one’s behavior is chosen and endorsed rather than forced and pressured. Competence refers to having a sense of mastery and accomplishment in one’s activities. Relatedness refers to feeling socially connected and sharing meaningful experiences with others. Crucially, both subjective SES and household income are positively associated with psychological need fulfillment, and in turn negatively associated with health complaints, suggesting that need fulfillment serves as the link from SES and income to self-rated well-being (Di Domenico & Fournier, 2014).

Fortifying psychosocial and community-level resources of pregnant individuals facing socioeconomic disadvantage may bolster these basic psychological needs which is an imperative step towards achieving perinatal health equity. However, qualitative exploration of specific multi-level resources that may be most protective and foster autonomy, competence, and relatedness are unclear. The present study applied a simultaneous explanatory mixed methods approach and the SDT to investigate specific patterns of psychological-, social-, and community-level resources that support well-being among individuals facing low SES during pregnancy. Our primary research hypothesis is that the high well-being group in this sample will endorse specific psychosocial- and community-level resources more than the low-wellbeing group and that these resources are supporting their basic psychological needs and ability to thrive.

Methods

Participants

Prior to recruitment, all procedures were approved by the Colorado Multiple Institutional Review Board (IRB #: 22–1725). Pregnant individuals in Colorado were recruited using non-probability purposive sampling techniques between May 2023 and December 2023. Eligibility criteria included >6 weeks pregnant, at least 18 years of age, English-speaking, receiving prenatal care at one of six health care clinics in the Denver metro area, and experiencing socioeconomic disadvantage. Participants were classified as experiencing socioeconomic disadvantage if they endorsed low income (defined in five ways: Medicaid-recipient, participation in federal assistance programs, household income <250% FPL, no- or partial-insurance, subjective experience of high financial stress), if they endorsed low educational attainment (less than college degree), or if they endorsed both factors. There were no exclusion criteria.

Procedures

The study consent and survey were administered via Research Electronic Data Capture (REDCap) (Harris et al., 2009). REDCap is a secure, web-based application designed to support data capture for research studies. The 125-item survey took approximately 20 minutes and participants received a $20 electronic gift card for survey completion. The survey included a yes/no question about willingness to participate in an interview. The study team reached out to those who agreed, by phone or email according to their preference, to schedule an interview. Interviews were held over the phone or videoconference and ranged from 30 to 60 minutes. Participants who completed an interview received an additional $20 electronic gift card.

Instruments

The survey instrument assessed psychosocial and community-level resources and mental health and well-being outcomes using validated instruments; However, the only quantitative variable from this survey that was analyzed for this mixed-methods study was well-being during pregnancy, assessed using the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). WEMWBS is a reliable and valid 14-item scale that measures well-being (a = .91) (Tennant et al., 2007). Demographic characteristics were also assessed including education, income, age, race/ethnicity, parity, marital status, and food insecurity.

The interview guide included questions about general psychological, social, and community-level resources that have been found to promote mental health and well-being in adult populations (e.g., optimism, self-efficacy, social support) as well as how accessing these resources helps individuals cope with external stressors and supports their well-being. Interview questions were framed by SDT to explore the multi-level resources that support the universal basic psychological needs of competence, autonomy, and relatedness in the perinatal period (Ryan & Deci, 2000). An example of a question regarding autonomy was: When you think about challenges you have had in your life, how are you able to bounce back or overcome those challenges? An example of a prompt that probed for competence was: How confident do you feel in your ability to be a parent? A question regarding relatedness was: What types of supports have helped you thus far and how have they helped you in your pregnancy?

Data Analysis

23 interviews were included in the final analysis. All interviews were transcribed using Microsoft Teams and imported into ATLAS.ti version 23.2.1 (ATLAS.ti Scientific Software Development GmbH, 2023). Coding was an iterative process including a deductive, theory-driven approach and an inductive, data-driven approach. There were two key reviewers and a third reviewer who double-coded 11 of the 23 interviews. All three reviewers and the principal investigator met weekly to discuss questions and reach consensus on any disagreements that arose. Once coding was complete, we reviewed our codes and identified key themes.

Next, we conducted subgroup analyses using ATLAS.ti to investigate differences in patterns of multi-level resources based on WEMWBS score. Descriptive statistics of WEMWBS scores were analyzed using SPSS software Version 29.0 (IBM Corp., 2023) and normality was investigated using numerical (i.e. skewness and kurtosis) and visual (i.e. histogram, box plot, P–P Plot, and Q–Q Plot) methods. Tertiles were dictated based on standard deviations from the mean; +1 SD or higher was categorized as high well-being and −1 SD or lower was categorized as low well-being. Once coding was completed, participants were separated into subgroups based on their overall Of the 23 interviews included in the analysis, 6 were with low well-being participants, 11 were with average well-being participants, and 6 were with high well-being participants. Data were normalized during subgroup analyses to facilitate the comparison of frequency of codes between groups since the sample size within each tertile were not equal. We also looked at relative frequencies instead of absolute frequencies to allow for more accurate comparison.

Results

Characteristics of the sample are described in Table 1. The average age was 29.77 years (SD = 6.08), and the average gestational age was 14.17 weeks (SD = 6.56). The average well-being scores based on the WEMWBS was 47.22 (SD=11.07; Median = 47.00; Range: 26–70). WEMWBS scores were normally distributed The marital status and race and ethnicity of the sample were diverse. Eight participants were married (34.78%), six were single and never married (26.09%), six were a member of an unmarried couple or partnered (26.09%), one was separated (4.35%), and two reported a marital status of other (8.70%). Participants were prompted to select all races that apply; 82.61% reported that they were White, 21.74% reported that they were Black, 8.70% reported that they were American Indian or Alaska Native, and 13.04% reported that they were Asian or Pacific Islander. 43.48% of participants reported non-Hispanic ethnicity and 56.52% reported Hispanic ethnicity. Approximately 30.43% of participants had completed a college degree or higher, and 69.57% reported Medicaid enrollment.

Table 1.

Demographics of Mixed-Methods Sample of Prenatal Individuals (N = 23)

	M	SD
Age	29.77	6.08
Gestational age	14.17	6.56
Warwick–Edinburgh Mental Wellbeing Scale	47.22	11.07
Marital status	n	%
Married	8	34.78
Single and never married	6	26.09
Unmarried couple	6	26.09
Separated	1	4.35
Other	2	8.70
Ethnicity
Non-Hispanic	10	43.48
Hispanic	13	56.52
Race (select all)
White	19	82.61
Black	5	21.74
American Indian or Alaskan Native	2	8.70
Asian or Pacific Islander	3	13.04
Education
Some high school	4	17.39
Completed high school	6	26.09
Associate’s degree	1	4.35
Some college	4	17.39
Completed college	2	8.70
Beyond college	5	21.74
Medicaid
Yes	16	69.57
No	7	30.43
Federal assistance programs
Yes	14	60.87
No	9	39.13

First, we identified resources that were endorsed by the full sample as promoting their well-being. Table 2 identifies the psychological, social, and community-level resources that were most frequently mentioned among the full sample (N = 23). Psychological resources were categorized as individual-level resources. The most frequently endorsed psychological resources included self-efficacy, optimism, resilience, hope, and mindfulness. Social resources are formal and informal supports derived from relationships. The most frequently endorsed social resources were family and significant other support as well as emotional, instrumental, and informational support. Community-level resources encompass the social setting in which one operates and other societal influences such as values and norms. The most frequently endorsed community-level resources were work-related supports, social capital bridging, and connection to the outdoors/nature.

Table 2.

Most Frequently Endorsed Resources Among the Full Sample (N = 23)

Resource	Quote
Psychological
Self-efficacy	“I can be an advocate for myself and my child” “I have a voice and so I can be an advocate for myself.”
Optimism	“I generally feel like things go my way.” “Just like attitude in general is really important, so it’s really important in who like you surround yourself with as well, because like negativity only brings negativity, but positivity always brings positivity.”
Resilience	“I have the skills to bounce back pretty easily.”
Hope	“I try to have more faith in what I can’t control and do what I can with what I can control.”
Mindfulness	“I like to think things through first and go over all my bases before I react.” “And then being cognizant of when I do need time to myself or, you know, just time away from kids or whatever it may be.”
Social
Family support	“[My mom] has said that they are thinking about getting a place out here and helping me, and that is huge and super helpful.”
Emotional support	“Therapy is helping a lot.” “I mean, they’re really easy to talk too…someone’s always available. I have a big family. so I feel like there’s always someone available to talk too.”
Significant other support	“My husband really helps a lot to keep me happy.”
Instrumental support	“[My significant other] has done a good job of … recognizing there are times when I need more help around the house.”
Informational support	“I feel better informed, so less concerned that I don’t know how to do any of it.” “It’s helpful like hearing about people that are just now having kids or are about to have kids. So you get to hear about different experiences learn about healthy behaviors and non-healthy behaviors so that you could try to change them before you have your baby.”
Community
Work-related supports	“I actually have amazing maternity leave.”
Social capital bridging	“Hearing other moms [talk about] some of their struggles and how they overcame those struggles, it’s soothing.”
Nature Connection	“Getting out of the house and just breathing the fresh air helps you reset a lot.” “Just being outside especially like getting sunshine.”

Quantitative data from the surveys and qualitative data from the interviews were integrated to examine the common resources among those with high well-being (n=6) to identify what resources were supporting these individuals to thrive despite experiencing significant structural adversities. Figure 1 shows a heat map reflecting mixed methods findings of the resources that were most frequently endorsed by the participants in the high well-being tertile. We then organized these resources by SDT construct to identify multi-level resources that are most supportive of basic psychological needs, thus moderating associations between low-SES and well-being outcomes.

Figure 1.

Heat Map of Resources Associated with Self-Determination Theory’s Basic Psychological Needs by Well-being Tertile (N = 23)

Autonomy

The autonomy-promoting resources that were most frequently endorsed by those with high well-being were mindfulness, excitement, and intended pregnancy. Regarding mindfulness, a participant with high well-being shared, “I can sometimes recognize that I’m in a spiraling thought pattern that is not logical and is not helping me, and kind of reverse that and get myself out of it by grounding in truth and affirmations, and that typically works.” Excitement signals that one’s actions are aligned with their values. A participant with high well-being stated, “I’m excited to have a third [baby] … to just watch the siblings play and continue to watch my husband be a dad.” Likewise, intended pregnancy, defined as the desire for and plan to have a baby, has a clear link to feeling a sense that one’s behavior was chosen rather than forced. For example, a participant with high well-being said that she “always wanted to be a mom.”

Competence

The competence-promoting resource that was most frequently endorsed by those with high well-being was perinatal-related knowledge, defined as information known about pregnancy, birth, and postpartum going into the perinatal period. A participant with high well-being expressed that “[t]his time we know what’s coming.”

Relatedness

Many of the resources that were most frequently mentioned by the high well-being group promoted relatedness, indicating its importance. These multi-level resources included methods of support (i.e., emotional support, informational support) and sources of support (i.e., friend support, social capital bridging and bonding, connection to outdoors/nature). Emotional support, or the verbal and nonverbal ways that one expresses love, empathy, and care for others, boosts relatedness. A participant with high well-being reported having “people who [she] could talk to about the experience [of having a baby] … That has been very helpful.” Informational support refers to advice, suggestions, and information about pregnancy, birth, and postpartum. For instance, when pondering whether to pursue a doula, a participant with high well-being stated that she “had several family members and friends who either didn’t have one and in hindsight really wished they had, or that did have one and felt like it was really helpful … [Getting] advice from those people [was helpful].” Support from friends was highest among the high well-being group. One participant with high well-being shared that “it’s nice to have somebody else to talk to other than your mom and your siblings.” Social capital bridging involves engaging individuals from looser, weaker networks (e.g., “I am a hairstylist, so I am pretty sociable”), whereas social capital bonding involves engaging individuals from closer-knit, stronger networks (e.g., “[My partner and I] share my pregnancy app and I’ll wake up and he’s telling me about all the stuff that he read on there”). Lastly, connection to nature and the outdoors was most frequently mentioned among participants with high well-being (e.g., “I really enjoy being outside, so anytime I can get out, especially with my kids, even for 45 minutes just to get out in the sunshine, I do that”).

Discussion

The purpose of this mixed-methods investigation was to apply the SDT to explore patterns of resources that support well-being among perinatal individuals facing socioeconomic disadvantage. The social-ecological model emphasizes that an individual’s well-being is affected by various intrapersonal, interpersonal, and community-level circumstances that are beyond their personal realm of control, such as their relationships and the communities where they live and work. Thus, the most effective health promotion interventions target multiple resource levels (McLeroy et al., 1988). Common psychological resources in our sample were self-efficacy, optimism, hope, resilience, and mindfulness. Prevailing social resources in our sample were emotional, informational, and instrumental support from one’s family and significant other. The most cited community-level resources in our sample were work-related supports, social capital bridging, and connection to nature and the outdoors.

There is evidence demonstrating the protective influence of multi-level resources during the perinatal period. For example, among pregnant women experiencing high stress, optimistic individuals were significantly less likely to go on to develop postpartum depression compared to those who were pessimistic (Grote & Bledsoe, 2007). Among women with high-risk pregnancies, those who reported high levels of social support also reported low levels of uncertainty and distress, less avoidance, and heightened feelings of preparedness and positivity (Giurgescu et al., 2006). Additionally, gratitude and mindfulness have been supplemented among pregnant individuals to improve perinatal well-being and subsequent outcomes (Corno et al., 2019).

Our mixed methods findings identified autonomy- (i.e., mindfulness, excitement, intended pregnancy), competence- (i.e., perinatal-related knowledge), and relatedness-promoting resources (i.e., emotional support, informational support, friend support, social capital bridging and bonding, connection to outdoors/nature) among those reporting high well-being. The mode and degree of one’s psychological need satisfaction is influenced by their own competencies as well as ambient demands, obstacles, and affordances in their lives (Ryan & Deci, 2000). Opportunities to achieve autonomy, competence, and relatedness follow a socioeconomic gradient where higher SES individuals are more likely to encounter opportunities that satisfy their basic needs (Di Domenico & Fournier, 2014). Importantly, SDT suggests that the resources that were most common among participants with high well-being are the most promotive of well-being in this sample of low-SES individuals. These resources may be integral to fostering resilience and subsequent adaptive coping behaviors that promote well-being despite experiencing external adversities.

An individual’s basic need for autonomy is satisfied when they reflectively choose behaviors that align with their needs, values, and interests (Ryan & Deci, 2000). The most frequently mentioned autonomy-promoting resources among the high well-being group were mindfulness, excitement, and intended pregnancy. Mindfulness is a particularly important resource and has a robust positive association with autonomous motivation (Donald et al., 2020). Mindfulness enables individuals to monitor internal and external conditions, thus supporting the insight and reflection necessary to align their behavior with their values and self-perception (Ryan & Deci, 2017; Schultz & Ryan, 2015). Whether a pregnancy was intended and how the pregnant individual feels about being pregnant have implications on well-being. Unplanned pregnancy is associated with increased odds of psychological distress compared to planned pregnancy, most prominently among women who report negative or neutral feelings in early pregnancy (Barton et al., 2017). Among women with unplanned pregnancies, those who welcome the pregnancy have lower odds of poor psychological health (Moreau et al., 2022). Having a planned pregnancy may foster an individual’s sense of autonomy by promoting a feeling of control over one’s actions which can contribute to improved well-being.

An individual’s basic need for competence is satisfied when they feel effective in producing desired outcomes as a result of their actions (Ryan & Deci, 2000). The most frequently mentioned competence-promoting resource among the high well-being group was perinatal-related knowledge. Uncertainty surrounding pregnancy, postpartum, and parenting is a common stressor among perinatal individuals, and those who feel competent are favorably suited to maintain positive perinatal mental health and well-being. Low SES pregnant women often rely on interpersonal sources such as family for pregnancy-related information, and the extent to which pregnant individuals feel informed is associated with higher levels of perceived informational support and lower levels of pregnancy uncertainty (Song et al., 2013). Those who feel more competent are positioned for better well-being.

An individual’s basic need for relatedness is satisfied when they feel a sense of belonging and connectedness with others (Ryan & Deci, 2000). Relatedness encompassed the majority of the most frequently mentioned resources among those with high well-being, demonstrating its importance. Common relatedness-promoting resources among the high well-being group were emotional support, informational support, friend support, connection to outdoors/nature, social capital bridging, and social capital bonding. The support derived from relationships helps uphold well-being, especially in low SES contexts (Byrd-Craven & Massey, 2013). Social support can supplement individuals’ intrapersonal coping skills, thereby serving as a powerful buffer of stress and its consequences.

Our small, non-random sample may limit the generalizability of the present study; however, our findings highlight the lived experiences of this sample of low SES pregnant individuals. Additionally, the small sample size limits our ability to investigate subgroup analyses by potential confounders including parity, gestational age, age and race/ethnicity. We hypothesis that these sociodemographic characteristics may be associated with multi-level resources as well as overall well-being. Future studies could employ a random sampling method to explore the reproducibility of our findings among other populations. However, the use of mixed-methods to extrapolate protective multi-level resources from the high well-being group was a novel approach to inform resources that may best support basic psychological needs and subsequent well-being of low-SES populations. Individual psychological, social, and community-level resources can be strengthened in the perinatal period with evidence-based interventions.

Conclusions

These findings can be used to tailor interventions to specifically support perinatal well-being among individuals experiencing socioeconomic disadvantage to interrupt the intergenerational transmission of poor mental health and well-being. For example, a group-based intervention supporting basic psychological needs may be particularly beneficial for this population. Intervention components that focus on providing informational and emotional support, as well as positive feedback from facilitators and peers regarding postpartum and parental (e.g., (e.g., breastfeeding) accomplishments will foster increased feelings of competence and relatedness. Additionally, supporting opportunities for individuals to connect with the natural environment (e.g., nature-based interventions), as well as community-based resources may enhance social capital and further enhance relatedness. Providing training on mind-body strategies, including mindfulness techniques and breathwork, may cultivate autonomous regulation by supporting an individuals ability to make choices and being aware of ones action in the present moment. Improving the mental health and well-being of perinatal individuals facing socioeconomic disadvantage is a crucial step towards achieving health equity.

Data Availability Statement:

Data is available from the authors upon request.