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Canadian Journal of Public Health = Revue Canadienne de Santé Publique logoLink to Canadian Journal of Public Health = Revue Canadienne de Santé Publique
. 2024 Oct 24;116(1):70–85. doi: 10.17269/s41997-024-00933-2

Experiences with discrimination during pregnancy in Canada and associations with depression and anxiety symptoms

Kelsey P Davis 1, Makayla Freeman 2, Pariza Fazal 3,4, Kristin A Reynolds 5, Charlie Rioux 6, Danielle L Beatty Moody 7, Beatrice Pui-Yee Lai 4, Gerald F Giesbrecht 3,8,9,10, Catherine Lebel 9,11,12, Lianne Tomfohr-Madsen 2,✉
PMCID: PMC11870713  PMID: 39446296

Abstract

Objectives

Experiences of discrimination reported during pregnancy are common and are associated with poor mental health and adverse birth outcomes. No Canadian studies have investigated interpersonal discrimination during pregnancy. This study aimed to quantify and identify lived-experiences of discrimination in a Canadian cohort of pregnant individuals, and examine associations with concurrent prenatal anxiety and depression symptoms.

Methods

Pregnant individuals from the pan-Canadian Pregnancy During the Pandemic (PdP) study (n = 1943) completed the Everyday Discrimination Scale (EDS), demographic measures and self-report measures of depression and anxiety symptoms. Descriptive statistics and ANCOVA were used to assess prevalence of discrimination and associated mental health outcomes. Open-text responses (n = 189) to a question investigating reasons for discrimination were analyzed using conventional content analysis.

Results

Approximately three quarters (72%) of pregnant individuals experienced at least one instance of discrimination during their pregnancy or within the year prior. Pregnant individuals experiencing more frequent and/or more types of discrimination were more likely to identify as non-white, not be partnered, have lower socioeconomic status, and have a pre-pregnancy history of anxiety and depression. The most common attributions for interpersonal discrimination were gender, age, and education/income level. Pregnant individuals who experienced more frequent discrimination and/or more types of discrimination were more likely to report clinically significant symptoms of depression and anxiety (n = 623; 35.2% and 49.1%, respectively) compared to those who reported no discrimination (n = 539; 11.5% and 19.1%, respectively). Conventional content analysis of open-text responses generated the following main themes: (1) personal attributes and sociodemographic characteristics, (2) occupation, (3) the COVID-19 pandemic, (4) pregnancy and parenting, and (5) causes outside the self.

Conclusion

Frequent discrimination was associated with more adverse concurrent mental health symptoms. Understanding experiences of discrimination can inform interventions that better address the needs of pregnant individuals and their infants.

Keywords: Depression, Anxiety, Discrimination, Pregnancy, Mental health, COVID-19

Introduction

Discrimination is defined as the unfair treatment of a person based on personal characteristics such as gender, age, ethnicity, sexual orientation, or disability (American Psychological Association, 2020). According to a Statistics Canada survey on experiences of discrimination during the COVID-19 pandemic, racial minorities, gender-diverse individuals, young people (aged 15–24), recent immigrants, individuals with low SES, sexual minorities, and women  were the groups most likely to report experiences of discrimination (Statistics Canada, 2020). In non-pregnant samples, discrimination is associated with increased psychological distress, anxiety, and depression and lower overall health and well-being (Schmitt et al., 2014). Chronic everyday discrimination is more strongly associated with poorer health outcomes when compared to exposure to more severe, but infrequent, discrimination (Williams et al., 1997).

During pregnancy, experiences of subtly hostile behaviours such as negative interpersonal treatment and/or stereotyping are common (Hackney et al., 2021). Studies of discrimination in pregnancy have revealed similar associations as among the general population, including higher rates of smoking and alcohol use (Bennett et al., 2010) and poorer sleep quality (Francis et al., 2017), in addition to greater risk of preterm birth, low birth weight (Larrabee Sonderlund et al., 2021), and gestational diabetes (MacGregor et al., 2020). Frequent discrimination is also associated with higher rates of perceived stress (Hackney et al., 2021), and an increased risk of postpartum depressive symptoms (Bennett et al., 2010; Canady et al., 2008). Discrimination is an experience that does not occur equally across race, gender or socioeconomic status due to systemically-rooted inequities and social exclusion (Canady et al., 2008; Pan-Canadian Public Health Network, 2018), and may contribute to disparities in the prevalence of perinatal anxiety and depression symptoms or other adverse health outcomes (Thomeer et al., 2022). Existing perinatal mental health disparities were widened by the COVID-19 pandemic (Lebel et al., 2020), where access to resources (Barbosa-Leiker et al., 2021), increased stressors (Kotlar et al., 2021), discrimination and stigma (Miconi et al., 2020; Statistics Canada, 2020), and healthcare disparities (Masters et al., 2021) likely contributed to widening the gap in mental health outcomes between marginalized and non-marginalized groups.

The perinatal period is a time of increased risk for mental illness (Dennis et al., 2017). Understanding potential vulnerability factors is key to identifying at-risk populations and providing effective prevention and treatment. Untreated mental illness in pregnancy is associated with greater obstetrical complications (Stein et al., 2014) and adverse neonatal outcomes (Mongan et al., 2019), and can affect the child’s cognitive and socio-emotional development (O’Donnell et al., 2014). Many of the risk factors for experiencing discrimination, including race, gender, sexual orientation, immigration status and socioeconomic status, are also factors associated with increased risk of perinatal mood and anxiety disorders (PMADs) (Yang et al., 2022). Accordingly, defining and identifying social factors that could contribute to the global prevalence of PMADs is critical for the development of successful risk reduction strategies.

There have been few studies examining the impact of everyday discrimination on prenatal anxiety and depression symptoms and none conducted in Canada. One European study found that discrimination in pregnancy was associated with an increased risk of postpartum depression, but concurrent mental health symptoms were not examined (Stepanikova & Kukla, 2017). One US study examined workplace discrimination during pregnancy and found an association with increased depression (Hackney et al., 2021). A second US study examined how lifetime experiences of discrimination were associated with prenatal depression symptoms but did not examine prenatal anxiety or experiences of everyday (i.e., more frequent instances) discrimination (Canady et al., 2008). To our knowledge, the only published study to date that assessed everyday discrimination and depressive symptoms in pregnancy was in a low-income, inner-city US sample at increased risk of poor pregnancy and mental health outcomes (Bennett et al., 2010). There have been no Canadian studies on experiences of discrimination during pregnancy. Thus, there is a calling for Canadian research aimed at understanding experiences of discrimination during pregnancy using a mixed methods approach to gain a thorough understanding of the (1) prevalence of discrimination, (2) reasons for discrimination, and (3) concurrent mental health associations, and (4) to identify demographic risk factors to provide guidance for prevention and intervention strategies.

Study hypotheses

We hypothesized that pregnant individuals from racialized minority groups and/or with lower household incomes would experience more frequent interpersonal discrimination in comparison to the rest of the cohort. We also hypothesized that everyday discrimination would be associated with poorer concurrent mental health outcomes, regardless of demographic risk factors. Qualitative inquiry into the experiences of discrimination experienced by Canadian perinatal individuals has yet to be conducted, and our analysis of the open-text responses is therefore exploratory.

Methods

Participants

The current study examines data collected as part of the Pregnancy During the COVID-19 Pandemic (PdP) (Giesbrecht et al., 2021), which assessed the mental health and well-being of pregnant and postpartum individuals during the COVID-19 pandemic. The study recruited pregnant individuals from across Canada via Facebook and Instagram advertisements between April 2020 and April 2021 to complete a series of online surveys during their pregnancy and postpartum period. All participants were Canadian residents, ≥ 17 years old, and able to read and write in English or French, and had a confirmed pregnancy < 35 weeks gestation at the time of recruitment. The first four time points of the study consisted of monthly surveys. The current study uses data from the third follow-up (fourth time point), when discrimination was measured to examine this study’s research questions.

A total of 10,692 pregnant individuals completed the baseline survey between April 5, 2020 and April 30, 2021. A total of 3403 participants completed the Everyday Discrimination Scale (EDS) at Follow-Up 3 (three months after enrolment), of whom 869 participants had given birth. Since current analyses focus on discrimination experiences during pregnancy, those who had given birth were excluded from this analysis. Of the 2534 pregnant participants who completed the EDS, 591 French-speaking participants were excluded from this analysis due to validity inconsistencies with the translated French version of the EDS. Accordingly, the sample for the present study consists of all English-speaking participants who completed the EDS during pregnancy (n = 1943).

Demographics

Participants provided comprehensive demographic information, including age, province of residence, due date, marital status, ethnicity, education, household income, and medical history.

Interpersonal discrimination

Interpersonal discrimination was assessed using the short version of the EDS (Sternthal et al., 2011). The EDS has shown acceptable psychometric properties in health research (Krieger et al., 2005). The scale consists of 5 items that assess the experience and frequency of unjust treatment in “day-to-day” life (e.g., “you are threatened or harassed”) (Krieger et al., 2005; Williams & Mohammed, 2009). Response categories ranged from 1 (almost every day) to 6 (never). Response categories were re-coded on a 0 (never) to 5 (almost every day) scale, such that total scores range from 0 (no experiences of discrimination) to 25 points, with higher scores indicating more frequent or more types of discrimination experienced. The internal consistency of the shortened EDS in the present sample was excellent (Cronbach’s α = 0.79). The total score was summed and then categorized as follows: no discrimination (EDS score = 0), low to moderate discrimination (EDS Score = 1–5), and high discrimination (EDS score ≥ 6). Score groupings were established based on score tertiles (Michaels et al., 2019). Participants who responded with “a few times a year” or more frequent experiences of discrimination were asked: “What do you think is the main reason for these experiences?”: (1) your ancestry or national origins; (2) your gender; (3) your race; (4) your age; (5) your religion; (6) your height; (7) your weight; (8) some other aspect of your physical appearance; (9) your sexual orientation; (10) your educational or income level; (11) a physical disability; (12) your shade of skin colour; and/or (13) “other”, with the option of an open-text response for anyone who answered with “other”. Participants had the option to check/select all that apply.

Anxiety and depression symptoms

Prenatal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987). The scale consists of 10 self-report items, and has well-established sensitivity and specificity. Scores range from 0–30. Scores ≥ 13 are used to identify individuals with clinically concerning levels of depression, and are often consistent with a diagnosis of major depressive disorder (Cox et al., 1987). Sensitivity ranges from 38% to 43% for a cut-off of 13 on the EPDS (depending on pregnancy trimester) and specificity is 98–99% (Bergink et al., 2011). The internal consistency of the EPDS in the present sample was excellent (Cronbach’s α = 0.89).

The PROMIS Anxiety Adult 7-item short form was used to assess prenatal anxiety symptoms. Each of the items that make up this scale are measured using a 5-point Likert scale from 1 (never) to 5 (always). Higher scores represent a greater severity of anxiety symptoms. Raw scores were converted to t-scores, with possible t-scores ranging from 36.3 to 82.7, where scores ranging between 60 and 69.9 are considered moderately elevated anxiety symptoms, and scores above 70 are considered severe (Cella et al., 2010). Internal consistency of the PROMIS Anxiety 7-item scale was excellent in the current study (α = 0.94).

Data analysis

Survey data were manually checked for accuracy and consistency before analysis. All quantitative analyses were conducted using SPSS 28.0. Descriptive statistics were computed for demographics and main study variables. Chi-square tests were conducted to determine whether there was any significant relationship between demographic characteristics and participants across discrimination groups (no discrimination, low/moderate discrimination, and high discrimination). Missing data for mental health measures were handled with listwise deletion for the analysis of variance (ANOVA analysis); n is provided in the tables for each analysis. An ANOVA was used to examine univariate relationships between discrimination and mental health (depression and anxiety). An analysis of covariance (ANCOVA) was used to examine relationships between discrimination and mental health while controlling for age, education, ethnicity, income, or couple status. Games-Howell Post-Hoc multiple comparisons tests were used to identify significant between-group differences.

Conventional content analysis (Hsieh & Shannon, 2005) was used to analyze the qualitative data from participants who responded “other” on the question, “What do you think is the main reason for these experiences?” (n = 189). Qualitative analysis was carried out by KD, MF, and PF, under the guidance of KR. The coders first familiarized themselves with the data by reading all responses twice before coding. Initial codes were generated by word-by-word review and highlighting key words, then labelling codes with central concepts. Coding was completed independently, then reviewed by the coders to co-create a shared understanding of key concepts and emerging themes. Themes were generated by sorting codes into groups of meaningful clusters, then labelled and defined according to their shared meaning. The themes were organized into patterns of meaning using an open, iterative process without preconceived categories, and are presented as a summary of the diversity of responses present in the data. The co-authors conducted this coding process using Microsoft Excel.

Results

Descriptive statistics

Pregnant participants were on average 29.82 years of age ± 6.4 (range 19–49 years). Participants lived across Canada, with nearly one third of the sample living in Ontario and one third living in Alberta. Of the participants who indicated their gender identity, 99.8% identified as cisgender women.

Differences in baseline characteristics and sociodemographic variables between participants across discrimination groups

The Chi-square tests showed that self-reported race (χ2 = 37.6; df = 20; p = 0.01), annual household income (χ2 = 44.4; df = 16; p < 0.001), couple status (χ2 = 21.88; df = 8; p = 0.005) and having a history of anxiety (χ2 = 48.6; df = 2; p < 0.001), depression (χ2 = 40.6; df = 2; p < 0.001), and obesity (χ2 = 27.08; df = 2; p < 0.036) pre-pregnancy differed significantly between pregnant individuals across discrimination groups (Table 1). Individuals in the high discrimination group were more likely to identify as First Nations or Southeast Asian, have an annual household income less than $39,999, be single, have a pre-pregnancy history of anxiety and depression, and/or identify as bisexual compared to pregnant individuals in the low to moderate or no discrimination groups. Individuals with no experiences of discrimination were also more likely to not have a history of self-reported pre-pregnancy obesity compared to pregnant individuals with more frequent experiences of discrimination. There was a significantly smaller proportion of white individuals in the high discrimination group and those with no experienced discrimination were more likely to report no health problems pre-pregnancy.

Table 1.

Descriptive statistics by discrimination group. Mean, standard deviation, n’s, percentages, and Chi-square statistics are provided for key demographic characteristics of the sample

Total
(n = 1943)		 No discrimination (EDS Score = 0)
(n = 539)		 Low to moderate discrimination (EDS Score 1–5) (n = 781) Moderate to high discrimination (EDS Score ≥ 6) (n = 623)
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Pa
Gestational age (Mean) 29.8 (6.4) 30.3 (6.2) 29.4 (6.3) 29.9 (6.6) 0.185
n (%) n (%) n (%) n (%)
Age 0.525
  < 25 29 (1.5) 6 (1.1) 17 (2.2) 6 (0.9)
  25–29 444 (22.9) 113 (20.9) 173 (22.2) 158 (25.4)
  30–34 912 (47) 258 (47.9) 371 (47.5) 283 (45.4)
  35–39 471 (24.3) 138 (25.6) 184 (23.6) 149 (23.9)
  ≥ 40 81 (4.2) 23 (4.3) 34 (4.4) 24 (3.9)
Race 0.010
  White 1665 (85.9) 468 (86.8) 684 (87.6) 511 (82.0)
  Biracial 62 (3.2) 19 (3.5) 21 (2.7) 22 (3.5)
  East Asian (eg, Chinese, Korean) 56 (2.1) 8 (1.5) 17 (2.2) 15 (2.4)
  South Asian (eg, East Indian, Pakistani) 45 (2.3) 10 (1.9) 19 (2.4) 16 (2.6)
  Hispanic/Latinx 31 (1.6) 14 (2.6) 11 (1.4) 6 (0.9)
  Métis 34 (1.7) 9 (1.7) 11 (1.4) 14 (2.2)
  Southeast Asian (incl. Filipino) 25 (1.3) 5 (0.9) 7 (0.9) 13 (2.1)
  Black 10 (0.5) 2 (0.4) 2 (0.3) 6 (0.9)
  First Nations 11 (0.01) 0 (0) 1 (0.1) 10 (1.6)
  Other 7 (0.4) 3 (0.6) 9 (1.2) 17 (2.7)
Education 0.192
  Doctoral degree 217 (11.2) 56 (10.4) 88 (11.3) 73 (11.7)
  Masters degree 471 (24.3) 142 (26.3) 201 (25.7) 128 (20.5)
  Undergraduate degree 812 (41.9) 227 (42.1) 331 (42.4) 254 (40.8)
  College/Trade school 333 (17.2) 89 (16.5) 122 (15.6) 122 (19.6)
  High school diploma 97 (5) 22 (4.1) 35 (4.5) 40 (6.4)
  ≤ High school diploma 7 (0.4) 2 (0.4) 2 (0.3) 3 (0.5)
Annual household income (2019)  < 0.001
  ≥ $200,000 233 (12) 76 (14.1) 86 (11) 71 (11.4)
  $150,000 to $199,999 418 (21.6) 129 (23.9) 165 (21.1) 124 (19.9)
  $100,000 to $149,999 694 (35.8) 201 (37.3) 298 (38.2) 195 (31.3)
  $70,000 to $99,999 346 (17.9) 84 (15.6) 142 (18.2) 120 (19.3)
  $40,000 to $69,999 178 (9.2) 37 (6.9) 70 (8.9) 71 (11.4)
  < $39,999 68 (3.5) 11 (2) 18 (2.3) 39 (6.3)
Birth country 0.476
  Canada 1707 (88.1) 478 (88.7) 678 (86.8) 551 (88.4)
  Other 230 (11.9) 60 (11.1) 101 (12.9) 69 (11.1)
Couple status 0.005
  Married 1508 (77.9) 423 (78.5) 621 (79.5) 464 (74.5)
  Common law 368 (19) 108 (20) 137 (17.5) 123 (19.7)
  Single 51 (2.6) 4 (0.7) 18 (2.3) 29 (4.7)
  Separated/Divorced 10 (0.5) 3 (0.6) 3 (0.4) 4 (0.6)
History of health conditions pre-pregnancy
  Anxiety 764 (39.3) 182 (33.8) 267 (34.2) 315 (50.6)  < 0.001
  Depression 386 (19.9) 83 (15.4) 127 (16.3) 176 (28.6)  < 0.001
  Asthma 136 (7) 71 (13.2) 79 (10.1) 75 (12) 0.212
  Hypothyroidism 214 (11) 36 (6.7) 59 (7.6) 41 (6.6) 0.733
  Irritable bowel syndrome 146 (7.5) 38 (7) 56 (7.2) 52 (8.3) 0.631
  Polycystic ovarian syndrome (PCOS) 130 (6.7) 30 (5.6) 49 (6.3) 51 (8.2) 0.17
  Infertility 224 (11.5) 68 (12.6) 78 (10) 78 (12.5) 0.218
  Obesity 184 (9.5) 37 (6.9) 77 (9.9) 70 (11.2) 0.036
  None 600 (30.9) 189 (35) 268 (34.3) 143 (22.9)  < 0.001
Province of residence 0.243
  Ontario 633 (32.6) 165 (30.6) 269 (34.3) 199 (31.9)
  Alberta 608 (31.3) 165 (30.6) 238 (30.5) 205 (32.9)
  British Columbia 316 (16.3) 84 (15.6) 134 (17.2) 98 (15.7)
  Quebec 95 (4.9) 38 (7) 35 (4.5) 22 (3.5)
  Manitoba 115 (5.9) 36 (6.7) 44 (5.6) 35 (5.6)
  Saskatchewan 67 (3.4) 22 (4) 18 (2.3) 27 (4.3)
  Nova Scotia 40 (2.1) 12 (2.2) 14 (1.8) 14 (2.2)
  New Brunswick 24 (1.2) 5 (0.9) 10 (1.3) 9 (1.4)
  Newfoundland 20 (1) 5 (0.9) 11 (1.4) 4 (0.6)
  Prince Edward Island 13 (0.7) 5 (0.9) 5 (0.6) 3 (0.5)
  Yukon 10 (0.5) 2 (0.4) 3 (0.4) 5 (0.8)
  Northwest Territories 2 (0.1) 0 (0) 0 (0) 2 (0.3)
Gender identity* 0.162
  Female 1707 (87.9) 484 (89.8) 688 (88.1) 535 (85.9)

  Genderqueer/Gender

  non-conforming

 2 (0.1) 0 (0) 0 (0) 2 (0.3)
  Prefer not to answer 1 (0.1) 0 (0) 0 (0) 1 (0.1)
  Missing 233 (12) 55 (10.2) 93 (11.9) 85 (13.7)
Sexual orientation*  < 0.001
  Straight/Heterosexual 1561 (80.3) 459 (85.2) 639 (81.8) 463 (74.3)
  Bisexual 117 (6.0) 22 (4.1) 41 (5.2) 51 (8.2)
  Lesbian 6 (0.3) 2 (0.3) 3 (0.4) 1 (0.2)
  Asexual 2 (0.1) 0 (0) 1 (0.1) 1 (0.2)
  None of the above 15 (0.8) 0 (0) 2 (0.3) 13 (2.1)
  Prefer not to answer 9 (0.5) 1 (0.1) 2 (0.3) 6 (0.9)
  Missing 233 (12) 55 (10.3) 93 (11.9) 88 (14.1)
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aDifferences between multi-group comparisons using ANOVA and Chi-square distribution. Bolded numbers reflect significant adjusted residuals

*The administered measure included gender identities and sexual orientations not represented in our sample. A full description of this measure has been published in Freeman et al., 2024

Discrimination

A total of 27.7% of participants reported no experiences of discrimination (EDS score = 0; n = 539) and 72.3% (n = 1404) of pregnant participants reported at least one instance of discrimination (total EDS score ≥ 1) to at least one of the five items on the Everyday Discrimination Scale, with 40.2% of participants reporting low to moderate discrimination (EDS Score = 1–5; n = 781), and 32.1% reporting moderate to high discrimination (EDS score ≥ 6; n = 623). The most common perceived reason for discrimination was gender, followed by age, other, education or income level, and some other aspect of physical appearance and race (Table 2).

Table 2.

Reasons for interpersonal discrimination experiences

Reasons for interpersonal discrimination n = 1154
n (%)
Checkbox responses
  Your gender 822 (71.2)
  Your age 432 (37.4)
  Your education or income level 152 (13.2)
  Some other aspect of your physical appearance 148 (12.8)
  Your weight 139 (12.0)
  Your race 125 (10.8)
  Your ancestry or national origins 85 (7.3)
  Your height 81 (7.0)
  Your shade of skin colour 64 (5.5)
  Your religion 38 (3.3)
  Your sexual orientation 17 (1.5)
  A physical disability 10 (0.8)
  Other 201 (17.4)
Open-text responses n = 189 Sample quote
Personal attributes and sociodemographic characteristics n = 41
  Personality 11 “personality clashes” (P188); “my disposition” (P144)
  Health status 11 “invisible disability” (P139); “my anxiety” (P76)
  Language/accent 8 “anglophone” (P185); “not speaking French in Quebec” (P41); “accent” (P89); “The language I speak. I am a native Spanish speaker and I also speak English and English, but I am treated differently when they hear that English is not my mother tongue, or that I prefer to speak English in Quebec.” (P124)
  Neighbourhood/place of residence 5 “Anglophone living in Quebec” (P129); “left wing in rural SK” (P163)
  Lifestyle/beliefs 3 “ideology” (P25); “political ideology” (P163)
  Marital status 2 “marital status” (P108)
  Interracial relationship 1 “Because my husband is also a visible minority (different race than I)…” (P63)
Occupation n = 111
  Career choice 82 “my career choice” (P189); “my job as a nurse in a hospital” (P96); “my profession” (P148); “job as a lawyer” (P74); “being a stay at home mom” (P29)
  Work environment 25 “negative work environment” (P150); “Working in customer service at restaurant. People can be rude” (P42); “Working in retail, general lack of respect” (P28); Power dynamic at work” (P100); “professional position of authority" (P83)
  Intersections of gender and workplace discrimination 4 “my employment – I’m in government and people think less of me as a female or due to their frustrations, they take out their anger on me in my position” (P106); “I work in a male dominated field mostly” (P109)
The COVID-19 pandemic n = 25
  Conflicting COVID-related beliefs and practices 14 “Not wearing a mask for medical reasons” (P10); “COVID – people being upset about distancing, for example standing too close to someone in line” (P149)
  Societal changes and weakening of social bonds during COVID-19 11 “Since covid people are generally less pleasant.” (P70); “…due to pandemic people can’t serve people the way they used to. There’s also a great element where people are scared to be too close to other people, minimizing socializing & basic human kindness” (P123)
Pregnancy and/or parenting n = 15
  Parenting decisions 6 “my choice to send my kids back to school” (P80); “role as a stepparent”(P132); “"because I have kids" (P116)
  Being pregnant 9 “pregnancy/hormonal” (P162); “being pregnant” (P72); “ppl have become self centred and want to get ‘ahead’ of the pregnant lady” (P18)
Causes outside the self n = 24
  Specific relationship 12 “issues with a family member” (P65); “ex partner was emotionally abusing me” (P101)
  “Sometimes people are just mean” 8 “that’s the way some people are” (P14); “People are wigged out and in their own understanding- kindness is failing our communities" (P173); “they might be having a bad day and lashing out” (P27)
Rude in specific context 4 “Ppl have become self centred and want to get ‘ahead’ of the pregnant lady” (P18); “People are not properly trained for service anymore” (P22)
Unclear/Unknown n = 14
  No discrimination 2 “I don’t feel this is a problem for me” (P95)
  Unclear 6 “I’m a mother’s child” (P9)
  Unknown 6 “unsure” (P12)
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Conventional content analysis of open text responses

Of those who selected “other” reasons for discrimination (n = 201), 189 participants wrote open-text responses. The main themes identified were discrimination due to personal attributes and sociodemographic characteristics (n = 41; subthemes: personality, health status, language/accent, neighbourhood/place of residence, lifestyle/beliefs, marital status, and ethnicity), occupation (n = 111; subthemes: career choice, work environment, intersections of gender and workplace discrimination), the COVID-19 pandemic (n = 25; subthemes: conflicting COVID-related beliefs and practices, societal changes and weakening of social bonds during COVID-19), pregnancy and parenting (n = 15; subthemes: parenting decisions, being pregnant), and causes outside the self (n = 24; subthemes: specific relationship, “sometimes people are just mean”, rude in specific contexts) (Table 2). Themes and subthemes are presented in Fig. 1.

Fig. 1.

Fig. 1

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Map of themes and sub-themes identified using conventional content analyses of reasons for interpersonal discrimination

Personal attributes and sociodemographic characteristics

This theme included responses that attributed experiences of discrimination to a personal attribute or a sociodemographic characteristic that was not listed in the EDS (n = 41). The subthemes of personality (e.g. “more introverted”, P62; n = 11), health status (e.g. “learning disability”, P5; n = 11), language/accent (e.g. “language barrier”, P172; n = 8), neighbourhood/place of residence (e.g. “where I live”, P122; n = 5), lifestyle/beliefs (e.g. “sustainability habits”, P126; n = 3), marital status (n = 2), and interracial relationship (n = 1) were identified.

Occupation

The most common theme (n = 111), occupation refers to instances when participants attributed experiences of discrimination to identities and/or experiences at work. Many participants (n = 82) mentioned their career choice was the cause of discrimination (e.g., working in hospitality, frontline health professionals, stay-home parent). Other participants identified specific dynamics of their work environment (n = 25), such as relationships with a co-worker or their clients (e.g., “…some patients and families don’t treat nurses well”, P51), or the power dynamics within the workplace (e.g. “Being in a hierarchical job and being on the bottom”, P160). Finally, some participants (n = 4) commented on the intersections of gender and workplace discrimination (e.g. “gender + employment in military”, P58).

The COVID-19 pandemic

This theme includes attributions of discrimination to the unique context of the COVID-19 pandemic. Two subthemes emerged: (1) Conflicting COVID-related beliefs and practices identifies participants (n = 14) who described conflict arising from beliefs and practices related to the COVID-19 pandemic, such as social distancing or mask-wearing (e.g. “Differing opinions on COVID restrictions” (P119)); (2) Societal changes and weakening of social bonds during COVID-19 identifies participants (n = 11) who referred to the broader impact of COVID-19 on how people navigate social and public spaces or made non-specific remarks about COVID-19. For example, one participant stated, “Everyone is scared of each other potentially having COVID” (P120).

Pregnancy and parenting

This theme includes responses that attributed their experiences of discrimination to being pregnant and/or parenting. Participants spoke about experiences of discrimination in relation to how others perceived their parenting decisions (n = 6), including the choice to be a parent at all (“Having many children, being a stay at home mom”, P29). Several participants (n = 9) attributed their experiences of discrimination to “being pregnant”. For example, one participant reported “having a child with me. Being pregnant. Being myself” (P16). It is of note that many of these responses also mentioned the added scrutiny of their choices that they experienced in the context of the pandemic (e.g. “being pregnant during the pandemic, people view it as a poor choice”, P94). Finally, a few participants mentioned “pregnancy brain” (P103, P104).

Causes outside the self

This theme includes responses that attributed their experiences of discrimination to the characteristics of the perpetrator of discriminatory behaviour, either generally (“people”) or specifically. Many participants mentioned a specific relationship in which the discrimination is experienced, such as discrimination from a family member (n = 12). Other participants attributed their mistreatment from others based solely on something to do with the other person, such as disposition or misdirected stress (e.g., “sometimes people are just mean” (P170) (n = 8). Four participants specified that people are rude in certain contexts, such as when waiting in line, dining out, or working in the service industry.

Unclear or unknown

Some participants indicated they did not believe they experienced discrimination (n = 2) or were unsure of how to attribute their experiences (n = 6). Other participant responses (n = 6) were indiscernible to researchers and were not interpreted so as to avoid misrepresenting participant experiences (e.g., “past”, P152).

Mental health

Mean mental health scores and severity of mental health symptoms by discrimination group are shown in Table 3. The proportion of participants with clinically elevated anxiety and depression symptoms increased across groups. Compared to participants with no experiences of discrimination, high discrimination participants had more than three times the proportion of participants with clinically elevated depression (EPDS scores ≥ 13), and double the proportion of participants with clinically elevated anxiety symptoms (T-scores > 60) (Table 3).

Table 3.

Comparison of mental health symptoms by discrimination group

No discrimination (EDS Score = 0)
(n = 539)		 Low to moderate discrimination (EDS Score 1–5)
(n = 781)		 Moderate to high discrimination (EDS Score ≥ 6) (n = 623) ANOVAa ANCOVAb
Mental health measures Mean (SD) Mean (SD) Mean (SD) F-value Eta-squared F-value Partial Eta-squared
EPDS 6.23 (4.7) 8.06 (5.1) 10.85 (5.1) 124.02 0.12 116.33 0.11

PROMIS

Anxiety t-scores

 52.09 (8.8) 55.20 (8) 59.47 (7.4) 120.75 0.11 112.4 0.11
n (%) n (%) n (%)
EPDS
  Low to Moderate (0–12) 465 (86.3) 610 (78.1) 373 (59.9)
  Clinically Elevated (13 +) 62 (11.5) 141 (18.1) 219 (35.2)
  Missing 12 (2.2) 30 (3.8) 31 (5)
PROMIS Anxiety T-Scores
  Within normal range (36–54.9) 332 (61.6) 357 (45.7) 136 (21.8)
  Clinically mild (55–59.9) 92 (17.1) 162 (20.8) 150 (24.1)
  Clinically moderate (60–69.9) 90 (16.7) 207 (26.5) 261 (41.9)
  Clinically severe (> 70) 13 (2.4) 25 (3.2) 45 (7.2)
  Missing 12 (2.2) 30 (3.8) 31 (5)
  Low or mild 424 (78.7) 519 (66.5) 286 (45.9)
  Clinically elevated 103 (19.1) 232 (29.7) 306 (49.1)
  Missing 12 (2.2) 30 (3.8) 31 (5)
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Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; EDS, Everyday Discrimination Scale; SD, standard deviation

a all p < 0.000

b model adjusted for maternal age, level of education, ethnicity, income, and couple status; all p < 0.000

As expected, measures of anxiety and depression symptoms were strongly associated with each other (r(1868) = 0.807, p < 0.001), and moderately associated with frequency of everyday discrimination (r(1869) = 0.366, p < 0.001 and r(1868) = 0.383, p < 0.001, respectively).

ANOVAs showed that respondents who reported the highest frequency of discrimination showed heightened levels of depression and anxiety (EPDS, F = 124.02, p < 0.001; PROMIS Anxiety, F = 120.75, p < 0.001). These associations remained unchanged in ANCOVAs after controlling for maternal age, level of education, ethnicity, income, and couple status (EPDS, F = 116.33, p < 0.001; PROMIS Anxiety, F = 112.4, p < 0.001) (Table 3). Discrimination explained a moderate amount of variance (11%) in depression and anxiety (partial R2 = 0.11 for both).

Discussion

Discrimination is a common experience for pregnant Canadians. This research provides evidence of associations between discrimination during pregnancy and clinically elevated levels of prenatal depression and anxiety symptoms, and demographic factors. Pregnant Canadians experiencing higher frequencies or more types of discrimination were more likely to have lower household incomes, have a history of pre-pregnancy mental health issues, identify as First Nations or Southeast Asian, be single, and/or identify as bisexual. Higher scores on the EDS was associated with greater risk of experiencing clinically elevated levels of depression and general anxiety. These health disparities reflect systemic, avoidable, and unjust social disadvantage (Braveman et al., 2011), and align with previous literature on groups that experience social and structural marginalization (Campbell et al., 2007; Goldberg et al., 2020; Owais et al., 2020; Robinson et al., 2016; Ross et al., 2018). Accordingly, Canadian reports of key health inequities identify sexual orientation, ethnicity, Indigeneity, and income as social stratifiers linked to health disparities (Pan-Canadian Public Health Network, 2018), and there are increasing calls for action addressing systemic discrimination and social exclusion in healthcare and perinatal supports (e.g., Browne et al., 2022; Kirubarajan et al., 2022).

Rates of discrimination (72%) reported by pregnant Canadians were substantially higher compared to the prevalence of discrimination in the broader Canadian population, where 35–38% of the Canadian population reported at least one form of discrimination or unfair treatment (Government of Canada, Statistics Canada, 2024; Statistics Canada, 2022). Within the general Canadian population, it was reported that individuals identifying as women reported higher frequencies of discrimination compared to men (Statistics Canada, 2020), which could explain why discrimination experiences are more frequent within the pregnant population, where the majority identify as women. Understanding the nature and type of discrimination experienced by perinatal populations is important to identify the intersecting facets of identity and social contexts that are associated with more frequent prenatal discrimination in Canada. The higher rate of discrimination in this sample compared to the general population of Canadian women suggests that pregnancy may intersect with gender and other identities in exacerbating experiences of discrimination.

It is necessary to acknowledge the significant impact of racism on perinatal mental health outcomes, given that race and ancestral origins accounted for 17% of the perceived reasons for discrimination in our sample. Studies have consistently shown that experiences of racism and racial discrimination contribute to adverse mental health outcomes among pregnant individuals from racialized communities (Bower et. al., 2023; Giurgescu et al., 2017). Understanding and addressing the intersectionality of discrimination, including racism, within the perinatal population is essential for improving maternal mental health outcomes.

Qualitative analysis of the open-text responses was used to supplement the reasons for attributions provided in the EDS, allowing us to identify potentially overlooked reasons for interpersonal discrimination. In the open-text responses, workplace discrimination was among the top cited discrimination experiences. This comes as no surprise, as pregnant individuals in professional settings are more likely to be stereotyped and labelled as emotional, irrational, less dedicated to their work, and less competent compared to their colleagues (Morgan et al., 2013). These stereotypes can contribute to instances of pregnancy discrimination (Fox & Quinn, 2015). Gender also emerged as a factor in the open-text responses, as participants commented on the intersections of gender and workplace discrimination. Additionally, open-text responses to the “other” categories of attribution presented a number of discriminatory experiences not represented in the EDS. Participants identified a number of characteristics that were not presented as possible targets of discrimination (e.g., language/accent, marital status), as well as experiences directly attributed to their parenting decisions or pregnancy. Due to the limited research on perinatal experiences of interpersonal discrimination, this demonstrates the importance of gathering qualitative data to capture experiences of discrimination unique to this population that may not yet be represented in the existing literature.

The COVID-19 pandemic exacerbated pre-existing patterns of inequality and discrimination due to heightened social tensions and stress, with increasing reports of race, age, and gender-related hostility (Miconi et al., 2021). Given the literature of increased discrimination during the pandemic, it is not surprising to see the COVID-19 pandemic emerge as a theme in the conventional content analysis. Specifically in the perinatal population, participants reported that the context of the pandemic compounded existing discrimination due to pregnancy/parenting status, magnifying the scrutiny of their parenting choices. Moreover, the enduring consequences of these discriminatory experiences extend beyond the pandemic itself, with research indicating long-term impacts of discrimination on mental health and well-being (Kessler et al., 1999). These findings are intended to shed light on existing disparities within a Canadian population which have been amplified in the context of the pandemic, and the affiliated psychological consequences that have potential to last beyond the pandemic.

Finally, a few participants attributed their experiences to misdirected stress, the disposition or mood of the other person, or a particular context rather than to a facet of their identity. This framing of attribution may be psychologically protective, or reflect interpretations wherein participants did not perceive a link between negative treatment and their social identities (Kaiser & Major, 2006). Future research should consider the factors influencing the perception of and attribution to discrimination, as well as use measures that are sensitive to the dynamic nature of everyday experiences of interpersonal discrimination (Potter et al., 2019).

Limitations

The EDS was included at a follow-up timepoint of a longitudinal study and although the attrition rate was within normal range for similar longitudinal studies (Fischer et al., 2001; Goodman & Blum, 1996; Miller & Wright, 1995), it may limit generalizability to the originally sampled population. Our findings suggest that demographics play a significant role in both the experience of discrimination and the prevalence of pregnancy-related mental health issues. However, we cannot definitively conclude causality based on this data alone. Additionally, in terms of variance, it is essential to recognize that our model may not account for all potential factors influencing mental health, and there may be unmeasured variables contributing to the variance observed. The sample was more likely to be married or cohabitating than the Canadian averages for the pregnant population (Chalmers et al., 2008). While this suggests that our data may not be entirely representative of Canadian pregnant individuals, samples where more individuals are partnered tend to have fewer prenatal anxiety and depression symptoms (Bedaso et al., 2022). Thus, the elevated anxiety and depression symptoms seen in this sample would be highly unexpected under normal, pre-pandemic circumstances. Additionally, the sample is predominantly cisgender, white, highly educated, higher income, and heterosexual and/or partnered with men. Considering the low sociodemographic risks observed in our sample, there may be experiences of discrimination that were not captured in this paper and the results may be amplified in populations with higher sociodemographic risks (e.g., gender-diverse, low education, low income, transgender, Black, Indigenous, and People of Colour (BIPOC) populations). Future research should explore the experiences of discrimination among more diverse groups, with particular attention to groups who are underrepresented in perinatal literature (e.g., transgender and gender-diverse pregnant people; Kirubarajan et al., 2022).

Implications

Studies show that discrimination has long-lasting intergenerational consequences, and can predict greater inhibition/separation problems and greater negative emotionality in infants at 6-months and 1-year postpartum (Rosenthal et al., 2018). With regards to the link between discrimination and perinatal mental health, when expectant individuals experience high levels of stress during crucial stages of fetal development, it is connected to various risk factors for psychopathology as their children develop (Weinstock, 2008). Ongoing maternal stress during the postnatal period has also been discovered to influence both short-term and long-term child development (Weinstock, 2008). To promote health equity and to mitigate the intergenerational consequences of discrimination, it is crucial to address discrimination both before and during pregnancy. In addition, perinatal mood and anxiety disorders (PMADs) have large economic costs associated with expenses such as prolonged hospitalization, psychological treatment, and follow-up appointments for the birthing parent, the child, and the family as a whole (Bauer et al., 2016), Understanding risk factors such as discrimination can help offset this economic burden.

This study adds to existing literature on discrimination in Canada and highlights the unique intersections in the experiences of pregnant individuals, and is, to the best of our knowledge, the first to assess discrimination in a Canadian sample of pregnant individuals. These results contribute to the current scientific understanding of how social factors, such as discrimination, may affect perinatal mental health during the prenatal period. This study also helps to better identify which pregnant populations are most at risk of experiencing greater instances of discrimination and subsequent mental health challenges, which may inform intervention targets and perinatal mental health program development. These findings also have implications for communities and work environments in general, and highlight the importance of increased societal awareness of prevalences and types of pregnancy discrimination, and the potential health risks associated with discrimination. These findings can also inform efforts aimed at decreasing pandemic-related discrimination, such as health communication and community programming, to protect and support pregnant individuals at risk of discrimination in the context of public health emergencies. Emphasizing the associated impact of discrimination on mental health contributes to the creation of healthier and supportive environments for expecting individuals and those planning to conceive.

Conclusion

Discrimination during pregnancy is common, and intersecting identities and the context of pregnancy may also lead to experiences of discrimination which are unique to pregnant populations. Given the known effects of adverse mental health outcomes on pregnancy, infant, and child outcomes, identifying social risk factors and increasing awareness to support pregnant individuals during this critical time is imperative to inform improved interventions that better address the needs of pregnant individuals and their infants.

Contributions to knowledge

What does this study add to existing knowledge?

  • The study sheds light on the prevalence of discrimination experienced by pregnant Canadians, highlighting that it is a common occurrence.

  • This research provides evidence linking experiences of discrimination during pregnancy with clinically elevated levels of prenatal depression and anxiety symptoms.

  • Discrimination during pregnancy is not solely based on a single factor but is influenced by intersecting facets of identity and social contexts. By using open-text responses to supplement quantitative data, the study captures nuanced discriminatory experiences and factors that may not be adequately represented in existing literature. This approach enriches the qualitative understanding of discrimination in perinatal populations.

What are the key implications for public health interventions, practice, or policy?

  • The findings of this study will help inform healthcare providers, employers, and the general public about the prevalence and mental health impact of interpersonal discrimination during pregnancy in Canada.

  • The findings will help shape policies and interventions to target pregnant individuals at increased risk for experiencing discrimination, to mitigate adverse mental health consequences.

Author contributions

GFG, CL, and LTM conceptualized the study, obtained funding, and supervised data collection. KD and MF wrote the first draft of the manuscript. KD, MF, PF, KR, CR, and BL assisted with study design and data collection. All authors revised and approved the final manuscript.

Funding

This project is supported by funds from the Owerko Centre at the Alberta Children’s Hospital Research Institute.

Availability of data and material

Data are available upon reasonable request made to the corresponding author and are subject to data sharing agreements.

Code availability

Not applicable.

Declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Conjoint Health Research Ethics Board (CHREB) at the University of Calgary, REB20–0500, and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Not applicable.

Conflict of interest

None to declare.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data are available upon reasonable request made to the corresponding author and are subject to data sharing agreements.

Not applicable.

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