Abstract
Objective.
Adverse childhood experiences (ACEs) are common risk factors for unhealthy behaviors and poor health outcomes throughout the life course, but their relationship with prenatal substance use is understudied. This retrospective cohort study included 44,284 patients with pregnancies between January 1, 2022, and June 28, 2024, in a large healthcare system in Northern California, United States of America with universal screening for ACEs, resilience, and substance use during early pregnancy.
Methods.
Multivariable regression models examined the relationship between ACEs and prenatal substance use and tested whether resilience moderated these associations.
Results.
Pregnant individuals with a greater number of ACEs had lower resilience, were younger, more likely to be Black, Non-Hispanic White, or Hispanic, and live in an area with greater neighborhood deprivation. In adjusted models, compared to those without ACEs, those with ACEs had a higher adjusted prevalence of prenatal alcohol use, cannabis use, nicotine use, pharmaceutical opioid use, stimulant use, and multiple substance use. Low resilience was independently associated with an increased prevalence of prenatal substance use.
Conclusions.
Results indicate that routine screening for ACEs may help identify pregnant individuals at risk for prenatal substance use, allowing for earlier linkage to resources and potentially improved maternal and child outcomes.
Keywords: Adverse childhood experiences, resilience, substance use, pregnancy
1. Introduction
Adverse childhood experiences (ACEs), including exposure to physical abuse, neglect, or household dysfunction, are prevalent and are associated with unhealthy behaviors and poor health outcomes across the lifespan (Hughes et al., 2017). ACEs are also associated with adverse perinatal outcomes, including prenatal depression and anxiety, gestational diabetes, preterm birth, and low birth weight offspring (Mamun et al., 2023; Wajid et al., 2020; Watson et al., 2024b).
Emerging evidence indicates that ACEs may be associated with an increased likelihood of prenatal substance use (Duka et al., 2023; Frankenberger et al., 2015; Pear et al., 2017; Racine et al., 2021; Testa et al., 2022; Thomas et al., 2023), a key modifiable risk factor for adverse maternal and fetal outcomes. However, studies have been limited by small samples, a focus on one versus multiple substances, high-risk samples, or reliance on self-reported substance use which often underestimates true use. Further, different types of ACEs (e.g., sexual versus physical abuse) may be differentially associated with mental health outcomes (Atzl et al., 2019), and studies are needed that examine both ACE count and ACE types in relation to prenatal substance use.
Resilience, defined as one’s ability to bounce back from adversity, has been shown to buffer the negative impacts of ACEs on perinatal mental health (Borg and Alhusen, 2023; Osofsky et al., 2021; Young-Wolff et al., 2019), but studies on ACEs and prenatal substance use have generally overlooked protective factors such as resilience (Merrick et al., 2020).
Using data from a large, diverse sample of pregnant individuals in Kaiser Permanente Northern California (KPNC), we examined whether ACEs and low resilience were associated with prenatal substance use, tested whether resilience moderated these associations, and examined whether specific ACE types were associated with prenatal substance use.
2. Methods
2.1. Setting
KPNC is a nonprofit, integrated healthcare system providing health services to ~4.6 million sociodemographically diverse members similar to the insured Northern California population. KPNC has universal screening for ACEs, resilience, and prenatal substance use as part of standard prenatal care. This study was approved by the KPNC Institutional Review Boardwith a waiver of consent and Health Insurance Portability and Accountability Act authorization.
2.2. Participants
All KPNC pregnant members aged ≥18 with a pregnancy onset date from 1/1/2022–6/28/2024, who attended ≥one prenatal care visit and had a livebirth or stillbirth were eligible. Those missing ACEs, resilience, or substance use screening were excluded. The first pregnancy per woman during the study period was included (eFigure1).
2.3. Measures
All measures were extracted from electronic health records (EHR). Patients completed the ACEs screening during routine prenatal care either upon examination or via an online patient portal at ~16 weeks gestation using the California ACEs Aware 10-item questionnaire (Aces Aware, 2020). Response options were yes or no, with scores ranging from zero-10. For patients who received ≥one screening (n=2,509, 5.6%), the screening closest to 16 weeks gestation was kept. ACE scores were categorized for primary analyses (zero, one, two to three, ≥four) as done previously (Watson et al., 2024a), and secondary analyses examined ACE type (family dysfunction, loss of a parent, emotional abuse, physical abuse, sexual abuse, neglect).
Resilience was assessed at the same time as ACEs using the eight-question Road to Resilience tool (Ridout et al., 2023), a validated questionnaire that assesses four domains of resilience: social connection (having supports, capacity to be connected), agency (internal strength, hope, problem solving), initiative (asking for help, able to try new things), and self-control (ability to self-soothe and handle stress). Each question has a value range from zero to two, with maximum score=16; scores were categorized based on the median (≥15=normal/high resilience, <15=low resilience), as done previously (Watson et al., 2024a).
The primary outcomes were any use (yes/no) of alcohol, cannabis, nicotine, pharmaceutical opioids, stimulants or ≥one substance during early pregnancy based on universal screening at entrance to prenatal care via a self-administered questionnaire and a urine toxicology test (median [interquartile range]: 5 [4–7] weeks gestation and 9 [6–12] weeks gestation, respectively) to which patients consent (eMethods1).
Prenatal alcohol use was defined as any self-reported alcohol use since pregnancy. Prenatal cannabis use was defined as any self-reported cannabis use since pregnancy or a positive confirmed toxicology test for tetrahydrocannabinol. Prenatal nicotine use was defined as any self-reported tobacco smoking or use of e-cigarettes/vapes containing nicotine since pregnancy. Prenatal pharmaceutical opioid use was defined as any self-reported pharmaceutical opioid pain medication use since pregnancy or a positive confirmed toxicology test for pharmaceutical opioids. Prenatal stimulant use was defined as any self-reported use of cocaine, crack, or methamphetamine since pregnancy or a positive confirmed toxicology test for amphetamine, methamphetamine, cocaine, or 3,4-methylenedioxymethamphetamine. Participants were classified as using multiple if they screened positive for >one of the categories above.
Data on maternal age at pregnancy onset (18–26 years, 26–34, ≥35), self-reported race and ethnicity (Asian, Black, Hispanic, Non-Hispanic White, and Other/multi-racial/unknown; included as a social construct due to known differences in the number of ACEs by race and ethnicity), parity (zero, one, ≥two), maternal insurance (Medicaid, other), and Neighborhood Deprivation Index (NDI, quartiles) were extracted from the EHR.
2.4. Statistical analysis
We fit modified Poisson models with robust standard errors using the sandwich variance estimator to improve the accuracy of standard errors between categorized ACE score and each of the six substance use measures. The associations between categorized ACEs score and prenatal substance use were reported as adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) after adjusting for maternal age, race and ethnicity, parity, Medicaid status, NDI, and resilience. Covariates were included to help account for structural and sociodemographic factors that could influence both risk of experiencing ACEs and of prenatal substance use and to minimize residual confounding.
The associations between resilience and prenatal substance use were also tested using the same model; aPRs with 95% CIs were reported after adjusting for maternal age, race and ethnicity, parity, Medicaid status, NDI, and categorized ACE score. The covariates included adjust for structural and sociodemographic factors that influence both the risk of experiencing ACEs and the risk of low resilience. We conducted tests for effect measure modification between ACE score and resilience score using generalized additive models in which ACEs and resilience were modeled flexibly using splines. Next, we tested for trends between ACEs and prenatal substance use by modeling ACEs as a continuous variable and checking for statistical significance. In secondary analyses, we fit modified Poisson models with robust standard errors using the sandwich variance estimator between each ACE type and each prenatal substance use outcome, adjusting for covariates.
Analyses were conducted using SAS 9.4 and R 4.3.1 from July 2024-January 2025. Two-sided P values <0.05 were considered statistically significant.
3. Results
The sample of 44,284 pregnant individuals was 29.7% Asian, 5.4% Black, 27.5% Hispanic, 5.7% Other/multiracial/unknown, and 31.7% Non-Hispanic White; 12.0% were aged 18–25 years, 60.2% were aged 26–34 years, and 27.8% were aged ≥35 years. Overall, 13.8% were insured by Medicaid; and 19.8% were in the most deprived NDI quartile; 44.5% were nulliparous. Approximately two-thirds of the sample reported zero ACEs (66.3%), 13.4% reported one ACE, 11.3% reported two-three ACEs, and 8.9% reported ≥four ACEs. Overall, 9.9% screened positive for prenatal alcohol use, 7.6% for prenatal cannabis use, 2.0% for prenatal nicotine use, 0.4% for prenatal pharmaceutical opioid use, 0.3% for prenatal stimulant use, and 2.9% for prenatal use of multiple substances. Most individuals (71.6%) had high resilience. Pregnant individuals with a greater number of ACEs had lower resilience, were younger, more likely to be Black, Non-Hispanic White, or Hispanic, and live in an area with greater neighborhood deprivation, and less likely to be Asian (Table 1).
Table 1.
Characteristics of a Cohort of Pregnant Women, Overall and by Number of Adverse Childhood Experiences, Kaiser Permanente Northern California, 2022–2024
| N (%) | |||||
|---|---|---|---|---|---|
| Number of Adverse Childhood Experiences | |||||
| Overall | 0 | 1 | 2–3 | ≥ 4 | |
| Characteristic | N = 44,284 | N = 29,382 (66.3%) | N = 5,951 (13.4%) | N = 5,026 (11.3%) | N = 3,925 (8.9%) |
| Age at pregnancy onset | |||||
| 18–26 | 5,316 (12.0) | 3,340 (11.4) | 695 (11.7) | 670 (13.3) | 611 (15.6) |
| 26–34 | 26,676 (60.2) | 17,948 (61.1) | 3,466 (58.2) | 2,957 (58.8) | 2,305 (58.7) |
| ≥35 | 12,292 (27.8) | 8,094 (27.5) | 1,790 (30.1) | 1,399 (27.8) | 1,009 (25.7) |
| Race and ethnicity | |||||
| Hispanic | 12,194 (27.5) | 7,678 (26.1) | 1,725 (29.0) | 1,509 (30.0) | 1,282 (32.7) |
| Non-Hispanic | |||||
| Asian | 13,173 (29.7) | 10,254 (34.9) | 1,408 (23.7) | 953 (19.0) | 558 (14.2) |
| Black | 2,374 (5.4) | 1,335 (4.5) | 391 (6.6) | 339 (6.7) | 309 (7.9) |
| White | 14,034 (31.7) | 8,481 (28.9) | 2,076 (34.9) | 1,953 (38.9) | 1,524 (38.8) |
| Other/multi-racial/unknowna | 2,509 (5.7) | 1,634 (5.6) | 351 (5.9) | 272 (5.4) | 252 (6.4) |
| Parity (n=42,188) | |||||
| 0 | 18,754 (44.5) | 12,252 (43.7) | 2,677 (47.1) | 2,203 (46.3) | 1,622 (44.1) |
| 1 | 15,416 (36.5) | 10,529 (37.5) | 1,968 (34.6) | 1,688 (35.5) | 1,231 (33.5) |
| ≥2 | 8,018 (19.0) | 5,285 (18.8) | 1,043 (18.3) | 863 (18.2) | 827 (22.5) |
| Insured by Medicaid | 6,132 (13.8) | 3,870 (13.2) | 784 (13.2) | 724 (14.4) | 754 (19.2) |
| Neighborhood Deprivation Index (n=44,272) | |||||
| Quartile 1 - Least Deprived | 10,648 (24.1) | 7,587 (25.8) | 1,331 (22.4) | 1,085 (21.6) | 645 (16.4) |
| Quartile 2 | 12,610 (28.5) | 8,273 (28.2) | 1,773 (29.8) | 1,462 (29.1) | 1,102 (28.1) |
| Quartile 3 | 12,265 (27.7) | 7,894 (26.9) | 1,661 (27.9) | 1,472 (29.3) | 1,238 (31.6) |
| Quartile 4 - Most Deprived | 8,749 (19.8) | 5,622 (19.1) | 1,186 (19.9) | 1,004 (20.0) | 937 (23.9) |
| Prenatal substance useb | |||||
| Alcohol | 4,372 (9.9) | 2,512 (8.5) | 720 (12.1) | 655 (13.0) | 485 (12.4) |
| Cannabis | 3,351 (7.6) | 1,653 (5.6) | 513 (8.6) | 549 (10.9) | 636 (16.2) |
| Nicotine (n=44,104) | 885 (2.0) | 408 (1.4) | 129 (2.2) | 154 (3.1) | 194 (5.0) |
| Pharmaceutical opioids | 174 (0.4) | 92 (0.3) | 23 (0.4) | 21 (0.4) | 38 (1.0) |
| Stimulants (n=44,119) | 127 (0.3) | 58 (0.2) | 11 (0.2) | 26 (0.5) | 32 (0.8) |
| Multiple substances (n=43,955) | 1,264 (2.9) | 601 (2.1) | 183 (3.1) | 228 (4.6) | 252 (6.5) |
| Resilience during pregnancy | |||||
| High | 31,692 (71.6) | 22,653 (77.1) | 4,057 (68.2) | 2,991 (59.5) | 1,991 (50.7) |
| Low | 12,592 (28.4) | 6,729 (22.9) | 1,894 (31.8) | 2,035 (40.5) | 1,934 (49.3) |
N,n=number; %=percentage
“Other” race and ethnicity includes American Indian, Alaska Native, Native Hawaiian, or Pacific Islander
180 individuals had unknown nicotine status; 165 had unknown stimulant status; 329 were missing one or more substances such that they had unknown multiple substance status.
In adjusted models, compared to those with zero ACEs, those with ACEs had a higher adjusted prevalence of prenatal alcohol use (one ACE:aPR=1.32, 95%CI:1.22–1.43; two-three ACEs:aPR=1.41, 95%CI:1.30–1.53; ≥four ACEs:aPR= 1.35, 95%CI:1.23–1.49), cannabis use (one ACE:aPR=1.32, 95%CI:1.20–1.45; two-three ACEs:aPR=1.57, 95%CI:1.43–1.72; ≥four ACEs:aPR=2.04, 95%CI:1.87–2.22), nicotine use (one ACE:aPR=1.41, 95%CI:1.16–1.72; two-three ACEs:aPR=1.84, 95%CI:1.53–2.22; ≥four ACEs:aPR=2.63, 95%CI:2.21–3.12), pharmaceutical opioid use (≥four ACEs:aPR=2.37, 95%CI:1.59–3.53), stimulant use (two-three ACEs:aPR=2.08, 95%CI:1.30–3.32; ≥four ACEs:aPR=2.92, 95%CI:1.84–4.62), and use of multiple substances (one ACE:aPR=1.32, 95%CI:1.12–1.56; two-three ACEs:aPR=1.84, 95%CI:1.58–2.14; ≥four ACEs:aPR=2.38, 95%CI: 2.05–2.76). Compared to those with zero ACEs, those with one ACE and two-three ACEs did not have a higher adjusted prevalence of pharmaceutical opioid use (one ACE:aPR=1.12, 95%CI: 0.71–1.77; two-three ACEs:aPR=1.15, 95%CI: 0.72–1.82); those with one ACE also did not have a higher adjusted prevalence of prenatal stimulant use (aPR=0.82, 95%CI: 0.43–1.57)(Figure 1). Trend tests indicated a dose-response relationship between number of ACEs and increased prevalence of each substance use outcome (trend-test p-values <0.0001).
Figure 1:
Association of Adverse Childhood Experiences with Substance Use in a Cohort of Pregnant Women, Kaiser Permanente Northern California, 2022–2024
N=number; %=percentage; aPR=adjusted prevalence ratio; CI=confidence interval; ACEs=adverse childhood experiences
aNumber using the listed substance (percentage of those using substance, among people with listed number of adverse childhood experiences [ACEs]). Overall, the number of individuals with zero ACEs=29,382, one ACE=5,951, two-three ACEs=5,026, and ≥four ACEs=3,925.
bAdjusted prevalence ratio and 95% confidence interval comparing categorized ACE score and prenatal substance use, adjusted for maternal age, race and ethnicity, parity, Medicaid status, Neighborhood Deprivation Index, and categorized resilience.
In adjusted models, compared to those with high resilience, those with low resilience had a higher prevalence of prenatal alcohol use (aPR=1.13, 95%CI:1.07–1.20), cannabis use (aPR=1.17, 95%CI:1.10–1.25), nicotine use (aPR=1.44, 95%CI:1.26–1.65), stimulant use (aPR=1.67, 95%CI:1.19–2.34), and multiple substance use (aPR=1.38, 95%CI:1.23–1.54). Low resilience was not associated with prenatal pharmaceutical opioid use (aPR=1.33, 95%CI:0.97–1.81).
The fit of the models did not improve after adding interaction terms between ACEs and resilience (measured by likelihood ratio test with a cutoff of p<0.05), indicating no statistical evidence for moderation.
The aPRs for prenatal substance use based on specific ACE types are presented in eTable 1. Exposure to each ACE type was positively associated with each category of substance use, except for loss of a parent and pharmaceutical opioids.
4. Discussion
In a large, diverse sample of pregnant individuals in a healthcare system with universal screening for ACEs, resilience, and prenatal substance use, higher ACEs and low resilience were independently associated with prenatal substance use. Further, trend tests found a dose-response association between ACEs and prevalence of prenatal substance use, supporting cumulative risk as ACEs increase. The strongest associations with ACEs and low resilience were generally found for stimulant and nicotine use. Importantly, while both ACEs and low resilience were associated with prenatal substance use, there was no statistical evidence that low resilience moderated the ACE-prenatal substance use relationship. The findings from this study suggest that preventive interventions may need to target both those with ACEs and those with low resilience.
Knowing whether individual ACEs are associated with prenatal substance use is valuable for informing concrete program designs for ACE prevention and intervention. In this study, while most ACEs were associated with prenatal substance use, family dysfunction, emotional abuse, physical abuse, and neglect were associated most consistently with prenatal substance use. These findings highlight the lasting impact of individual ACEs on maternal health behaviors.
Our findings have important implications for clinical practice. The dose-response association between ACEs and prenatal substance use supports the use of ACEs screening as part of standard prenatal care to identify pregnant individuals who may need additional support. This information can guide referral to tailored trauma-informed care models, substance use counseling, or interventions developed specifically for those with ACEs (Watson et al., 2024c). Another key finding was the independence of the relationship between resilience and prenatal substance use, regardless of ACE score. Resilience is modifiable and our results suggest that interventions that enhance resilience, such as mindfulness programs or cognitive behavioral therapy, may help support individuals during the preconception and prenatal periods (Chmitorz et al., 2018).
Finally, the prevalence of ACEs and low resilience was higher among racially and socioeconomically marginalized pregnant individuals, highlighting the importance of addressing social determinants of health for early prevention.
Limitations
Our study addresses key limitations of prior research, which has generally focused on a single substance, used high-risk or convenience samples, had a small number of pregnant individuals with prenatal substance use, or relied solely on self-reported substance uses. However, our sample comprised insured patients in a large healthcare system in Northern California. While screening is meant to be universal, not everyone was screened (eFigure1), and the prevalence of ACEs was lower than prior research using representative survey data. Findings may not generalize to those outside of California, to uninsured individuals, or to those with pregnancy loss before the ACEs screening. Screening for ACEs and resilience occurred after the prenatal substance use screening, and our cross-sectional design limits causal interpretation. Our screening for pharmaceutical opioid use does not distinguish between prescribed versus unauthorized use. Further, some covariates that were included to minimize residual confounding may also be on the causal pathway between ACEs and prenatal substance use, and results should be interpreted as conservative.
Conclusions
ACEs and resilience screening during routine women’s health visits even prior to pregnancy could help identify individuals who may benefit from early education, prevention, and intervention strategies to prevent substance use during pregnancy.
Supplementary Material
Funding:
This study was supported by grants R01DA058201 and K01DA043604 funded by the National Institute on Drug Abuse (NIDA). The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. A portion of the data was obtained through the Kaiser Permanente Northern California Division of Research’s Perinatal Research Unit’s Perinatal Obstetric Database.
Disclosures:
Ms. Does has received support managed through her institution from the Industry PMR Consortium, a consortium of companies working together to conduct post-marketing studies required by the Food and Drug Administration that assess risks related to opioid analgesic use. All remaining authors declare no conflict of interest.
Footnotes
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Declaration of generative AI and AI-assisted technologies in the writing process.
Statement: During the preparation of this work Dr. Kelly Young-Wolff used ChatGPT (OpenAI) for minor editing assistance to improve grammar and readability. The content was reviewed and verified.
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
- Aces Aware, 2020. Adverse Childhood Experience Questionnaire for Adults.
- Atzl VM, Narayan AJ, Rivera LM, Lieberman AF, 2019. Adverse Childhood Experiences and prenatal mental health: Type of ACEs and age of maltreatment onset. J Fam Psychol 33:304–14. [DOI] [PubMed] [Google Scholar]
- Borg LE, Alhusen JL, 2023. A review of factors that serve to protect pregnant and post-partum women from negative outcomes associated with Adverse Childhood Experiences. Maternal and child health journal 27:1503–17. [DOI] [PubMed] [Google Scholar]
- Chmitorz A, Kunzler A, Helmreich I, Tuscher O, Kalisch R, Kubiak T, Wessa M, Lieb K, 2018. Intervention studies to foster resilience - A systematic review and proposal for a resilience framework in future intervention studies. Clin Psychol Rev 59:78–100. [DOI] [PubMed] [Google Scholar]
- Duka S, Rahman S, Hansen SE, Esernio-Jenssen D, 2023. The effect of maternal Adverse Childhood Experiences (ACES) on substance use during pregnancy. Maternal and child health journal 27:153–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Frankenberger DJ, Clements-Nolle K, Yang W, 2015. The association between adverse childhood experiences and alcohol use during pregnancy in a representative sample of adult women. Womens Health Issues 25:688–95. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hughes K, Bellis MA, Hardcastle KA, Sethi D, Butchart A, Mikton C, Jones L, Dunne MP, 2017. The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. Lancet Public Health 2:e356–e66. [DOI] [PubMed] [Google Scholar]
- Mamun A, Biswas T, Scott J, Sly PD, McIntyre HD, Thorpe K, Boyle FM, Dekker MN, Doi S, et al. , 2023. Adverse childhood experiences, the risk of pregnancy complications and adverse pregnancy outcomes: a systematic review and meta-analysis. BMJ Open 13:e063826. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Merrick JS, Narayan AJ, Atzl VM, Harris WW, Lieberman AF, 2020. Type versus timing of adverse and benevolent childhood experiences for pregnant women’s psychological and reproductive health. Child Youth Serv Rev 114:105056. [Google Scholar]
- Osofsky JD, Osofsky HJ, Frazer AL, Fields-Olivieri MA, Many M, Selby M, Holman S, Conrad E, 2021. The importance of adverse childhood experiences during the perinatal period. Am Psychol 76:350–63. [DOI] [PubMed] [Google Scholar]
- Pear VA, Petito LC, Abrams B, 2017. The role of maternal adverse childhood experiences and race in intergenerational high-risk smoking behaviors. Nicotine Tob Res 19:623–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Racine N, McDonald S, Chaput K, Tough S, Madigan S, 2021. Pathways from maternal adverse childhood experiences to substance use in pregnancy: Findings from the all our families cohort. J Womens Health (Larchmt) 30:1795–803. [DOI] [PubMed] [Google Scholar]
- Ridout KK, Ridout SJ, Harris B, Felitti V, 2023. Universal Adverse Childhood Experience screening in primary care. NEJM Catalyst 4. [Google Scholar]
- Testa A, Jackson DB, Boccio C, Ganson KT, Nagata JM, 2022. Adverse childhood experiences and marijuana use during pregnancy: Findings from the North Dakota and South Dakota PRAMS, 2017–2019. Drug Alcohol Depend 230:109197. [DOI] [PubMed] [Google Scholar]
- Thomas SA, Clements-Nolle KD, Wagner KD, Omaye S, Lu M, Yang W, 2023. Adverse childhood experiences, antenatal stressful life events, and marijuana use during pregnancy: A population-based study. Prev Med 174:107656. [DOI] [PubMed] [Google Scholar]
- Wajid A, van Zanten SV, Mughal MK, Biringer A, Austin MP, Vermeyden L, Kingston D, 2020. Adversity in childhood and depression in pregnancy. Arch Womens Ment Health 23:169–80. [DOI] [PubMed] [Google Scholar]
- Watson CR, Eaton A, Campbell CI, Alexeeff SE, Avalos LA, Ridout KK, Young-Wolff KC, 2024a. Association of Adverse Childhood Experiences and resilience with depression and anxiety during pregnancy. Obstetrics and Gynecology 143:707–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Watson CR, Eaton A, Campbell CI, Hedderson MM, Ridout KK, Alexeeff SE, Young-Wolff KC, 2024b. Associations between adverse childhood experiences, resilience, and excess gestational weight gain. Am J Obstet Gynecol MFM 6:101542. [DOI] [PubMed] [Google Scholar]
- Watson CR, Wei J, Rios N, Staunton M, Koper A, Shiels J, Lee N, Young-Wolff KC, 2024c. Evaluation of an embedded health psychologist intervention for obstetric patients with Adverse Childhood Experiences. Perm J 28:144–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Young-Wolff KC, Alabaster A, McCaw B, Stoller N, Watson C, Sterling S, Ridout KK, Flanagan T, 2019. Adverse Childhood Experiences and mental and behavioral health conditions during pregnancy: The role of resilience. J Womens Health (Larchmt) 28:452–61. [DOI] [PMC free article] [PubMed] [Google Scholar]
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