Associations of cumulative adversity on Hispanic mothers’ perceived stress with infants admitted to the Neonatal Intensive Care Unit (NICU)

Abstract

Background

Mothers with a history of cumulative adversity (adverse experience throughout a lifetime) can face unique challenges in maintaining mental stability when compounded with other stressors during the perinatal period (pregnancy and postpartum). Such stressors can be having infants admitted to the Neonatal Intensive Care Unit (NICU), where stress levels often escalate due to the separation from their newborn and feelings of uncertainty regarding their child’s health. This study assessed cumulative adversity levels among 200 Latina mothers with NICU-admitted infants between 2017 and 2022 in Puerto Rico.

Methods

Mothers were contacted between 1 to 8 weeks after their infants’ NICU admission and interviewed using a structured psychological assessment protocol that included the 6-item Spielberger State Trait Anxiety Index (STAI-6), the Parental Stressor Scale: NICU (PSS: NICU), the Patient Health Questionnaire (PHQ-9) for depression severity, and the Cumulative Stressor Inventory (CSI) for cumulative adversity in the 12 months before childbirth.

Results

Most participants were low-income, high school-educated mothers receiving government assistance. While anxiety (STAI-6, M = 6.26, SD = 3.9) and depression levels (PHQ-9, Mean = 5.4, SD = 4.8) were low, moderate NICU-related stress was reported (PSS: NICU, Mean = 90.7, SD = 44.06). Regression analyses revealed that cumulative stress is moderately associated with maternal psychological symptoms, including anxiety, depression, and NICU-related stress (R = 0.47, R² = 0.22, p < 0.05; f (1,173) = 9.44, p < 0.001).

Conclusion

Higher cumulative adversity (environmental hazards, economic hardships, unsafe neighborhoods, among others) is associated with NICU-related stress within this population. Early psychological interventions and continuous support are essential to mitigating effects of the NICU experience in mothers that have faced cumulative adversity experiences prior to childbirth and postpartum.

Supplementary information

The online version contains supplementary material available at 10.1186/s40748-026-00248-9.

Background

It is well documented that early childhood adversity has a long-term impact on the sufferer’s mental and physical well-being throughout life [1, 2]. When mothers come into parenting with a history of cumulative adversity (adverse childhood experiences-ACEs and adult experienced adversity-AA), their mental stability can be very different from those not exposed to such adversity [3]. Cumulative adversity encompasses both single and repeated exposure to stressors across a lifetime. This is linked to theories of early stress acceleration exposures, increasing the physiological effects of stress responses. Elucidating how cumulative or prolonged adversities impact mental and physical well-being has received increasing attention over the past decade [4–6]. Broad research has shown that exposure to multiple stressors, or repeated exposure to the same stressors over time, has more detrimental health consequences than single exposures [6]; leading to cumulative adverse experiences and prolonged stress responses (see Fig. 1). According to the Center for the Developing Child [7], a cumulative stress response can result from cumulative adverse experiences. When someone experiences strong, frequent, and/or prolonged adversity such as burdens of family economic hardship, exposure to violence and abuse, sudden illness, etc., without adequate support [8], the effects on well-being, development, and mental stability can be detrimental for the developing child. So, we can conclude that cumulative adversity is known to elevate levels of stress, which are not beneficial to anyone, but particularly to mother-infant dyads who are at critical windows of the developmental lifespan [9, 10].

Fig. 1.

Cumulative adversity timeline

The rates and incidences of adversity exposures, and more cumulative adversity exposures, are dependent upon many biopsychosocial factors [11–15]. For certain cultures, like Hispanic mothers (in mainland US and its territories), additional structural, geographical, and environmental factors further complicate their ability to access resources for coping when exposed to stressors and adversity [14, 15]. Layering this reality over the heightened risk for stress and mental stability conditions during the perinatal period (encompassing pregnancy, childbirth, and postpartum), increases risks of adverse outcomes within the mother-infant dyad.

Notably, approximately one in five mothers has an elevated likelihood of developing a perinatal psychological disorder, which has become one of the most common complications of childbearing [16, 17]. There are individual and social factors that contribute to the incidence of mental health disorders across this population. Aspects of socioeconomic status, specifically in low-income country like Puerto Rico, a territory of the United States, has 87% of households of pregnant women under poverty levels (HRSA PR Report open access available online). This US territory is classified as a maternal desert zone, and women must travel 2.5 times as far to reach a hospital to give birth and receive care (March of Dimes Report 2023). This is like about 35% of rural areas in the mainland US, including counties in North Dakota, South Dakota, Oklahoma, Missouri, Nebraska, and Arkansas (March of Dimes Report 2023). Rodriguez-Reynaldo et. al. (2025) point out that the Pregnancy Assessment Monitoring System (PRAMS) in PR has found that 48% of pregnant women suffer from stress, making it almost half of the pregnant population in the island. All this adds more burden and increases the potential incidence of cumulative adversity, increasing chronic stress exposure within the household [18]. Furthermore, if the birth process results in a neonate with compromised medical conditions, requiring admission to the Neonatal Intensive Care Unit (NICU), levels of maternal stress can also be severely elevated. Maternal stress responses can certainly override brain-survival/threat circuits, negatively impacting overall physical and mental stability of the dyad (mother-baby) [19–21].

Then, narrowing our focus to Hispanic mothers of infants admitted to the NICU, we know they have an increased risk of experiencing higher levels of stress that may develop into postpartum psychological disorders (e.g. depression, anxiety [22]). Admission to the NICU disrupts the natural postpartum processes within the mother-child dyad [23, 24]. Specially, the separation from her newborn, who requires specialized medical care in an unfamiliar and high-stress environment. This can negatively impact the dyadic synchrony, regulation, and development of parenting behaviors [25–27]. Additionally, maternal concern over the infant’s health, along with the physical and logistical challenges of NICU visitation during postpartum recovery, further intensifies maternal stress levels [28, 29]. It is not clear how mothers with a history of cumulative adversity perceive and cope with the NICU experience. Specifically, we must ask: Does the NICU experience add another layer of adversity, and does it intensify more perceived stress for mothers already burdened with cumulative adverse experiences? Answering these questions is crucial, as maternal mental health preservation is vital to nurturing healthy postpartum outcomes and supporting infant development [30, 31].

The overall objective of this study was to begin exploring how cumulative adversity during the year prior to childbirth impacted maternal stress and perinatal mental stability (anxiety and depression) in the context of the NICU experience. The specific purpose of this cross-sectional study was to assess the presence of cumulative adversity levels (i.e. perceived stress throughout life, major life events 12-months prior to childbirth, food and housing instability, neighborhood safety, and stressful events when the child was born) among Hispanic mothers whose neonates were admitted to the NICU. We hypothesized that higher levels of maternal psychological symptoms (anxiety, NICU stress, and depression) would be associated with higher levels of cumulative adversity the year prior to childbirth. These results could potentially inform preventive and supportive interventions for mothers with neonates admitted to the NICU.

Methods

All methods and procedures for this study are a follow-up from previous publications [32, 33]. For this manuscript, we extracted variables of interest from the database for the ongoing Maternal Animic Study part of the Neonatal Intensive Care Unit (NICU) at the Pediatric Hospital, University of Puerto Rico, Medical Sciences Campus in San Juan (HOPU). This study has been approved by the Institutional Review Board, Medical Sciences Campus, University of Puerto Rico, for the ongoing collection of voluntary maternal psychological interviews performed one time during her neonate’s hospital stay at the NICU. IRB approval for secondary analysis of gathered data allowed us to collect variables related to cumulative adversity exposure during the 12 months prior to childbirth, neonate birth characteristics, maternal sociodemographic characteristics and maternal mental stability assessments (perceived stress, NICU Stress, anxiety, and depression).

Participants

Two hundred Hispanic mothers’ interviews were collected. Sample was recruited for from 2017 through 2022. These mothers had infants who were admitted to the NICU at the Pediatric Hospital, University of Puerto Rico, Medical Sciences Campus in San Juan (HOPU) and completed all psychological scales, forms, and assessments relevant to this study.

Procedures

To identify potential participants, the researchers received a weekly census of NICU admissions, which included medical and sociodemographic data on mothers and their infants. Trained researchers (undergraduate and graduate assistants, residents, and staff neonatologists), contacted the mother while her baby was still at the NICU. Researchers were trained to conduct interviews, we had psychological procedures in place, and constant supervision of a perinatal or developmental clinical psychologist. If the participant agreed to take part in the study, interview appointments (time and date) were established, and informed consent was obtained. Inclusion criteria included being 21 years of age or older, being able to consent, having her neonate currently admitted to the NICU, and being available to complete the interview before discharge. Exclusion criteria were the mother’s history of severe neurodevelopmental disorders, which present an inability to communicate verbally and/or understand verbal/written language. Once voluntary consent was obtained, the interview was performed in-person or via telehealth, lasting approximately 45–60 minutes, ensuring the mother’s comfort and reducing any potential external influences on her responses. Researchers administered questions verbally, and the mother’s responses were collected via pen-and-paper. After the interview was completed, the neonate’s medical diagnosis was obtained from medical records. Variables included seven potential diagnostic areas: neurological, respiratory, cardiac, gastrointestinal, hematologic, renal, and ophthalmologic. These were recorded as either present or absent. During the COVID-19 pandemic, researchers scheduled telephone calls in accordance with the hospital’s guidelines. Digital informed consent was sent to the mothers before the interview began. Once the consent form was filled out, the interview proceeded. As soon as all questionnaires were completed, the interviewer checked to ensure all responses were filled out and legible. Following this initial screening, the pre-coded responses were entered directly into a database software (Excel and SPSS). To maintain data quality and integrity, a random sample of electronic records was checked against the original questionnaires. This procedure significantly reduced data-entry errors, including invalid entries, out-of-range values, inconsistent data, and potentially duplicated records.

Measures/instruments

During the interview, the following demographic data were obtained: the mother’s age, marital status, education level, and receipt of government assistance. Information on the infant’s sex, birth weight (in grams), gestational age (days), and neonatal medical diagnosis was obtained from the admission record. In addition, a series of standard psychological questionnaires was administered to the mother. For this study, we included all relevant to perceived stress, anxiety, depression, and adversity exposure:

State Trait Anxiety Inventory (STAI-6)

The Trait Anxiety Inventory (STAI-6) is a 6-item scale designed to assess anxiety symptoms. Developed initially to assess high school and college students [34], the STAI-6 is currently used for anyone over 12 years of age [35]. The original version, composed by Spielberger [36], was more extended, but Marteau and Bekker [37] generated a shorter 6-item version with a Cronbach’s alpha of 0.82 and a correlation of 0.94 with the full version. A Spanish adaptation of the short scale, which has demonstrated good reliability and validity (Cronbach’s alpha = 0.89) and a sound factor structure, was used [38]. In this Spanish version, the six items are rated on a three-point scale: 0 (not at all), 1 (somewhat), 2 (quite a lot), and 3 (very much) [37]. The scale has a range of 20 to 80 [39], with scores between 20 and 37 indicating “no or low anxiety symptoms”, 30–44 indicating “moderate anxiety symptoms”, and 45–80 indicating “high anxiety symptoms” [40]. This instrument has been successfully used in our previous studies with this population [33].

Parental Stressor Scale: NICU (PSS: NICU)

Parental Stressor Scale: NICU (PSS: NICU) is a 46-item scale to assess parents’ perceived stress during their infant’s admission to the Neonatal Intensive Care Unit. This questionnaire, developed by Miles et al. [41], can be scored in multiple ways. One method is the Stress Occurrence Level (Metric 1), which measures stress related to a particular situation experienced by mothers. Another method is the Overall Stress Level (Metric 2), which measures the overall stress level triggered by the NICU environment. In both approaches, items are scored only for those who reported having the experience. Scale scores are computed by averaging these stress responses for each sub-scale item and the total scale [41, 42]. For this study, both Metrics provided significant data regarding different aspects of the perceived stress in the NICU. Cronbach’s alpha for each subscale was > 0.70, and for the whole instrument, it was 0.94 for Metric 1 and 0.81 for Metric 2 [41]. For this study, a Spanish adaptation was used with parents of critically ill newborns in Mexico [43]. The scale consists of four subscales that measure mothers’ stress related to (a) the sights and sounds of the unit (5 items), (b) the baby’s appearance and behavior (19 items), (c) their role as mothers and their relationships with the newborn (10 items), and (d) staff behavior and communication (11- items). In the last item, mothers were asked about overall stress related to having their infant in the NICU during the COVID-19 pandemic. Mothers rated their perceived stress on a 5-point Likert scale from 1 (not at all stressful) to 5 (extremely stressful) [41]. Scores were derived for each subscale and for the total stress associated with the NICU. We successfully used this scale in a previous study with the same population [33].

Patient Health Questionnaire − 9 (PHQ-9)

The Patient Health Questionnaire-9–9 (PHQ-9) is a 9-item scale used to assess depressive symptoms in individuals aged 12 and older, developed by Kroenke, Spitzer, and Williams [44]. This scale demonstrates good internal reliability, with Cronbach’s alphas of 0.89 in the PHQ Primary Care Study and 0.86 in the PHQ Ob-Gyn Study [44]. For this study, a Spanish version of this questionnaire was used [45]. The psychometric measure of the Spanish version exhibits a one-dimensional property with proper values less than 2.0, local independence with a correlation of 0.3 or more, consistent fit with the Rasch IRT model with a Rasch coefficient of 1.6, and moderate reliability [46], with minor idiomatic adjustments (“Desesperanzada” rather than “Sin esperanzas”). The PHQ-9 asks, “Over the last 2 weeks, how often have you been bothered by any of the following problems?” [44]. The answers range from 0 (not at all) to 3 (almost every day). Scores range from 0 to 27, with scores from 0 to 4 indicating minimal depression, 5–9 mild depression, 10–14 moderate depression, 15–19 moderately severe depression, and 20–27 severe depression [44]. The Spanish version of PHQ-9 is available for public use and was provided by the authors of the PHQ [47]. We have used this scale successfully in a previous study [33].

Cumulative Stressor Inventory (CSI)- measure of cumulative adversity (see Fig. 2)

Fig. 2.

Cumulative stressor index of cumulative adult experienced adversity

An adapted version of the Cumulative Stressor Inventory published by Slopen et al. 2022 [48] was used in this study. Indicators included in the calculation of the cumulative adversity index (which considered the history of adult adversity experienced 12 months before childbirth) were presence of: (1) perceived stress in the past 12 months, (2) major life events, (3) instability, neighborhood safety, and (5) stressful events at the time of the child’s birth. These individual indicators were summed to create a Cumulative Stress Index, yielding a continuous score used for predictive analysis (See supplementary file for more information).

Statistical analysis

Descriptive statistics were conducted to summarize the sociodemographic characteristics of the study participants. To explore the degree of association between cumulative stress and maternal mental stability questionnaires (depression, anxiety, and perceived NICU stress), we performed correlational and linear regression analysis. Results from all questionnaires were analyzed using IBM SPSS (Statistical Package for the Social Sciences) version 29. The analysis controlled for maternal age and infant gestational age, APGAR score, and birth weight, given that most of the samples were from premature infants. Additionally, standardized values for all measures (residuals similar to z-scores, with zero corresponding to the mean and 1 to the expected standard deviation) were calculated to generate scatter plots illustrating the associations of interest. The statistical significance level (p) for the different analyses was set at p < 0.05 CI 95%.

Missing data

To address the possibility of missing data, the data collection procedure was monitored weekly, and any missing data was reported as close to real time as possible throughout the study. If missing information was detected after the participant finished the interview, the participant was contacted by phone and asked to provide the missing values.

Results

Mother-infant dyad characteristics

A total of 200 mother-infant dyad interviews were conducted. Sociodemographic data is shown in Table 1. Mothers’ age ranged from 15 to 46 years. Our sample was constituted mainly of mothers who reported completing high school. It was shown that a high percentage of our sample came from low-income families receiving government assistance, such as food stamps and housing support. The infants in our study were predominantly born prematurely (33 weeks of gestation), presenting medical complications, including (not limited to): respiratory, hematological, and cardiovascular conditions (see Table 1).

Table 1.

Mother-infant dyad sociodemographic characteristics

	Male (M)	Girl (F)
Baby’s Sex	123%)	76%)
Total n	n = 200
Average Birth weight in (g)	2125.12
Gestational Age (days)	237.84
Infant Medical Diagnosis at Birth	Yes (Y)	No (N)
Neurological	19.70%	4.00%
Cardiovascular	36.90%	2.00%
Hematological	41.90%	0.50%
Ophthalmologic	2.50%	1.00%
Renal	3.60%	1.00%
Respiratory	51.80%	1.50%
	Maternal Characteristics
Age	27.3 (SD- 6.7)
Education	12 yrs. (34.2%)
	13 yrs. (14.8%)
	16 yrs. (20.9%)
	Married (28.3%)
Marital Standing	Single (41.4%)
	Living w. Partner (28.8%)
Government Assistance	137 (68%)
WIC	94 (47%)
Housing Assistance	11 (5%)
Government Health	36 (18%)

Maternal psychological state

In contrast to prior research, our sample of 200 Hispanic mothers reported low levels of anxiety and low levels of depression. Table 2 presents the descriptive statistics for the cumulative stress and maternal psychological state questionnaires. The anxiety scales assess personality traits that predispose an individual to experience anxiety, reflecting low levels of anxious characteristics in our sample. Simultaneously, the PHQ-9 assesses clinical symptoms related to a possible major depressive episode, in which our sample also yielded low levels of clinical depression.

Table 2.

Cumulative adversity and maternal mental wellbeing

Cumulative Stress Indicators	Mean (SD)	% (Dichotomous variable)
Major Life Event		72% (0)
Perceived Stress	1.1 (1.2)	-
Instability	-	51% (0)
Neighborhood Safety	-	94% (0)
Stressful events when child was born	4.11 (1.4)	-
Total Cumulative Stress Index (Sum of all)	6.27 (2.6)	63% (5)
Depression
PHQ-9 Total Score	5.4 (4.8)	–
Anxiety
STAI-6 Total Score	6.26 (3.9)	-
PSS: NICU
NICU Environment	9.13 (5.3)	-
NICU Situations	33.5 (22.5)	-
NICU Close Relationships	29.6 (11.6)	-
NICU Communication	18.5 (14.2)	-
Total NICU Stress Score	90.7 (44.06)	-

In contrast, the Cumulative Stress Index (quantified number of adverse exposures) and the PSS: NICU total score (44.06) indicated moderate levels of maternal stress in response to various psychosocial factors, including aspects of the NICU experience. Interestingly, there is much dispersion within the average score related to PSS: NICU, with a deviation > 40 points. This variability may be partly attributed to differences across the PSS subscales: NICU Situations (M = 33.5, SD = 22.5) and NICU Close Relationships (M = 29.6, SD = 11.6), in comparison to all other subscales. These scales reflect how mothers respond to what happens during NICU hospitalization, how close external relationships provide support in managing these experiences, and how the closeness to their infant is affected by the process.

Cumulative Adversity associated to maternal mental stability: Subsequently, we performed multiple regression analysis, where the cumulative stress index served as a predictor variable of each of the maternal psychological symptom scales (PHQ-9, STAI-6, PSS: NICU). In these regressions, maternal age, gestational age, APGAR scores, and birth weight were controlled as possible confounders. R, R-square, and beta values were evaluated at a p < 0.05 significance across each regression model. Figure 1 shows the results of the three linear regressions performed to test associations between maternal cumulative stress and psychological symptoms (anxiety scores, depression scores, and NICU-related stress scores).

All three multiple regression models were statistically significant. Maternal scores of cumulative stress were significantly associated with maternal mental stability outcomes as follows: Anxiety [R = 0.36, R² = 0.13, p < 0.05); f (1,172) = 19.33, p < 0.001], Depression [R = 0.44, R² = 0.20, p < 0.05; f (1,173) = 8.11, p < 0.001], and NICU Stress [R = 0.47, R² = 0.22, p < 0.05); f (1,173) = 9.44, p < 0.001]. These associations remained significant even after controlling for maternal age, gestational age, APGAR score, and birthweight (β> p0.05). The Cumulative Stress Index (adversity exposures 12 months prior to childbirth) maintained its principal statistical prediction value (beta, p < 0.001).

Comparing the models, the cumulative stress index appeared to be most strongly related to NICU Stress experiences, with the model’s adjusted R² the highest of the three (R² = 0.22), although it still explained only a low to moderate amount of variance. This means that 22% of the variance in a mother’s stress experience in the NICU could be associated with her accumulated stress experiences prior to having her neonate; further mediation analysis should be performed (See Figs 3, 4, and 5).

Fig. 3.

Standardized regression values for maternal anxiety with cumulative adversity as predictor

Fig. 4.

Standardized regression values for maternal depression with cumulative adversity as predictor

Fig. 5.

Standardized regression values for maternal NICU stress with cumulative adversity as predictor

Clarification of the Enter model’s cumulative stress index was a significant predictor across the three steps (beta value = p0.000) (after adjusting for all covariates). The standardized residual value of the predictor assumes a mean of 0 and a standard deviation of 1 to identify possible outliers and consistent tendencies. Models Enter Process: First: cumulative stress total score, Second: Cumulative Stress, gestational age, and maternal age, Third: Cumulative stress, gestational age, maternal age, and childbirth outcomes- APGAR score and birthweight.

Discussion

The perinatal period is recognized as a time of higher risk for emotional distress in mothers, even before considering the possibility of a NICU hospitalization for the infant [29] or the impact of other ongoing adverse exposures on her health and that of her baby. This study focused on exploring the associations of cumulative adversity on the perinatal mental stability of Hispanic mothers. We aimed to examine the presence of cumulative adverse experiences (including the presence of significant life events, instability, neighborhood safety, and stressful events before the child was born) and their potential associations with mothers’ psychological symptoms while their infants are in the NICU. A NICU hospitalization is a deviation from the expected experience of a healthy pregnancy and birth, and can become an emotionally overwhelming situation, leading to psychological distress [3]. As we know, this is the first study that considers cumulative adversity as an antecedent of maternal psychological symptoms during the initial postpartum period while her baby is in the NICU.

Surprisingly, although our sample was highly exposed to cumulative adversity, experiencing more than three adverse events on average 12 months leading into childbirth, they yielded non-clinical levels of depression and anxiety. A first limitation is the lack of all clinical diagnostic tools available for the perinatal community, like the Edinburgh Postpartum Depression Scale and the Generalized Anxiety Disorder scale. They were not included as the initial aims of the Animic Study were to identify psychological risk factors, not diagnose or screen for disorders. After 2022, the study now includes diagnostic screeners to compare with previous questionnaires. However, the STAI and PHQ-9 can certainly help assess psychological risk factors for clinical symptomatology. This paradoxical result, in which highly adversity-exposed mothers do not yield clinical levels of anxiety and depression, must be further studied. Indeed, this is a non-clinical sample of mothers exposed to cumulative adversity, in which they can be suffering from other undiagnosed disorders, such as those relevant to psychological trauma (Post-Traumatic Stress Disorder-PTSD). Also, the accelerated stress exposure theory points out that prolonged exposure to adversity can also attenuate and blunt the sympathetic nervous system, resulting in poorer emotional and physiological discrimination. This can lead to a “normalization” of adversity, making it your constant state and leading to reporting biases or a lack of symptom identification. Another phenomenon that could have played a role is social desirability bias, in which women underreport current symptoms due to aspects of the health care infrastructure, which could have affected our results. This is contrary to prior research findings, which have found high rates of depressive symptomatology in mothers with infants in the NICU, especially among Hispanic mothers with high-risk factors for perinatal depression [24, 49]. For example, Segre et al. [50], found that 25.5% of mothers presented symptoms of depression during their infants’ stay in the NICU. Not seen with our sample, which reported more discomfort related to cumulative adversity experiences. Similarly, our sample also yielded low levels of trait-anxiety symptoms, in contrast to other studies with NICU mothers, where prevalence estimates of clinically significant symptoms of anxiety range from 18% to 43% among mothers [50]. A second limitation is we used the abbreviated STAI- which only comprises of 6 items and thus focuses on personality traits that could be a risk factor for experiencing anxiety rather than symptoms of clinical anxiety (e.g., Generalized Anxiety Scale GAD-7).

Certainly, further study is warranted to understand how lower levels of anxiety and depression are seen in our sample of Hispanic mothers. One aspect to consider in culturally diverse groups is how social and behavioral norms also shape the mothering process. In our previous studies, we found that there is familial support during mothers’ neonatal stays in the NICU and that social support perception is protective among our samples [32]. This social and behavioral environment can be highly influenced by norms and values embedded in Hispanic culture, which foster very familiar, close, and intimate interactions, making the person feel supported. Also, it has been found that Hispanic culture may have some protective cultural values, such as familism/“familismo”, in which mothers are not expected to be mothers alone. Instead, they are expected to receive support from their own mothers and other matriarchal figures down their familial generation [51]. However, this could also inhibit a woman from being self-aware of her psychological well-being processes related to maternity, having a more collective experience. Moreover, there is evidence that Hispanic mothers in the mainland US need to overcome strenuous and emotionally challenging epochs as foreign-born individuals and people of color. Mental stability can be better preserved in a context where they are a majority [52–54].

We must undoubtedly acknowledge that there may also be many environmental, structural, and contextual factors affecting Hispanic mothers in this study. During the past five to seven years of data collection (2017–2022), Puerto Rico underwent several environmental stressors that impacted life stability and protocols within the NICU (e.g. governmental economic bankruptcy, Hurricane Irma/Maria, earthquakes, COVID-19 Pandemic). Previous studies have found that mothers who experienced anxiety and depression, as well as PTSD, during these times were those who were exposed to hurricane Maria-related disasters more severely (e.g., loss of power for months, loss of personal belongings, major flooding in their households, among others) [55–57]. With just this scenario, we expect stress levels entering parenting to be higher, and thus many of these external experiences could have been identified as adverse and added to their cumulative adversity histories. The need to follow these mothers’ post-NICU hospitalization is crucial to monitor ongoing levels of stress and the development of subsequent psychological disorders, as high stress can, at times, be a preamble of possible psychological disorders in the future (including those disorders of critical stress). Strategies such as involving a multidisciplinary team to work with parents and establishing individualized care, flexible pre- and post-discharge plans, including individual psychological and psychosocial support for mothers (including trauma-informed care practices), are crucial for ensuring a healthy transition to home and community [61–63]. Also, identifying which types of adversity exposure are associated with other social and governmental infrastructures can inform public health measures and socio-political movements to increase resources for these communities.

Limitations

Overall, our study is primarily focused on data gathered via a cross-sectional design from Hispanic mothers with low-income upbringings, with no within-group comparison and no control group of non-exposed mothers. To better identify how cumulative adversity is associated with maternal stability and stress, more detailed mediation and moderation analyses can pinpoint the direct and indirect effects. Also, considering more specific aspects relevant to the timeline and medical diagnosis of the postpartum process, the neonate, and the NICU stay can more clearly account for any unexplained variances. Adding more clinically based screeners of mental health disorders will also speak more to risk factors relevant to psychopathology in the presence of cumulative adversity and NICU stress. Further, recalling these mother-infant dyads and assessing child development longitudinally will also evidence how cumulative maternal adversity poses a risk factor for developmental delays. Adding more information on adverse exposures in the 12 months preceding childbirth will allow better assessment of trajectories and effects. Lastly, expanding to include the second parental figure and their history of adversity exposures, in association with maternal stress, mental stability, and overall child development, will be beneficial to understanding how to assist this population.

Conclusions

This study is the first to examine the role of cumulative adversity on the perinatal mental stability of Hispanic mothers with infants in the NICU. Despite high exposure to cumulative adversity, mothers in our sample reported non-clinical levels of depression and anxiety, though they experienced moderate to severe stress primarily related to the NICU environment. This suggests the need to study the pathways and trajectories of adversity exposures’ impact on maternal mental health and how that interacts with stressors specific to the childbirth and postpartum process. Cultural protective factors and social support may protect against high levels of anxiety and depression, highlighting the need to consider cultural context within assessments and interventions. The cumulative adversity these mothers have experienced puts them in a more vulnerable position to experience stress. Because stress can accumulate over time and lead to toxic stress, it is crucial to follow these mothers over time and to implement proper care when needed, and reduce the long-term impact of stress on the mother-infant dyad.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

NICU

Neonatal Intensive Care Unit

STAI-6

State Trait Anxiety Index

PSS:NICU

The Parental Stressor Scale: NICU

PHQ9

The Patient Health Questionnaire

CSI

Cumulative Stressor Inventory

M

Mean

SD

Standard deviation

ACE

Adverse childhood experiences

AA

Adult experienced adversity

HOPU

Pediatric Hospital, University of Puerto Rico, Medical Sciences Campus in San Juan

COVID-19

Coronavirus disease

IBM SPSS

Statistical Package for the Social Sciences

P

Statistical significance level

GAD

Generalized Anxiety Scale

Author contributions

Polaris Gonzalez-Barrios: Main author and corresponding author. Participated in data collection, synthesis, analysis, and interpretation. Wrote most of the manuscript. Conceptualized and created figures and tables. Edmarie Sanchez: Participated in data collection, synthesis, analysis, and interpretation. Participated in writing the introduction, methods, and results, including assisting in creating the tables. Jose Martinez: Participated in data collection, synthesis, analysis, and interpretation. Oversaw and edited all portions of the manuscript. Cynthia Garcia Coll: Participated in data collection, synthesis, analysis, and interpretation. Oversaw and edited all portions of the manuscript. Keimarisse Colon-Diaz: Participated in editing, reviewing and formatting manuscript. Roberto Y. Rodríguez Lozada: Edited the article for clarity and alignment with the provided guidelines, verified article references, contributed to the development of the abstract. Paula C. Román Villamil: Edited the article for clarity and alignment with the provided guidelines, verified content and article references, and contributed to the development of the abstract and conclusions. Andrea C. Morales Dávila: Edited the article for clarity and alignment with the provided guidelines, contributed to the development of the abstract. Lourdes Garcia-Fragoso: Oversaw and edited all portions of the manuscript. Zayhara Reyes Bou: Supervised in person data collection of the study. Oversaw and edited all portions of the manuscript. Ines García-García: Supervised in person data collection of the study. Oversaw and edited all portions of the manuscript.

Funding

Dr. Polaris Gonzalez-Barrios’ ongoing funding support: NIMHD RCMI Award Number U54 MD007600 University of Puerto Rico Medical Sciences Campus, Junior Faculty Research Fellowship Award from the Hispanic Center of Excellence Research Scholar HRSA D34HP24463 US Dept. of Health, Component II Postdoctoral Scholar Grant R25MD007607, Loan Repayment Awardee (L70HD113116).

Data availability

The datasets generated and/or analyzed during the current study are not publicly available because we do not have access to a repository. However, they are all available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This research has been approved by the Ethics Institutional Review Board at the University of Puerto Rico Medical Sciences Campus. All data were anonymized, and participants were given the opportunity to refuse participation by opting out

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.The authors declare that they have no competing interests