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. 2026 Sep 15;36:101969. doi: 10.1016/j.ssmph.2026.101969

More expansive state supplemental nutrition assistance program eligibility, intimate partner violence, and mental health during the preconception, prenatal, and postpartum periods

Mariana Rodrigues a,⁎, Dorian S Odems b, Anna E Austin c
PMCID: PMC13626925  PMID: 42824065

Abstract

Background

Intimate partner violence (IPV) and depressive symptoms are major public health concerns during the preconception, prenatal, and postpartum periods and are shaped by both interpersonal and structural conditions, including economic hardship and food insecurity. State-level Supplemental Nutrition Assistance Program (SNAP) eligibility policies, including eliminating the SNAP asset test and increasing the SNAP income limit under broad-based categorical eligibility (BBCE), influence access to food assistance and may be associated with maternal well-being.

Methods

We conducted a repeated cross-sectional analysis of data from 66,677 women with lower income in the 2016-2020 Pregnancy Risk Assessment Monitoring System. We categorized states as having two BBCE policies, one BBCE policy, or no BBCE policies, reflecting more expansive SNAP eligibility. We conducted log-binomial regression with generalized estimating equations to calculate adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs), estimating associations of state BBCE policies with preconception and prenatal physical IPV and postpartum depressive symptoms.

Results

Compared to women in states with no BBCE policies, those in states with both BBCE policies had a lower prevalence of preconception and prenatal physical IPV (PR: 0.79, 95% CI: 0.66–0.94) and postpartum depressive symptoms (PR: 0.83, 95% CI: 0.75–0.93). Estimates for states with one BBCE policy were smaller and less precise but also suggested a decreased prevalence of preconception and prenatal physical IPV and postpartum depressive symptoms compared to states with no BBCE policies (PR = 0.80, 95% CI: 0.64-1.00; PR = 0.91, 95% CI: 0.81-1.03, respectively).

Conclusions

Results suggest that structural conditions shaping access to economic resources may represent a pathway through which risk for IPV and maternal mental health challenges can be prevented.

Keywords: Supplemental nutrition assistance program, SNAP, Pregnancy, Intimate partner violence, Postpartum depression

Highlights

  • •

    More expansive state SNAP eligibility linked to lower preconception and prenatal IPV.

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    More expansive state SNAP eligibility linked to lower postpartum depressive symptoms.

  • •

    Strongest associations observed in states with both BBCE policies.

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    Graded pattern suggests more expansive SNAP eligibility may shape maternal well-being.

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    Structural conditions shaping economic access may prevent IPV and mental health risks.

1. Introduction

Intimate partner violence (IPV) and mental health challenges during the preconception, prenatal, and postpartum period are major public health concerns (Kapaya et al., 2019; Mercier et al., 2024). Exposure to IPV before and during pregnancy is associated with an increased risk for adverse pregnancy outcomes, including preterm birth and low birthweight (Steele-Baser, 2024), maternal death (Alhusen et al., 2015), delays in prenatal and postpartum care (Steele-Baser, 2024), and disruptions in early caregiving environments (Kita et al., 2016). Poor mental health, and specifically postpartum depression, is similarly associated with an increased risk of disruptions in early caregiving environments, delays in postpartum and well-childcare, and adverse maternal and infant physical health outcomes (Slomian et al., 2019). Exposure to IPV and poor maternal mental health shortly before, during, and after pregnancy are each associated with not only short-term, but also long-term consequences for maternal and child well-being (Howard et al., 2013; White et al., 2024). Importantly, pregnancy and childbirth are marked by substantial physiological, psychological, and social changes, making these periods a uniquely vulnerable window for both exposure to violence (Alhusen et al., 2015) and mental health challenges (The Lancet, 2023) and underscoring these periods as a critical time for focused prevention efforts.

Research on IPV and mental health during the preconception, prenatal, and postpartum periods has traditionally emphasized individual and relationship-level determinants (Capaldi et al., 2012; Chen et al., 2025; Gelaye et al., 2016). Consistent with the Family Stress Model (Conger et al., 2000), economic hardship can undermine emotion regulation, intensify relational strain, and increase vulnerability to both IPV and poor mental health (Lucero et al., 2016; Neppl et al., 2016; Newland et al., 2013). These processes may be especially salient during periods surrounding pregnancy and childbirth, when changes in employment, rising financial demands, and greater reliance on external supports can heighten economic strain and relational stress (Marcil et al., 2020; Marti-Castaner et al., 2022; Taylor et al., 2021). Among the various forms of material hardship, food insecurity has emerged as an important stressor and risk factor for experiences of violence, including IPV, as well as maternal distress (Frank et al., 2024; McKay & Bennett, 2025). Defined as limited or uncertain access to adequate food, food insecurity reflects both the resource deprivation and the chronic stress of scarcity, which may heighten household tension and strain within intimate relationships, thereby contributing to psychological distress and increasing risk for IPV (Hatcher et al., 2022; Myers, 2020; Waterman et al., 2024).

Growing evidence suggests that experiences of violence and mental health are shaped not only by individual and relationship-level determinants, but also by the broader structural and policy environments (Armstead et al., 2021; Beyer et al., 2015; Webb et al., 2023). Of particular relevance, social safety net programs and income supports influence households’ economic stability and material hardship, which in turn may shape relational dynamics, vulnerability to conflict and IPV, and mental health outcomes (Austin, Frank, et al., 2023; Austin, Naumann, et al., 2023; Pilkauskas, 2023). The Supplemental Nutrition Assistance Program (SNAP) is the central social safety net program through which food insecurity is addressed in the United States (Potluri et al., 2025). Under broad-based categorical eligibility (BBCE), states can expand SNAP eligibility by increasing the income limit from 130% to up to 200% of the federal poverty level (FPL) and/or eliminating the asset test used to determine eligibility, thereby allowing more households to participate in the program (Han, 2016). In turn, these policy choices generate meaningful cross-state variation in access to food purchasing assistance and in the material conditions of low-income households, particularly among populations facing heightened financial vulnerability, such as pregnant and postpartum individuals (Han, 2016; Potluri et al., 2025). Prior research shows that more expansive state SNAP eligibility under BBCE increases SNAP participation and decreases the number of households experiencing food insecurity (Han, 2016; Potluri et al., 2025).

Recent evidence indicates that state BBCE policies are associated with additional outcomes beyond increases in SNAP participation and reductions in food insecurity. Specifically, recent studies demonstrate lower rates of interpersonal violence, including IPV, and improved mental health among adults in states with more expansive SNAP eligibility under BBCE compared to those in states without these expansions (Austin et al., 2023a, 2023c). To date, no research has focused specifically on periods shortly before, during, and after pregnancy, a time of heightened vulnerability to both IPV (Jean Simon et al., 2025) and poor maternal mental health (Provencio et al., 2026) and a critical window for prevention efforts to support improved maternal and infant outcomes (Peck et al., 2010). Further, prior studies have largely relied on aggregate, state-level measures of interpersonal violence exposure, IPV, and mental health (Austin et al., 2023a, 2023c), leaving associations with these outcomes at the individual level unexamined. This represents a gap in knowledge regarding how social safety net policies may be associated with maternal well-being during this sensitive developmental window (Davis & Narayan, 2020).

The present study addresses these gaps by examining whether more expansive state SNAP eligibility under BBCE is associated with preconception and prenatal physical IPV and postpartum depressive symptoms among women with lower income. Consistent with the Family Stress Model and prior evidence linking more expansive SNAP eligibility to lower rates of interpersonal violence and improved mental health, we hypothesized that women residing in states with more expansive SNAP eligibility under BBCE will have a lower prevalence of preconception and prenatal IPV and postpartum depressive symptoms than women residing in states with less expansive eligibility. Given their shared associations with economic hardship and interpersonal stress processes, examining IPV and postpartum depressive symptoms together within a unified framework can provide an integrated understanding of how structural conditions are related to overall maternal well-being (Ankerstjerne et al., 2022; Biaggi et al., 2016; Howard et al., 2013).

2. Materials and methods

2.1. Data source

We used data from the 2016-2020 Pregnancy Risk Assessment Monitoring System (PRAMS) survey, an annual survey administered by the Centers for Disease Control and Prevention (CDC) in collaboration with state and local health departments (Shulman et al., 2018). Each year, states use their birth certificate files to select a systematic, stratified sample of women who had a recent live birth, with sampling stratified by factors such as maternal race and ethnicity and infant birthweight to ensure a sufficient sample size of smaller, but potentially higher-risk populations. Participating women complete a survey by mail or telephone approximately two to six months postpartum. Data were available from the CDC for participating states with a ≥55% response rate. We also used data from the SNAP Policy Database, an online resource available from the U.S. Department of Agriculture (United States Department of Agriculture, 2022). The SNAP Policy Database includes data on state adoption of various SNAP policies, including BBCE policies, for 1996-2020.

2.2. Study population

We included PRAMS participants ages 18 years and older who had a household income ≤200% of the federal poverty level (FPL) or who were enrolled in Medicaid prior to pregnancy to capture women likely eligible for SNAP (United States Department of Agriculture, 2025a; Supplemental Table 1). Reported income was missing for approximately 13% of PRAMS participants. To reduce exclusion due to these missing data, we included women who reported Medicaid health insurance coverage prior to their pregnancy (<1% missing household income and pre-pregnancy health insurance information) as there is substantial overlap in Medicaid and SNAP income eligibility, particularly in Medicaid expansion states (United States Department of Agriculture, 2025a). On PRAMS, household income is reported in categories (e.g., $35,000-$49,999). Consistent with prior research, we used the midpoint of income categories and household size to determine whether households had income ≤200% FPL (Eliason et al., 2021). To further capture women likely eligible for and potentially enrolled in SNAP, we included only women who were primi- or multi-parous (i.e., who previously had a live birth), given that meeting SNAP eligibility criteria as an adult without dependents is challenging. During 2016-2020, adults ages 18-64 years without dependent children were limited to three months of SNAP eligibility every three years if not employed or in an employment training program for at least 30 h per week (United States Department of Agriculture, 2025b). Navigating the process to document compliance with these work requirements or to document an exemption from these work requirements, including pregnancy, is complex and often results in eligible populations not enrolling in or being disenrolled from SNAP (Brantley et al., 2020; Gray et al., 2023). In sensitivity analyses, we included all women regardless of a history of prior live births.

2.3. Exposure

We determined the years from 2016 to 2020 that each state had both BBCE policies (i.e., had the income limit increased and the asset test eliminated), one BBCE policy (i.e., either had the income limit increased or the asset test eliminated), or no BBCE policies (Supplemental Table 2; Fig. 1). In sensitivity analyses, we examined specific types of BBCE policies, categorizing states as having had both BBCE policies, only the asset test eliminated, or no BBCE policies. To avoid making inferences based on a single state, we did not examine states with only the income limit increased because Michigan was the only state in this category during our study period. In additional sensitivity analyses, we excluded 2020 data given the onset of the COVID-19 pandemic.

Fig. 1.

Fig. 1

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Map of states by number of policies under broad-based categorical eligibility (BBCE) to expand eligibility for the Supplemental Nutrition Assistance Program, 2016-2019

2.4. Outcomes

We examined experiences of preconception and prenatal physical IPV based on responses to two questions: “In the 12 months before you got pregnant with your new baby, did your (ex-) husband or (ex-) partner push, hit, slap, kick, choke, or physically hurt you in any other way?” and “During your most recent pregnancy, did (ex-) husband or (ex-) partner push, hit, slap, kick, choke, or physically hurt you in any other way?” We considered a response of “yes” to either question to indicate preconception or prenatal physical IPV. In sensitivity analyses, we examined preconception physical IPV (i.e., experienced prior to pregnancy) and prenatal physical IPV (i.e., experienced during pregnancy) separately.

We examined postpartum depressive symptoms based on responses to two questions: “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and “Since your new baby was born, how often have you had little interest or little pleasure in doing things you usually enjoyed?” Response options included “always”, “often”, “sometimes,” “rarely,” or “never”. Consistent with prior research (Bauman, 2020), we considered a response of “always” or “often” to at least one of these questions to indicate postpartum depressive symptoms. These two questions are demonstrated to have high sensitivity and specificity as compared to a structured clinical interview to diagnose major depression (O'hara et al., 2012).

2.5. Covariates

To identify potential confounders in the association of state BBCE policies with preconception and prenatal physical IPV and postpartum depressive symptoms, we created a conceptual diagram using principles of directed acyclic graphs (Supplemental Fig. 1) (Austin et al., 2019). Based on our conceptual diagram, we adjusted analyses for indicators of state economic conditions (e.g., percent of population unemployed and median household income) and the state policy context (e.g., minimum wage, Earned Income Tax Credit rate, Medicaid expansion, and paid family leave). We also adjusted analyses for maternal characteristics including maternal age, race and ethnicity, education, health insurance type at delivery, receipt of benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during pregnancy, and pregnancy intention. In sensitivity analyses, we adjusted for additional state indicators including the political affiliation of the governor, the number of firearm policies related to IPV, the homicide rate, and the number of women ages 18 to 64 years with no health insurance per 100,000. See Supplemental Table 3 for a description of all covariates.

2.6. Statistical analysis

We first calculated the prevalence of maternal characteristics, state economic conditions, and state policy context for women who resided in states with both BBCE policies, one BBCE policy, and no BBCE policies. We then conducted log-binomial regression to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) comparing the prevalence of preconception and prenatal physical IPV and postpartum depressive symptoms among women in states with both BBCE policies, one BBCE policy, and no BBCE policies. We adjusted all models for the above-noted covariates and a linear time trend to account for secular trends over time. We applied generalized estimating equations (GEE) with an exchangeable correlation matrix to all models to account for nesting of women within states (Gardiner et al., 2009). GEE is a set of equations applied to regression models to obtain population average estimates while accounting for the fact that outcomes for women residing in the same state are likely to be more similar than outcomes for women residing in different states. We did not use a quasi-experimental design, such as difference-in-differences, because only four states changed policy categories during 2016-2020, indicating minimal pre-policy time to leverage in analyses.

To assess the validity of our results and the potential for unmeasured confounding to affect results, we conducted a placebo test using a binary indicator for whether prenatal care was initiated in the first trimester of pregnancy as the outcome. We expect the timing of prenatal care initiation to be affected by similar maternal characteristics and indicators of the state economic and policy context as preconception and prenatal IPV and postpartum depression but not to be associated with state BBCE policies.

We conducted weighted analyses in SAS to account for the complex sampling design of PRAMS. To interpret results, we relied on the magnitude of the PRs and the location and width of the corresponding 95% CIs rather than solely relying on p-values (Wasserstein & Lazar, 2016). This study was reviewed and approved by the Institutional Review Board at the University of North Carolina at Chapel Hill.

3. Results

A total of 66,677 PRAMS participants were primi- or multi-parous and had household income ≤200% FPL or were enrolled in Medicaid prior to pregnancy. Nearly half lived in states that had both BBCE policies, 27% lived in states with one BBCE policy, and 23% lived in states with neither BBCE policy. Women in states with one or two BBCE policies were more likely to have public health insurance (77.9% and 75.0% vs. 71.6%, respectively), intended pregnancies (44.2% and 45.6% vs. 41.3%), and receive WIC during pregnancy (62.8% and 58.9% vs. 54.0%), than those in states with no BBCE policies (Supplemental Table 4). Women in states with two BBCE policies were more likely to identify as Hispanic (28.5% vs. 18.2% and 15.5%) and less likely to identify as Black non-Hispanic (20.5% vs. 27.2% and 25.6%) than those in states with one BBCE policy or no BBCE policies (Supplemental Table 4). Women in states with one or two BBCE policies were more likely to live in a state with Medicaid expansion (61.0% and 75.9% vs. 37.7%) and paid family leave (7.9% and 11.9% vs. 0.0%) than those in states with no BBCE policies. Average state minimum wage ($9.08 vs. $7.97 and $7.72), state EITC rate (0.12 vs. 0.08 and 0.06), and median household income ($67,473 vs. $57,789 and $59,285) were higher for women in states with two BBCE policies than for those in states with one or no BBCE policies (Supplemental Table 5).

The prevalence of preconception and prenatal physical IPV was higher among women residing in states with no BBCE policies (7.1%) than among women in states with one (5.8%) or two BBCE policies (5.5%). The prevalence of postpartum depressive symptoms was higher among women residing in states with no BBCE policies (18.9%) and one BBCE policy (17.6%) than among women in states with two BBCE policies (15.0%) (Fig. 2).

Fig. 2.

Fig. 2

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Prevalence of intimate partner violence and postpartum depressive symptoms among primi- and multi-parous low-income women by state Supplemental Nutrition Assistance Program (SNAP) broad-based categorical eligibility (BBCE)a, 2016-2020 Pregnancy Risk Assessment Monitoring System Survey (N = 66,677).

Note: Please see Supplemental Table 2 for a list of years of data included for each state; PRAMS-Pregnancy Risk Assessment Monitoring System.

After adjusting for individual and state-level covariates, residing in states with two BBCE policies was associated with a lower prevalence of preconception and prenatal physical IPV and postpartum depressive symptoms (Fig. 3; Supplemental Table 6). Women in states with two BBCE policies had a 21% lower prevalence of preconception and prenatal physical IPV (PR: 0.79, 95% CI: 0.66-0.94) and 17% lower prevalence of postpartum depressive symptoms (PR = 0.83, 95% CI: 0.75-0.93) than women in states with no BBCE policies. Women living in states with one BBCE policy had a lower prevalence of preconception and prenatal physical IPV (PR = 0.80, 95% CI: 0.64-1.00) and postpartum depressive symptoms (PR = 0.91, 95% CI: 0.81-1.03) than women in states with no BBCE policies. While the magnitude of the PRs and the location of the 95% CIs for these estimates were consistent with a reduced prevalence of the outcomes, the 95% CIs included the null.

Fig. 3.

Fig. 3

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Adjusted association of state Supplemental Nutrition Assistance Program (SNAP) broad-based categorical eligibility (BBCE)a policies with intimate partner violence and postpartum depressive symptoms among primi- and multi-parous low-income women, 2016-2020 Pregnancy Risk Assessment Monitoring System Survey (N = 66,677).

a1 BBCE policy indicates states had either eliminated the SNAP asset test or increased the SNAP income limit to up to 200% of the federal poverty level, and 2 BBCE policies indicates that states had both eliminated the SNAP asset test and increased the SNAP income limit to up to 200% of the federal poverty level.

bAdjusted for maternal age, race and ethnicity, education, health insurance type at delivery, pregnancy intention, and receipt of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) benefits during pregnancy; state Medicaid expansion, paid family leave, percent population unemployed, minimum wage, Earned Income Tax Credit rate, and median household income; and a linear time trend.

cCompared to no BBCE policies.

4. Discussion

In the current study, we found a lower prevalence of preconception and prenatal physical IPV and postpartum depressive symptoms among women who resided in states that had two BBCE policies, as compared to women who resided in states with no BBCE policies. These associations persisted after adjustment for maternal characteristics, state-level economic conditions, and co-occurring state policies. Our estimates of associations among women who resided in states with one BBCE policy were consistent with a decreased prevalence of both outcomes, but these estimates were smaller in magnitude than estimates among women in states with two BBCE policies.

We observed a graded pattern in associations, with the lowest prevalence of preconception and prenatal physical IPV and postpartum depressive symptoms among women in states with two BBCE policies to expand SNAP eligibility, followed by women in states with one BBCE policy and women in states with no BBCE policies. Notably, this pattern was consistent across two closely linked but conceptually distinct outcomes, IPV and depressive symptoms (Howard et al., 2013; Navarrete et al., 2021; Pardo et al., 2024). Although IPV and depressive symptoms frequently co-occur and have been examined in relation to one another, they are typically addressed through different clinical and service frameworks (Babazadeh et al., 2025; Motrico et al., 2022), potentially obscuring the extent to which they may be related to shared social and economic conditions (Howard et al., 2013; Navarrete et al., 2021; Pardo et al., 2024). Within the Family Stress Model, economic hardship may disrupt emotional regulation, increase psychological distress, and intensify relational conflict, processes that are directly relevant to both IPV and depressive symptoms (Beydoun et al., 2012; Masarik & Conger, 2017; Meyer et al., 2025). The convergence of our results across these outcomes suggests that state policy environments are relevant to maternal well-being, potentially through material conditions that influence both relational dynamics and psychological experiences during the preconception, prenatal, and postpartum periods (Meyer et al., 2025; Taylor et al., 2021). There are several interrelated pathways through which SNAP eligibility policies may be relevant to maternal well-being. At the most proximal level, more expansive SNAP eligibility and lower barriers to SNAP participation result in decreased food insecurity, a dimension of material deprivation that also functions as a chronic stressor with implications for mental health and relational functioning (Bruening et al., 2017; Frank et al., 2024; Potluri et al., 2025; Waterman et al., 2024). Reductions in economic strain may lessen chronic stress burden and associated psychological distress, which are among the proximate mechanisms through which economic hardship is thought to translate into poorer relational and mental health outcomes (Meyer et al., 2025; Taylor et al., 2021). Pregnancy and postpartum involve shifting caregiving demands, increased financial pressure, and broader role transitions, all of which may heighten sensitivity to material conditions (Pardo et al., 2024). In this context, differences in access to resources, including food, may be particularly consequential for relational and psychological well-being (Pardo et al., 2024; Refaeli et al., 2024) and subsequent experiences of IPV and depressive symptoms.

SNAP eligibility policies may also be related to the relational conditions under which preconception and prenatal IPV occur. Material hardship and food insecurity are well-documented correlates of IPV risk (Breiding et al., 2017; Hatcher et al., 2022; Johnson et al., 2022; Meyer et al., 2025). Indeed, prior work suggests that these conditions may influence relationship power dynamics, dependence, and conflict, while also constraining autonomy and reducing IPV survivors’ ability to leave unsafe relationships, particularly when access to independent economic resources is limited (Breiding et al., 2017; Hatcher et al., 2022; Johnson et al., 2022; Meyer et al., 2025). For individuals in abusive relationships, where economic control and financial abuse are well-documented tactics of coercion (Johnson et al., 2022), it is possible that access to food assistance before and following separation may help reduce one structural barrier relevant to safety planning and decisions about leaving the relationship (Johnson et al., 2022; Sabri et al., 2022). More expansive SNAP eligibility criteria, including higher income thresholds and the elimination of the asset test, have the potential to improve economic well-being and access to material resources for survivors establishing a separate household (Han, 2016; Wang et al., 2026).

The stronger associations observed among women in states with both BBCE policies highlight the potential importance of policy design. BBCE policies that simultaneously increase SNAP income eligibility thresholds and eliminate the SNAP asset test may lower barriers to program access more effectively than narrower policy designs or policy options implemented in isolation (Potluri et al., 2025; Wang et al., 2026). More comprehensive policies have the potential to support more consistent access to financial and material resources, with potential downstream implications for both interpersonal and psychological outcomes. Notably, this finding is aligned with prior longitudinal research showing larger reductions in rates of child protective services reports and foster care entries in states with both BBCE policies as compared to states with only one BBCE policy (Austin et al., 2023a, 2023b).

Consistent with prior work demonstrating that more expansive SNAP eligibility is associated with reductions in interpersonal violence and improvements in mental health, results from this study further underscore the potential contribution of structural conditions to the population-level burden of outcomes that are often approached primarily through individual or clinical frameworks (Austin et al., 2022, 2023c; Austin et al., 2023a, 2023b). Preconception and prenatal IPV and postpartum depressive symptoms are typically addressed through screening, referral, follow-up, and treatment, all of which remain essential (Bailey, 2010; Chisholm et al., 2017; Gjerdingen & Yawn, 2007). The present findings suggest that upstream economic policies may represent an additional, complementary point of intervention, shaping the broader conditions under which risk for violence and poor mental health emerges rather than intervening only after risk is established. This is further reinforced by existing longitudinal and cross-sectional research demonstrating associations of other economic policies, including paid family leave (Bullinger et al., 2024), refundable state Earned Income Tax Credits and higher state Earned Income Tax Credit rates (Shields-Zeeman et al., 2021; Showalter et al., 2026; Spencer et al., 2020; Stanley & Conway, 2025), and higher state minimum wage (Kuroki, 2021; Merrill-Francis et al., 2024), with lower rates of violence and adverse mental health outcomes. As such, recent efforts to restrict SNAP eligibility, including stricter work requirements and proposed limits on BBCE, may increase barriers to food assistance for populations already experiencing economic vulnerability during pregnancy and postpartum (Wang et al., 2026). Although the present analyses do not directly evaluate these restrictions, the lower prevalence of preconception and prenatal physical IPV and postpartum depressive symptoms observed in states with more expansive SNAP eligibility suggests that restricting access to food assistance may increase exposure to material hardship with downstream implications for a range of maternal outcomes.

Several limitations should be considered when interpreting the current findings. First, most states did not newly expand SNAP eligibility under BBCE during our study period. Thus, our analyses did not capture temporal variation in policy environments, limiting the ability to assess how changes in SNAP eligibility may relate to changes in maternal outcomes, including the timing of policy exposure relative to pregnancy and postpartum stages. Second, although we adjusted primary and sensitivity analyses for a range of individual- and state-level covariates, unmeasured confounding remains possible, including differences in policy implementation, access to other forms of social support, and broader state-level contexts associated with both SNAP eligibility under BBCE and maternal outcomes. While null findings in our placebo test strengthen confidence in our results, to further assess the potential for unmeasured confounding to bias results, we calculated E-values (Supplemental Table 13). E-values indicate the strength of an association on the PR scale that an unmeasured confounder would need to have with the exposure and outcome to account for observed associations (Bi et al., 2025; VanderWeele & Ding, 2017). The association of an unmeasured confounder with all policy categories and the outcomes would need to be moderate or strong to fully explain the results. Third, our measures of IPV and depressive symptoms relied on self-report and may be subject to underreporting, particularly given the sensitivity of these experiences. However, we do not expect this underreporting to differ by state SNAP policy context. In addition, the PRAMS data capture only physical forms of IPV, limiting the ability to assess the association of more expansive SNAP eligibility with other dimensions of intimate partner violence, including emotional, sexual, or psychological abuse.

Despite these limitations, this study makes several contributions to existing literature. It extends prior research on SNAP eligibility and interpersonal violence to the preconception, prenatal, and postpartum periods, a developmental window of heightened vulnerability that has received comparatively limited attention in the structural policy literature, and does so using individual-level outcome data from a large, nationally representative surveillance system. The consistent, graded pattern observed across two conceptually distinct, but clinically siloed outcomes suggests that the structural conditions shaping access to material resources may be associated with maternal well-being more broadly than is captured by frameworks focused solely on IPV or maternal mental health. These patterns are consistent with pathways through which policy contexts may contribute to maternal well-being, including reductions in material hardship and stress and shifts in relational dynamics associated with IPV risk (Hatcher et al., 2022; Meyer et al., 2025; Taylor et al., 2021). Future longitudinal research will be important for establishing causality and assessing how changes in policy environments relate to changes in maternal outcomes across the preconception, prenatal, and postpartum periods. Integrating measures of individual program participation with policy exposure in this research will help to elucidate underlying proximal and structural pathways and identify specific points for focused intervention.

5. Conclusion

In the current study, more expansive SNAP eligibility under BBCE was associated with a lower prevalence of both preconception and prenatal physical IPV and postpartum depressive symptoms, with the strongest associations observed in states with both BBCE policies. These findings are consistent with existing evidence (Austin et al., 2023a, 2023c) and suggest that state economic policy environments are relevant to maternal interpersonal and psychological outcomes.

CRediT authorship contribution statement

Mariana Rodrigues: Conceptualization, Project administration, Writing – original draft, Writing – review & editing. Dorian S. Odems: Conceptualization, Validation, Writing – original draft, Writing – review & editing. Anna E. Austin: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Writing – original draft, Writing – review & editing.

Ethics declaration

Written informed consent to take part in the study and to publish the article has been obtained from all participants or their legal representatives. The privacy rights of participants have been observed.

This study was performed in compliance with relevant laws, regulatory frameworks and guidelines where the research took place. This study was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill. (Approval No. 21-2494)

Clinical trial number

Not applicable.

Funding

This study was supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R25HD116367-01).

Declaration of competing 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.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ssmph.2026.101969.

Appendix A. Supplementary data

The following is the Supplementary data to this article:

Multimedia component 1
mmc1.docx (105.1KB, docx)

Data availability

PRAMS data are available from participating states (https://www.cdc.gov/prams/php/participating-states/index.html).

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Associated Data

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

Supplementary Materials

Multimedia component 1
mmc1.docx (105.1KB, docx)

Data Availability Statement

PRAMS data are available from participating states (https://www.cdc.gov/prams/php/participating-states/index.html).

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