Abstract
Objectives
Prenatal psychosocial stress has been associated with adverse pregnancy outcomes, even after controlling for known risk factors. This paper aims to evaluate correlates of high perceived stress among Hispanic women, a group with elevated rates of stress during pregnancy.
Methods
We conducted this analysis among 1426 pregnant Hispanic women using data from Proyecto Buena Salud, a prospective cohort study conducted in Western Massachusetts. Cohen’s Perceived Stress Scale (PSS-14) validated in English and Spanish was administered in early (mean=12.4 wks gestation), mid (mean=21.3 wks gestation) and late (mean=30.8 wks gestation) pregnancy at which time bilingual interviewers collected data on socio-demographic, acculturation, behavioral, and psychosocial factors. High perceived stress was defined as a PSS score>30.
Results
Young maternal age (odds ratio (OR) =0.6; 95% confidence interval (CI) 0.4-0.9 for <19 vs. 19-23yrs), pre-pregnancy consumption of alcohol (OR=2.2; 95% CI 1.4-3.5 for >12 drinks/mo. vs. none) and smoking (OR=2.2; 95% CI 1.3-3.7 for >10 cigarettes/day vs. none) were associated with high perceived stress during early pregnancy. Furthermore, higher annual household income (OR=0.4; 95% CI 0.1-0.9 for >$30,000 vs. <$15,000), greater number of adults in the household (OR=1.8; 95% CI 1.1-3.0 for ≥3 vs. 1) and language preference (OR=0.6; 95% CI 0.4-0.9 for Spanish vs. English) were associated with high stress during mid-pregnancy. Likewise, annual household income was inversely associated with high stress during late pregnancy.
Conclusion
Our results have important implications for incorporation of routine screening for psychosocial stress during prenatal visits and implementation of psychosocial counseling services for women at high risk.
Keywords: perceived stress, correlates, pregnancy, Hispanic
INTRODUCTION
Considerable evidence supports a modest adverse effect of prenatal psychosocial stress on fetal and infant birth outcomes including preterm birth, low birth weight, intrauterine growth restriction, behavioral and mental health problems, and fetal morbidity (1-6). Biomedical risk factors such as medical and obstetric history, lifestyle and behavioral factors, and socio-demographic characteristics account for 50 percent or less of the incidence of low birth weight, preterm birth, and their postnatal sequelae (2, 7, 8). Therefore, a significant portion of adverse pregnancy outcomes may be attributable to psychosocial factors, even after controlling for known risk factors (2, 5).
Prenatal maternal stress is common, yet the prevalence among pregnant women is unclear (9). Variability in measures used to capture psychosocial stress has resulted in differing rates across studies. For example, 12% of women from the Canadian Maternity Experiences Survey (MES) experienced high levels of perceived stress in the year prior to the birth of their baby in response to one overall question about the amount of stress in their lives (10). In a cross-sectional study among predominantly non-Hispanic white prenatal care patients in Seattle, 78% of participants reported low-moderate psychosocial stress and 6% reported high stress as measured by the Prenatal Psychosocial Profile Stress Scale (9). Laraia et al. found higher mean perceived stress scores using Cohen’s Perceived Stress Scale (PSS-14) in early pregnancy among 606 participants with incomes ≤400% of the poverty line (22.3±8.14, range of 2 to 47) (11), as compared to those reported by prior studies among non-pregnant women (20.2±7.8; 16.14±7.56) (12, 13).
Because maternal stress is a potentially modifiable risk factor for adverse perinatal outcomes such as preterm birth and low birth weight (1, 3, 4, 14) and fetal and infant behavior and development (1, 2, 6, 14, 15), evaluation of correlates of stress during pregnancy may be useful in identifying high risk women (16). However, few studies have specifically explored factors that contribute to or coexist with psychosocial stress during pregnancy (9, 10, 17). In these studies, correlates of high stress included demographic characteristics (i.e., younger age, higher income, lower educational status, being unmarried, unemployment), psychosocial variables (unhappy feelings about being pregnant, current and previous history of depression, low perceived psychosocial support during pregnancy), behavioral factors (smoking, alcohol, and drug use), obstetric history (previous miscarriage, greater pregnancy-related complications), and domestic violence (9, 10, 17). These studies were limited by varying measures of stress, cross-sectional design, and small sample sizes. In addition, correlates of stress were assessed at only one time point in pregnancy precluding the evaluation of change in stress during pregnancy.
Women of low socioeconomic status and racial/ethnic minorities such as Hispanics may experience higher levels of psychosocial stress during pregnancy (18, 19). In a previous paper in our study population, pregnant Hispanic Caribbean Islanders reported higher mean levels of psychosocial stress, as measured by the PSS-14, of 26.9±7.1 (range 5–48) (20) than those reported previously among predominantly non-Hispanic white pregnant women (11). Hispanics from the Caribbean islands (i.e., Puerto Ricans and Dominicans) constitute the largest Hispanic subgroup in the northeast U.S., the second largest group of Hispanics in the U.S., and the fastest growing subgroup (21, 22). As compared to other Hispanics, Puerto Ricans and Dominicans experience the greatest health disparities, least education, lowest incomes, and exhibit more adverse behaviors such as poor nutrition (23, 24). Thus pregnant Hispanic women represent a high risk group for increased levels of psychosocial stress and its associated perinatal complications. These findings have important implications because Hispanics have the highest birth and immigration rates of any minority group (18); by 2050 Hispanic women will comprise approximately 24% of the female population in the United States (25). To our knowledge, no studies have examined correlates of high stress among pregnant Hispanic women.
Therefore, we prospectively evaluated correlates of high perceived stress during early, mid and late pregnancy among Hispanic women using data from Proyecto Buena Salud (PBS), a cohort study of Hispanic prenatal care patients in Western Massachusetts.
METHODS
Study Setting
Proyecto Buena Salud was conducted from 2006 to 2011 in the ambulatory obstetrical practices of a large tertiary care facility in Western Massachusetts (20). The overall goal of Proyecto Buena Salud was to examine the relationship between physical activity, psychosocial stress, and risk of gestational diabetes in Hispanic women of Caribbean Island heritage. Bilingual interviewers recruited patients at prenatal care visits early in pregnancy (up to 20 weeks gestation), informed them of the aims and procedures of the study and obtained written informed consent. This study was approved by the Institutional Review Boards of the University of Massachusetts-Amherst and Baystate Health.
At the time of enrollment (mean=12.4 weeks gestation), bilingual interviewers collected information on socio-demographic, acculturation, behavioral, and psychosocial factors. Information on behavioral and psychosocial factors was updated in mid (mean=21.3 weeks gestation) and late (mean=30.8 weeks gestation) pregnancy. Medical factors were abstracted from medical records. Interviews were conducted in Spanish or English (based on patient preference) in order to eliminate potential language or literacy barriers.
Eligibility
Eligibility was restricted to women of Puerto Rican or Dominican Republic (PR/DR) heritage. Exclusion criteria included: 1) current medications that adversely influence glucose tolerance, 2) multiple gestation, 3) history of diagnosis of diabetes, hypertension, heart disease or chronic renal disease, and 4) age less than 16 years or over 40 years. A total of 1620 prenatal care patients were enrolled in Proyecto Buena Salud. For the current analysis, we excluded participants missing information on psychosocial stress at all 3 time points (n=194) for a total of 1,426 women in the final sample.
Perceived Psychosocial Stress
Perceived stress was measured at each interview using the PSS-14 which includes 14 items designed to address a person’s sense of control over daily life demands (26). Each item was rated on a 5-point scale ranging from never (0) to almost always (4). Positively worded items were reverse scored, and the ratings were summed. Scores ranged from 0 to 56, with higher scores indicating more perceived stress. Internal consistency of the PSS as assessed by Cronbach’s alpha was 0.85 in three samples tested by Cohen et al and 0.78 in a general population study (26-28). Correlations were also observed with indices of depressive symptomatology (0.65 and 0.76). The European Spanish version of the PSS-14 demonstrated adequate reliability (internal consistency, alpha=0.81, and test-retest, r=0.73), validity (concurrent), and sensitivity (28).
Sociodemographic Factors
At the time of enrollment, interviewers collected information on age, education, annual household income, marital status, living situation (i.e., with a partner/spouse), and number of children under 18 years and adults in the household.
Acculturation Factors
At the time of enrollment, interviewers collected information on language preference for speaking/reading (English, Spanish), generation in the Continental U.S., and administered the 10-item Psychological Acculturation Scale (PAS) which measures an individual’s sense of psychological attachment to and belonging within Anglo-American and Latino/Hispanic cultures. Item responses are scored on a 5-point Likert scale ranging from 1 (only Hispanic/Latino) to 5 (only Anglo/American) (29). We defined scores <3 as low acculturation and scores ≥3 as high acculturation. PAS scores have been correlated with migration history and patterns of Spanish and English language use in a sample of Puerto Rican females; correlations between PAS scores from the Spanish and English versions (r=0.94) suggest a high degree of cross-language measurement equivalence (29).
Behavioral Factors
Behavioral factors were assessed at each interview using questions designed by the Pregnancy Risk Assessment Monitoring System (PRAMS) and included alcohol consumption and cigarette smoking (30).
Physical activity during pre-pregnancy (1 year prior) and early pregnancy was assessed at the time of enrollment and updated during the mid- and late pregnancy interviews using the Pregnancy Physical Activity Questionnaire (PPAQ), a semi-quantitative questionnaire that evaluates participation in four domains of activities: household/caregiving, occupational, sports/exercise, and transportation (31).
Psychosocial Factors
Trait anxiety was assessed at each interview using the Spielberger State-Trait Anxiety Inventory (STAI) which measures relatively stable individual differences in anxiety proneness and contains 20 statements about how the respondent generally feels (32). The instrument has been previously used in studies during the prenatal period (33). The Spanish version of the STAI was validated and adapted by TEA Editions (34). Depressive symptoms were assessed at each interview using the 10-item Edinburgh Postnatal Depression Scale (EPDS) available in English and Spanish (35, 36). Women with a score ≥13 were considered to have probable minor depression or a score ≥15 probable major depression (37-39). The EPDS has been validated as a depression screening tool in pregnant and postpartum Hispanic women and has a sensitivity of 90%–100% and a specificity of 78%–88% for the identification of major and minor depression (36, 40).
Medical History Factors
After delivery, medical records were abstracted for medical and obstetrical history, including pre-pregnancy body mass index (BMI), parity, clinical characteristics of the current pregnancy, and reproductive history.
Data Analysis
Repeated-measures analyses of variances (ANOVAs) were computed to examine time differences in PSS scores within each stage of pregnancy. In light of prior literature suggesting a threshold effect of psychosocial factors on adverse maternal and fetal outcomes (41), we evaluated correlates of high perceived stress. Because there are no published cutpoints for high vs. moderate or low stress for the PSS, we compared women in the top quartile with those in lower quartiles of stress. Specifically, we chose a cut-off of PSS>30 to define high stress, based on the average of the 75th percentile scores (early=29, mid=30, and late=31) at each stage in pregnancy. Distributions of socio-demographic, acculturation, behavioral, medical and psychosocial factors were examined according to high and low stress categories using Chi Square Tests or Fisher’s Exact Test, in cases of small cell size. Multivariable logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CI) for high perceived stress during each stage of pregnancy in relation to potential correlates.
The basic model included correlates of high stress observed in prior literature (age, education, income, living situation and number of children in the household). Demographic, acculturation, behavioral and medical factors that were associated with high stress in unadjusted models at p<0.20 were added to the basic model, one at a time to evaluate the potential confounding effect on variables in the naïve model. Variables with a p-value <0.05 from likelihood ratio tests or that caused a greater than 10 percent change in the coefficient estimates for initial variables in the basic model were retained in subsequent models. We excluded trait anxiety and depression from the regression models as these factors may reflect aspects of stress and were highly correlated with perceived stress (r=0.66-0.81, p<0.01) (42). A missing indicator category was created for all variables that were missing information for more than 25 observations, aside from age, education, insurance, living situation, number of adults in the household, language preference and pre-pregnancy smoking and alcohol consumption. Tests for linear trend were calculated by modeling the ordinal variables as continuous variables.
Finally, to account for the correlation between repeated measures on the same subject, we used the generalized linear mixed effects model (Proc Glimmix) to model the effect of all correlates on stress (high vs. low) across pregnancy. This procedure allows specification of a mixed logistic regression model and handling of unbalanced data with correlated outcome and missing data. In all mixed models, the intercept was allowed to vary between subjects, and the regression slopes were assumed to be fixed effects. Statistical analysis was conducted using SAS 9.2 software by SAS Institute Inc. (SAS Campus Drive, Cary, North Carolina).
RESULTS
A total of 1,426 women had information on perceived stress at one or more time points during pregnancy as follows: early (n=979), mid (n=792), and late (n=751) pregnancy. Mean (Standard Deviation) PSS scores decreased from 26.2 (7.1) during early pregnancy to 25.2 (7.5) and 23.4 (7.7) during mid- and late pregnancy, respectively (p<.0001). Overall, participants were young, with low levels of education, and income (Table 1). In bivariate analyses, younger age and higher generation in the US were inversely associated with early pregnancy stress while pre-pregnancy alcohol consumption, pre- and early pregnancy smoking, depression, and trait anxiety were positively associated with early pregnancy stress (Table 1).
Table 1.
Baseline participant characteristics by perceived stress in early pregnancy, Proyecto Buena Salud, 2006-2011 Total Sample
| Total Sample |
PSS ≤
30 |
PSS >
30 |
P-value e | ||
|---|---|---|---|---|---|
| Nd | % | % | % | ||
| 979 | 100.0 | 73.1 | 26.9 | ||
| Demographic Factors | |||||
| Age | |||||
| Less than 19 | 211 | 21.6 | 23.6 | 16.0 | 0.01 |
| 19-23 years | 417 | 42.6 | 40.9 | 47.2 | |
| 24-29 years | 236 | 24.1 | 22.6 | 28.1 | |
| 30 years and above | 115 | 11.8 | 12.9 | 8.8 | |
| Educational status | |||||
| <High school | 460 | 47.5 | 46.5 | 50.0 | 0.29 |
| High school graduate | 313 | 32.3 | 32.0 | 33.1 | |
| Some college/graduate | 196 | 20.2 | 21.4 | 16.9 | |
| Annual Household Income | |||||
| <$15,000 | 283 | 28.9 | 28.2 | 30.8 | 0.09 |
| >$15,000-$30,000 | 147 | 15.0 | 15.8 | 12.9 | |
| >$30,000 | 74 | 7.6 | 8.7 | 4.6 | |
| Don’t know/Refused/Missing | 475 | 48.5 | 47.4 | 51.7 | |
| Health Insurance | |||||
| Public | 909 | 93.5 | 93.2 | 94.3 | 0.56 |
| Private | 63 | 6.5 | 6.8 | 5.7 | |
| Marital status | |||||
| Single/divorced/separated/widowed | 840 | 85.8 | 85.5 | 86.7 | 0.39 |
| Married | 103 | 10.5 | 11.2 | 8.8 | |
| Refused/Missing | 36 | 3.68 | 3.4 | 4.6 | |
| Live with spouse/partner | |||||
| No | 473 | 49.1 | 49.6 | 47.9 | 0.64 |
| Yes | 490 | 50.9 | 50.4 | 52.1 | |
| Children (<18 yrs) in householda | |||||
| 0 | 181 | 18.5 | 17.7 | 20.5 | 0.89 |
| 1 | 333 | 34.0 | 34.1 | 33.8 | |
| 2 | 237 | 24.2 | 24.6 | 23.2 | |
| 3+ | 192 | 19.6 | 19.8 | 19.0 | |
| Adults (>18 yrs) in householda | |||||
| 1 | 234 | 24.4 | 24.9 | 22.9 | 0.44 |
| 2 | 458 | 47.7 | 48.2 | 46.1 | |
| 3+ | 269 | 28.0 | 26.9 | 31.0 | |
| Acculturation Factors | |||||
| Language preference for speaking/reading | |||||
| English | 750 | 76.6 | 75.4 | 79.9 | 0.15 |
| Spanish | 229 | 23.4 | 24.6 | 20.2 | |
| Acculturation Statusb | |||||
| <3 | 746 | 76.2 | 77.5 | 72.6 | 0.25 |
| ≥3 | 192 | 19.6 | 18.7 | 22.1 | |
| Generation in the continental USc | |||||
| First generation | 446 | 45.6 | 46.8 | 42.2 | <.01 |
| Second generation | 446 | 45.6 | 42.7 | 53.2 | |
| Third generation | 54 | 5.5 | 6.6 | 2.7 | |
| Behavioral Factors | |||||
| Pre-pregnancy alcohol consumption | |||||
| None | 553 | 57.3 | 60.9 | 47.3 | <.0001 |
| 0 to 5 drinks per month | 172 | 17.8 | 18.1 | 17.1 | |
| Over 5 to 12 drinks per month | 107 | 11.1 | 10.0 | 14.0 | |
| Over 12 drinks per month | 134 | 13.9 | 11.0 | 21.7 | |
| Early pregnancy alcohol consumption | |||||
| None 929 | 94.9 | 94.7 | 95.4 | 0.89 | |
| Yes | 24 | 2.5 | 2.5 | 2.3 | |
| Pre-pregnancy cigarette smoking | |||||
| None | 640 | 66.3 | 69.8 | 56.6 | <.0001 |
| ≤ 10 cigarettes per day | 242 | 25.1 | 23.9 | 28.3 | |
| > 10 cigarettes per day | 84 | 8.7 | 6.4 | 15.1 | |
| Early pregnancy cigarette smoking | |||||
| None | 815 | 83.3 | 85.3 | 77.6 | 0.01f |
| ≤ 10 cigarettes per day | 124 | 12.7 | 10.9 | 17.5 | |
| > 10 cigarettes per day | 13 | 1.3 | 1.0 | 2.3 | |
| Total physical activity during early pregnancy |
|||||
| Quartile1 | 229 | 23.4 | 23.7 | 22.4 | 0.54 |
| Quartile2 | 229 | 23.4 | 23.7 | 22.4 | |
| Quartile3 | 229 | 23.4 | 24.2 | 21.3 | |
| Quartile4 | 228 | 23.3 | 21.9 | 27.0 | |
| Medical History Factors | |||||
| BMI | |||||
| Less than 18.5 | 45 | 4.6 | 4.1 | 6.1 | 0.44 |
| 18.5 to under 25 | 427 | 43.6 | 43.7 | 43.4 | |
| 25 to under 30 | 196 | 20.0 | 21.1 | 17.1 | |
| 30 or above | 196 | 20.0 | 19.8 | 20.5 | |
| Parity | |||||
| 0 | 365 | 37.3 | 38.1 | 35.0 | 0.36 |
| 1 | 267 | 27.3 | 28.1 | 25.1 | |
| ≥2 | 230 | 23.5 | 22.5 | 26.2 | |
| History of adverse pregnancy outcome | |||||
| No | 699 | 71.4 | 73.2 | 66.5 | 0.08 |
| Yes | 106 | 10.8 | 10.6 | 11.4 | |
| Psychosocial Factors | |||||
| Edinburgh Depression Scale | |||||
| At risk for depressive illness | |||||
| No | 678 | 69.3 | 81.7 | 35.4 | <.0001 |
| Yes | 272 | 27.8 | 15.5 | 61.2 | |
| Probable depression | |||||
| No | 780 | 79.7 | 89.3 | 53.6 | <.0001 |
| Yes | 170 | 17.4 | 8.0 | 43.0 | |
| Trait Anxiety | |||||
| Quartile1 | 268 | 27.4 | 36.6 | 2.3 | <.0001 |
| Quartile2 | 233 | 23.8 | 29.2 | 9.1 | |
| Quartile3 | 236 | 24.1 | 22.8 | 27.8 | |
| Quartile4 | 216 | 22.1 | 8.9 | 57.8 | |
Including the participant as appropriate: if <18 yrs, included as a child; if >18 yrs, included as an adult.
Acculturation is measured by the Psychological Acculturation Scale and ranges from 1-5; score <3=low acculturation
First generation: born in Puerto Rico/Dominican Republic (PR/DR) or parent born in PR/DR; Second generation: born in US but parents born in PR/DR; Third generation: born in US, parents born in US, grandparents born in PR/DR.
Numbers may not total to 979 due to missing data.
P-values from Chi square tests for categorical variables
P-values from Fishers test if expected cell counts less than 5
Associations in Early Pregnancy
Women less than 19 years of age were 50 percent less likely to have high levels of perceived stress during early pregnancy compared to women between 19 and 23 years (OR=0.5; 95% CI: 0.4,0.8, ptrend=0.48) (Table 2, Model A). After further adjustment for language preference (Model B), women who preferred Spanish had a 30 percent lower odds of high perceived stress compared to those who preferred English (95% CI: 0.5, 1.0). With further adjustment for generation and pre-pregnancy alcohol consumption (Model D), participants with annual household income greater than $30,000 were 60 percent less likely to have high stress as compared to those with income of $30,000 or less (95% CI: 0.2, 0.9, ptrend=0.06) (Model D). Participants reporting consumption of greater than 5 to 12 drinks and over 12 drinks per month during pre-pregnancy had 1.8 (95% CI: 1.1, 2.9) and 2.4 times (95% CI: 1.6, 3.6, ptrend<0.0001) higher odds of high stress as compared to those with no alcohol consumption in pre-pregnancy. In the final model (Model E) which adjusted for education, income, living situation, children in the household, language preference and generation, younger maternal age, pre-pregnancy smoking and alcohol consumption continued to be associated with perceived stress.
Table 2.
Odds ratios (95% confidence intervals) for high perceived stress during early pregnancy (n=979), Proyecto Buena Salud, 2006-2011
| Model A |
Model B |
Model C |
Model D |
Model E |
||||||
|---|---|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Demographic factors | ||||||||||
| Age | ||||||||||
| <19 | 0.5 | (0.4, 0.8) | 0.5 | (0.4, 0.8) | 0.5 | (0.3, 0.8) | 0.6 | (0.4, 0.9) | 0.6 | (0.4, 0.9) |
| 19-23 | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| 24-29 | 1.2 | (0.9, 1.8) | 1.3 | (0.9, 1.9) | 1.3 | (0.9, 1.9) | 1.3 | (0.9, 1.9) | 1.2 | (0.8, 1.8) |
| ≥30 | 0.7 | (0.4, 1.2) | 0.8 | (0.4, 1.3) | 0.8 | (0.5, 1.3) | 0.8 | (0.5, 1.4) | 0.7 | (0.4, 1.3) |
| Educational status | ||||||||||
| <High school | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| High school graduate | 0.9 | (0.6, 1.3) | 0.9 | (0.6, 1.3) | 0.9 | (0.6, 1.3) | 0.8 | (0.6, 1.2) | 0.9 | (0.6, 1.2) |
| Some college/graduate | 0.7 | (0.4, 1.1) | 0.7 | (0.4, 1.1) | 0.7 | (0.5, 1.1) | 0.6 | (0.4, 1.0) | 0.7 | (0.4, 1.1) |
| Annual Household Income | ||||||||||
| <$15,000 | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| >$15,000-$30,000 | 0.8 | (0.5, 1.3) | 0.8 | (0.5, 1.2) | 0.7 | (0.5, 1.2) | 0.8 | (0.5, 1.2) | 0.8 | (0.5, 1.2) |
| >$30,000 | 0.6 | (0.3, 1.1) | 0.5 | (0.2, 1.0) | 0.5 | (0.2, 1.0) | 0.4 | (0.2, 0.9) | 0.5 | (0.2, 1.0) |
| Don’t know/Refused/Missing | 1.1 | (0.8, 1.6) | 1.1 | (0.8, 1.6) | 1.1 | (0.8, 1.6) | 1.2 | (0.8, 1.7) | 1.2 | (0.8, 1.7) |
| Live with spouse/partner | ||||||||||
| No | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| Yes | 1.1 | (0.8, 1.5) | 1.1 | (0.8, 1.5) | 1.1 | (0.8, 1.5) | 1.2 | (0.8, 1.6) | 1.2 | (0.9, 1.6) |
| Children (<18 yrs) in household | ||||||||||
| 0 | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| 1 | 0.8 | (0.6, 1.3) | 0.9 | (0.6, 1.3) | 0.8 | (0.6, 1.3) | 0.9 | (0.6, 1.4) | 0.9 | (0.6, 1.4) |
| 2 | 0.8 | (0.5, 1.2) | 0.8 | (0.5, 1.3) | 0.8 | (0.5, 1.3) | 0.8 | (0.5, 1.3) | 0.8 | (0.5, 1.3) |
| 3+ | 0.8 | (0.5, 1.3) | 0.8 | (0.5, 1.4) | 0.8 | (0.5, 1.4) | 0.9 | (0.6, 1.5) | 0.9 | (0.6, 1.5) |
| Acculturation Factors | ||||||||||
| Language preference for | ||||||||||
| English | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent | ||
| Spanish | 0.7 | (0.5, 1.0) | 0.7 | (0.5, 1.1) | 0.8 | (0.5, 1.1) | 0.8 | (0.5. 1.2) | ||
| Generation in the continental US | ||||||||||
| Born in PR/DR | 1.0 | referent | 1.0 | referent | 1.0 | referent | ||||
| Parent born in PR/DR | 1.4 | (1.0, 1.9) | 1.3 | (0.9, 1.8) | 1.3 | (0.9, 1.8) | ||||
| Grandparent born in PR/DR | 0.4 | (0.2, 1.0) | 0.4 | (0.2, 1.0) | 0.4 | (0.2, 1.1) | ||||
| Behavioral Factors | ||||||||||
| Pre-pregnancy alcohol consumption | ||||||||||
| None | 1.0 | referent | 1.0 | referent | ||||||
| 0 to 5 drinks per month | 1.2 | (0.8, 1.9) | 1.2 | (0.8, 1.8) | ||||||
| Over 5 to 12 drinks per month | 1.8 | (1.1, 2.9) | 1.7 | (1.1, 2.8) | ||||||
| Over 12 drinks per month | 2.4 | (1.6, 3.6) | 2.2 | (1.4, 3.5) | ||||||
| Pre-pregnancy cigarette smoking | ||||||||||
| None | 1.0 | referent | ||||||||
| ≤ 10 cigarettes per day | 1.0 | (0.7, 1.5) | ||||||||
| > 10 cigarettes per day | 2.2 | (1.3, 3.7) | ||||||||
| c-statistic | 0.6 | 0.6 | 0.6 | 0.7 | 0.7 | |||||
Odds ratios (OR)s and 95% Confidence Intervals (CI)s calculated from multivariable logistic regression models.
Each variable was adjusted for all other variables in the model.
Model A = age, education, income, living with spouse/partner, and number of children in the household
Model B = Model A + language preference for speaking/reading
Model C = Model B + generation in the U.S.
Model D = Model C + pre-pregnancy alcohol consumption
Model E = Model D + pre-pregnancy cigarette smoking
Associations in Mid-Pregnancy
Unlike early pregnancy, younger maternal age was not associated with high perceived stress during mid-pregnancy (Table 3, Model A). Women with annual household income between $15,000 and $30,000 were 60 percent less likely to report high stress as compared to those with income below $15,000 (95% CI: 0.2, 0.8, ptrend<0.01). After adjustment for adults in the household (Model B), participants who reported living with three or more adults had an 80 percent increased odds of mid-pregnancy stress when compared with one-adult households (95% CI: 1.1, 3.0, ptrend=0.01). After further adjustment for language preference (Model C), women with annual household income of >$15,000 to $30,000 (OR=0.4, 95% CI: 0.2, 0.7) and >$30,000 (OR=0.4; 95% CI: 0.1, 0.9, ptrend<0.01) were less likely to report high stress compared to women with income ≤$15,000. Finally participants who preferred Spanish had a 40 percent reduced odds of high stress during mid-pregnancy as compared to those who preferred English as a language (95% CI: 0.4, 0.9).
Table 3.
Odds ratios (95% confidence intervals) for high perceived stress during mid-pregnancy (n=792), Proyecto Buena Salud, 2006-2011
| Model A |
Model B |
Model C |
||||
|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Demographic factors | ||||||
| Age | ||||||
| <19 | 0.7 | (0.4, 1.1) | 0.7 | (0.4, 1.1) | 0.7 | (0.4, 1.1) |
| 19-23 | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| 24-29 | 0.7 | (0.4, 1.1) | 0.8 | (0.5, 1.2) | 0.8 | (0.5, 1.3) |
| ≥30 | 0.9 | (0.5, 1.6) | 1.0 | (0.6, 1.9) | 1.2 | (0.6, 2.1) |
| Educational status | ||||||
| <High school | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| High school graduate | 0.9 | (0.6, 1.4) | 0.9 | (0.6, 1.4) | 1.0 | (0.7, 1.4) |
| Some college/graduate | 0.6 | (0.4, 1.1) | 0.6 | (0.4, 1.0) | 0.6 | (0.4, 1.1) |
| Annual Household Income | ||||||
| <$15,000 | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| >$15,000-$30,000 | 0.4 | (0.2, 0.8) | 0.4 | (0.2, 0.8) | 0.4 | (0.2, 0.7) |
| >$30,000 | 0.4 | (0.2, 1.1) | 0.4 | (0.2, 1.0) | 0.4 | (0.1, 0.9) |
| Don’t know/Refused/Missing | 0.7 | (0.5, 1.0) | 0.6 | (0.4, 1.0) | 0.7 | (0.5, 1.0) |
| Live with spouse/partner | ||||||
| No | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| Yes | 0.9 | (0.6, 1.3) | 0.8 | (0.6, 1.2) | 0.8 | (0.6, 1.3) |
| Children (<18 yrs) in household | ||||||
| 0 | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| 1 | 0.8 | (0.5, 1.2) | 0.8 | (0.5, 1.2) | 0.8 | (0.5, 1.3) |
| 2 | 0.8 | (0.5, 1.3) | 0.8 | (0.5, 1.3) | 0.8 | (0.5, 1.3) |
| 3+ | 1.3 | (0.7, 2.2) | 1.2 | (0.7, 2.1) | 1.3 | (0.7, 2.2) |
| Adults (>18 yrs) in household | ||||||
| 1 | 1.0 | referent | 1.0 | referent | ||
| 2 | 1.2 | (0.7, 1.9) | 1.1 | (0.7, 1.9) | ||
| ≥3 | 1.8 | (1.1, 3.0) | 1.8 | (1.1, 3.0) | ||
| Acculturation Factors | ||||||
| Language preference for | ||||||
| English | 1.0 | referent | ||||
| Spanish | 0.6 | (0.4, 0.9) | ||||
| c-statistic | 0.6 | 0.7 | 0.7 | |||
Odds ratios (OR)s and 95% Confidence Intervals (CI)s calculated from multivariable logistic regression models.
Each variable was adjusted for all other variables in the model.
Model A = age, education, income, living with spouse/partner, and number of children in the household
Model B = Model A + number of adults in the household
Model C = Model B + language preference for speaking/reading
Associations in Late Pregnancy
Annual household income >$15,000 to $30,000 was the only variable associated with high late pregnancy stress, when compared with income ≤$15,000 (OR=0.4; 95% CI: 0.2, 0.8, ptrend=0.16) (Table 4, Model A). No other sociodemographic, acculturation, and behavioral factors were significant correlates of high stress during late pregnancy.
Table 4.
Odds ratios (95% confidence intervals) for high perceived stress during late pregnancy (n=751), Proyecto Buena Salud, 2006-2011
| Model A |
Model B |
|||
|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | |
| Demographic factors | ||||
| Age | ||||
| <19 | 0.6 | (0.3, 1.0) | 0.6 | (0.3, 1.1) |
| 19-23 | 1.0 | referent | 1.0 | referent |
| 24-29 | 1.2 | (0.8, 2.0) | 1.2 | (0.8, 2.0) |
| ≥30 | 0.5 | (0.2, 1.2) | 0.5 | (0.2, 1.2) |
| Educational status | ||||
| <High school | 1.0 | referent | 1.0 | referent |
| High school graduate | 0.9 | (0.6, 1.4) | 0.9 | (0.6, 1.4) |
| Some college/graduate | 0.5 | (0.3, 1.0) | 0.5 | (0.3, 1.0) |
| Annual Household Income | ||||
| <$15,000 | 1.0 | referent | 1.0 | referent |
| >$15,000-$30,000 | 0.4 | (0.2, 0.8) | 0.3 | (0.2, 0.7) |
| >$30,000 | 1.0 | (0.4, 2.3) | 0.9 | (0.4, 2.2) |
| Don’t know/Refused/Missing | 0.8 | (0.5, 1.2) | 0.8 | (0.5, 1.2) |
| Live with spouse/partner | ||||
| No | 1.0 | referent | 1.0 | referent |
| Yes | 0.8 | (0.5, 1.2) | 0.8 | (0.5, 1.1) |
| Children (<18 yrs) in household | ||||
| 0 | 1.0 | referent | 1.0 | referent |
| 1 | 0.8 | (0.5, 1.4) | 0.8 | (0.5, 1.5) |
| 2 | 0.6 | (0.3, 1.2) | 0.6 | (0.3, 1.2) |
| 3+ | 1.0 | (0.5, 1.9) | 1.1 | (0.5, 2.1) |
| Generation in the continental US | ||||
| Born in PR/DR | 1.0 | referent | ||
| Parent born in PR/DR | 1.2 | (0.8, 1.8) | ||
| Grandparent born in PR/DR | 0.3 | (0.1, 1.2) | ||
| c-statistic | 0.6 | 0.7 | ||
Odds ratios (OR)s and 95% Confidence Intervals (CI)s calculated from multivariable logistic regression models.
Each variable was adjusted for all other variables in the model.
Model A - age, education, income, living with spouse/partner, and number of children in the household
Model B - Model A + generation in the U.S.
Overall Pregnancy
Results from the random intercept logistic regression models were similar to those obtained within each stage of pregnancy (Table 5). In the initial model (model A), age less than 19 years (OR=0.6; 95% CI: 0.4, 0.8), college education (OR=0.6; 95% CI: 0.4, 0.9), annual household income >$15,000 to $30,000 (OR=0.5; 95% CI: 0.4, 0.8), and late stage of pregnancy (OR=0.5; 95% CI: 0.4, 0.7) were inversely associated with reporting stress over time. After adding generation (Model B), participants with parents born in PR/DR were 40 percent more likely to report high stress as compared to those who themselves were born in PR/DR (95% CI: 1.1, 1.7). With further adjustment for pre-pregnancy alcohol consumption (Model C), women who reported consumption of over 12 drinks per month were 70 percent more likely to report high stress across pregnancy as compared to those with no alcohol consumption in pre-pregnancy (95% CI: 1.2, 2.5). In the final model which further adjusted for pre-pregnancy smoking (model D), age, income, and stage of pregnancy were significantly inversely associated with high stress across pregnancy; whereas pre-pregnancy alcohol consumption and smoking (OR= 1.9; 95% CI: 1.2, 2.8) were positively associated with high stress.
Table 5.
Adjusted odds of reporting high perceived stress using generalized linear mixed effects regression Proyecto Buena Salud, 2006-2011
| Model A |
Model B |
Model C |
Model D |
|||||
|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Demographic factors | ||||||||
| Age | ||||||||
| <19 | 0.6 | (0.4, 0.8) | 0.6 | (0.4, 0.8) | 0.6 | (0.4, 0.9) | 0.6 | (0.5, 0.9) |
| 19-23 | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| 24-29 | 1.0 | (0.8, 1.4) | 1.0 | (0.8, 1.4) | 1.0 | (0.8, 1.4) | 1.0 | (0.8, 1.4) |
| ≥30 | 0.7 | (0.5, 1.0) | 0.7 | (0.5, 1.1) | 0.7 | (0.5, 1.1) | 0.7 | (0.4, 1.0) |
| Educational status | ||||||||
| < High school | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| High school graduate | 0.9 | (0.7, 1.2) | 0.9 | (0.7, 1.2) | 0.9 | (0.7, 1.2) | 0.9 | (0.7, 1.2) |
| Some college/graduate | 0.6 | (0.4, 0.9) | 0.6 | (0.4, 0.9) | 0.6 | (0.4, 0.9) | 0.7 | (0.5, 1.0) |
| Annual Household Income | ||||||||
| <$15,000 | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| >$15,000-$30,000 | 0.5 | (0.4, 0.8) | 0.5 | (0.3, 0.8) | 0.5 | (0.3, 0.8) | 0.5 | (0.3, 0.8) |
| >$30,000 | 0.6 | (0.3, 1.0) | 0.6 | (0.3, 1.0) | 0.6 | (0.3, 1.0) | 0.6 | (0.3, 1.1) |
| Don’t know/Refused/Missing | 0.9 | (0.7, 1.1) | 0.9 | (0.7, 1.1) | 0.9 | (0.7, 1.2) | 0.9 | (0.7, 1.2) |
| Live with spouse/partner | ||||||||
| No | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| Yes | 0.9 | (0.7, 1.2) | 0.9 | (0.7, 1.2) | 0.9 | (0.7, 1.2) | 0.9 | (0.7, 1.2) |
| Children (<18 yrs) in household | ||||||||
| 0 | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| 1 | 0.8 | (0.6, 1.1) | 0.8 | (0.6, 1.1) | 0.8 | (0.6, 1.2) | 0.9 | (0.6, 1.2) |
| 2 | 0.7 | (0.5, 1.1) | 0.7 | (0.5, 1.1) | 0.8 | (0.5, 1.1) | 0.8 | (0.5, 1.1) |
| 3+ | 1.0 | (0.7, 1.4) | 1.0 | (0.7, 1.5) | 1.1 | (0.7, 1.6) | 1.1 | (0.7, 1.6) |
| Stage of pregnancy | ||||||||
| Early | 1.0 | referent | 1.0 | referent | 1.0 | referent | 1.0 | referent |
| Mid | 0.8 | (0.6, 1.0) | 0.8 | (0.6, 1.0) | 0.8 | (0.6, 1.0) | 0.8 | (0.6, 1.0) |
| Late | 0.5 | (0.4, 0.7) | 0.5 | (0.4, 0.6) | 0.5 | (0.4, 0.7) | 0.5 | (0.4, 0.7) |
| Acculturation Factors | ||||||||
| Generation in the continental US | ||||||||
| Born in PR/DR | 1.0 | referent | 1.0 | referent | 1.0 | referent | ||
| Parent born in PR/DR | 1.4 | (1.1, 1.7) | 1.3 | (1.0, 1.7) | 1.3 | (1.0, 1.7) | ||
| Grandparent born in PR/DR | 0.6 | (0.3, 1.0) | 0.6 | (0.3, 1.0) | 0.6 | (0.3, 1.0) | ||
| Behavioral Factors | ||||||||
| Pre-pregnancy alcohol consumption | ||||||||
| None | 1.0 | referent | 1.0 | referent | ||||
| 0 to 5 drinks per month | 1.0 | (0.7, 1.5) | 1.0 | (0.7, 1.4) | ||||
| Over 5 to 12 drinks per month | 1.5 | (1.0, 2.2) | 1.4 | (1.0, 2.1) | ||||
| Over 12 drinks per month | 1.7 | (1.2, 2.5) | 1.6 | (1.1, 2.3) | ||||
| Pre-pregnancy cigarette smoking | ||||||||
| None | 1.0 | referent | ||||||
| ≤ 10 cigarettes per day | 1.1 | (0.8, 1.4) | ||||||
| > 10 cigarettes per day | 1.9 | (1.2, 2.8) | ||||||
Odds ratios (OR)s and 95% Confidence Intervals (CI)s calculated from generalized linear mixed effects regression models.
Each variable was adjusted for all other variables in the model.
Model A - age, education, income, living with spouse/partner, number of children in the household, stage of pregnancy
Model B - Model A + generation in the US
Model C - Model B + prepregnancy alcohol consumption
Model D - Model C + prepregnancy smoking
Finally, women missing information on psychosocial stress did not differ from those not missing stress with regards to socio-demographic, acculturation, behavioral, and psychosocial factors aside from insurance type (14.9% vs. 7.3% with private insurance, p=0.01).
DISCUSSION
In this prospective study of pregnant Hispanic women, we found that stress levels significantly decreased over the course of pregnancy. Increasing age, pre-pregnancy alcohol, and smoking were positively associated with high early pregnancy stress. Number of adults in the household was positively associated with high mid-pregnancy stress; while increasing household income and Spanish language preference were inversely associated with high mid-pregnancy stress. Likewise, higher annual household income was inversely associated with high late pregnancy stress.
Our findings of a significant decrease in stress from early to mid- to late pregnancy are consistent with other studies that measured psychosocial stress at different time points (43-45), however one prior study conducted among predominantly non-Hispanic white women in Canada found that stress measures followed a U-shaped pattern with the lowest scores seen in the second trimester (46).
There are both similarities and differences between our findings and those of the prior literature. Stancil et al. found that higher perceived stress measured by the PSS-10 was statistically significantly associated with younger age, higher income, and lower educational status in a sample of 94 African-American pregnant women (17). Similarly, we found lower education levels to be associated with higher perceived stress, while in contrast we found that younger maternal age and higher income were associated with low perceived stress. Kingston et al., in a sample of Canadian pregnant women (10), found that history of depression, parity, and prior history of adverse pregnancy outcomes were positively related to stress. Our findings were similar for depression, but in contrast, we found that maternal age, annual household income and number of adults in the household were significantly associated with perceived stress while parity and prior history of adverse pregnancy outcomes were not significantly associated. Our results concur with a longitudinal study by Woods et al. conducted among predominantly non-Hispanic white women in Seattle, who found that marital status, employment, education, race, age, and history of pregnancy complication were not significantly associated with high psychosocial stress as measured by the Prenatal Psychosocial Profile Stress scale (9). Our finding that English language preference was positively associated with high stress may reflect higher acculturation status, which has been found to be associated with increased stressful life experiences and risk behaviors (47).
Differences in findings between our study and prior literature may be due to the differences in study populations, the timing of assessment during pregnancy, as well as the measurement tools used to assess stress. Only Stancil et al. used the PSS-10 to measure stress, and their findings in African American women were similar to ours (17).
Our study had several limitations. We relied on self-reported measures of perceived stress. Differences in stress levels among participants may reflect real differences in stress or cultural differences in the conceptualization and expression of stress. Some studies have suggested higher stigma regarding mental illness in Hispanics as compared to non-Hispanic whites and therefore greater reluctance to disclose such problems outside of the family (48, 49). Self-reported depressive symptoms in Hispanic women have also been found to differ by acculturation (50). However, the PSS has been validated against other instruments that measure similar constructs including average weekly stress, number of life events, distress and anxiety measures with adequate sensitivity to detect populations under different levels of stress (13, 28).
Additionally, our use of the top quartile to reflect high perceived stress may have led to misclassification. However, prior research has suggested a threshold effect for stress on preterm delivery with increased risk limited to women with scores in the highest quartile (41). Finally, due to the prospective nature of our study, such misclassification would tend to bias our results toward the null.
The present analysis was conducted among participants with complete stress information in early, mid, and late pregnancy. Those missing data did not differ significantly from those not missing data on all factors with the exception of insurance status. To the extent that insurance status is associated with stress, such missing data could have led to bias.
Residual confounding is a possibility due to errors in measurement or incorrect categorization of correlates. However, items on the questionnaire were adapted from previously validated scales and exposure categories included fairly standard groupings, thus minimizing this concern. We did not have information on history of mental health prior to pregnancy; however these measures would likely be highly correlated with pregnancy mental health (10, 37, 51). Finally, perceived stress levels and their correlates may differ according to race/ethnicity and socioeconomic status, thus limiting the generalizability of our findings.
In summary, in this prospective cohort of pregnant Hispanic women, maternal age, annual household income, pre-pregnancy alcohol and cigarette consumption were correlates of high perceived stress across pregnancy. Our findings that differing factors affected perceived stress during early, mid- and late pregnancy, underscores the importance of adjusting for these factors in analyses of stress and health outcomes. Our results have important implications in incorporation of routine screening for psychosocial stress during prenatal visits and implementation of psychosocial counseling services for women at high risk of adverse perinatal outcomes.
Acknowledgements
This work was supported by NIH/NIDDK grant R01DK064902
References
- 1.Austin MP, Leader L. Maternal stress and obstetric and infant outcomes: Epidemiological findings and neuroendocrine mechanisms. Aust N Z J Obstet Gynaecol. 2000;40(3):331–7. doi: 10.1111/j.1479-828x.2000.tb03344.x. [DOI] [PubMed] [Google Scholar]
- 2.Federenko IS, Wadhwa PD. Women’s mental health during pregnancy influences fetal and infant developmental and health outcomes. CNS Spectr. 2004;9(3):198–206. doi: 10.1017/s1092852900008993. [DOI] [PubMed] [Google Scholar]
- 3.Hobel CJ, Goldstein A, Barrett ES. Psychosocial stress and pregnancy outcome. Clin Obstet Gynecol. 2008;51(2):333–48. doi: 10.1097/GRF.0b013e31816f2709. [DOI] [PubMed] [Google Scholar]
- 4.Littleton HL, Bye K, Buck K, Amacker A. Psychosocial stress during pregnancy and perinatal outcomes: A meta-analytic review. J Psychosom Obstet Gynaecol. 2010;31(4):219–28. doi: 10.3109/0167482X.2010.518776. [DOI] [PubMed] [Google Scholar]
- 5.Mulder EJH, Robles dM, Huizink AC, Van dB, Buitelaar JK, Visser GHA. Prenatal maternal stress: Effects on pregnancy and the (unborn) child. Early Hum Dev. 2002;12;70(1-2):3–14. doi: 10.1016/s0378-3782(02)00075-0. [DOI] [PubMed] [Google Scholar]
- 6.Rice F, Jones I, Thapar A. The impact of gestational stress and prenatal growth on emotional problems in offspring: A review. Acta Psychiatr Scand. 2007;115(3):171–83. doi: 10.1111/j.1600-0447.2006.00895.x. [DOI] [PubMed] [Google Scholar]
- 7.Enkin M, Keirse MJNC, Chalmers I, Enkin E. A guide to effective care in pregnancy and childbirth. Oxford university press; Oxford: 1995. [Google Scholar]
- 8.American College of Obstetricians and Gynecologists Committee on Gynecologic Practice ACOG committee opinion no. 483: Primary and preventive care: Periodic assessments. Obstet Gynecol. 2011 Apr;117(4):1008–15. doi: 10.1097/AOG.0b013e318219226e. [DOI] [PubMed] [Google Scholar]
- 9.Woods SM, Melville JL, Guo Y, Fan MY, Gavin A. Psychosocial stress during pregnancy. Am J Obstet Gynecol. 2010 Jan;202(1):61.e1–61.e7. doi: 10.1016/j.ajog.2009.07.041. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Kingston D, Heaman M, Fell D, Dzakpasu S, Chalmers B. Factors associated with perceived stress and stressful life events in pregnant women: Findings from the Canadian maternity experiences survey. Matern Child Health J. 2012 Jan;16(1):158–68. doi: 10.1007/s10995-010-0732-2. [DOI] [PubMed] [Google Scholar]
- 11.Laraia BA, Siega-Riz AM, Gundersen C, Dole N. Psychosocial factors and socioeconomic indicators are associated with household food insecurity among pregnant women. J Nutr. 2006 Jan;136(1):177–82. doi: 10.1093/jn/136.1.177. [DOI] [PubMed] [Google Scholar]
- 12.Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009. J Appl Soc Psychol. 2012 [Google Scholar]
- 13.Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In: Spacapam S, Oskamp S, editors. The social psychology of health: Claremont Symposium on applied social psychology. Sage; Newbury Park, CA: 1988. [Google Scholar]
- 14.Dunkel Schetter C. Psychological science on pregnancy: Stress processes, biopsychosocial models, and emerging research issues. Annu Rev Psychol. 2011;62:531–58. doi: 10.1146/annurev.psych.031809.130727. [DOI] [PubMed] [Google Scholar]
- 15.Knackstedt MK, Hamelmann E, Arck PC. Mothers in stress: Consequences for the offspring. Am J Reprod Immunol. 2005;54(2):63–9. doi: 10.1111/j.1600-0897.2005.00288.x. [DOI] [PubMed] [Google Scholar]
- 16.Lynn FA, Alderdice FA, Crealey GE, McElnay JC. Associations between maternal characteristics and pregnancy-related stress among low-risk mothers: An observational cross-sectional study. Int J Nurs Stud. 2011 May;48(5):620–7. doi: 10.1016/j.ijnurstu.2010.10.002. [DOI] [PubMed] [Google Scholar]
- 17.Stancil TR, Hertz-Picciotto I, Schramm M, Watt-Morse M. Stress and pregnancy among African-American women. Paediatr Perinat Epidemiol. 2000 Apr;14(2):127–35. doi: 10.1046/j.1365-3016.2000.00257.x. [DOI] [PubMed] [Google Scholar]
- 18.Zambrana RE, Olivia Carter-Pokras. Health data issues for Hispanics: Implications for public health research. J Health Care Poor Underserved. 2001;12(1):20–34. doi: 10.1353/hpu.2010.0547. [DOI] [PubMed] [Google Scholar]
- 19.Gaffney KF, Choi E, Yi K, Jones GB, Bowman C, Tavangar NN. Stressful events among pregnant Salvadoran women: A cross-cultural comparison. J Obstet Gynecol Neonatal Nurs. 1997 May-Jun;26(3):303–10. doi: 10.1111/j.1552-6909.1997.tb02146.x. [DOI] [PubMed] [Google Scholar]
- 20.Chasan-Taber L, Fortner RT, Gollenberg A, Buonnaccorsi J, Dole N, Markenson G. A prospective cohort study of modifiable risk factors for gestational diabetes among Hispanic women: Design and baseline characteristics. J Womens Health (Larchmt) 2010 Jan;19(1):117–24. doi: 10.1089/jwh.2009.1416. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.U.S. Department of Commerce Economics and Statistics Administration. US Census Bureau [2007 cited 7/20/2012];The American Community—Hispanics: 2004 [Internet] Available from: http://www.census.gov/prod/2007pubs/acs-03.pdf.
- 22.Flegal KM, Ezzati TM, Harris MI, Haynes SG, Juarez RZ, Knowler WC, et al. Prevalence of diabetes in Mexican Americans, Cubans, and Puerto Ricans from the Hispanic health and nutrition examination survey, 1982-1984. Diabetes Care. 1991 Jul;14(7):628–38. doi: 10.2337/diacare.14.7.628. [DOI] [PubMed] [Google Scholar]
- 23.Himmelgreen DA, Bretnall A, Perez-Escamilla R, Peng Y, Bermudez A. Birthplace, length of time in the US, and language are associated with diet among inner-city Puerto Rican women keywords. Ecol Food Nutr. 2005;44(2):105–22. [Google Scholar]
- 24.Hajat A, Lucas JB, Kington R. Health outcomes among Hispanic subgroups: Data from the national health interview survey, 1992-95. Adv Data. 2000 Feb 25;(310):1–14. (310) [PubMed] [Google Scholar]
- 25.Misra D. The women’s health data book: A profile of women’s health in the united states. Jacobs Inst of Womens Health. 2001 [Google Scholar]
- 26.Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983 Dec;24(4):385–96. [PubMed] [Google Scholar]
- 27.Cohen LH, McGowan J, Fooskas S, Rose S. Positive life events and social support and the relationship between life stress and psychological disorder. Am J Community Psychol. 1984 Oct;12(5):567–87. doi: 10.1007/BF00897213. [DOI] [PubMed] [Google Scholar]
- 28.Remor E. Psychometric properties of a European Spanish version of the perceived stress scale (PSS) Span J Psychol. 2006 May;9(1):86–93. doi: 10.1017/s1138741600006004. [DOI] [PubMed] [Google Scholar]
- 29.Tropp LR, Erkut S, Coll CG, Alarcon O, Vazquez Garcia HA. Psychological acculturation: Development of a new measure for Puerto Ricans on the U.S. mainland. Educ Psychol Meas. 1999 Apr 1;59(2):351–67. doi: 10.1177/00131649921969794. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Williams LM, Morrow B, Lansky A, Beck LF, Barfield W, Helms K, et al. Surveillance for selected maternal behaviors and experiences before, during, and after pregnancy. pregnancy risk assessment monitoring system (PRAMS), 2000. MMWR Surveill Summ. 2003 Nov 14;52(11):1–14. [PubMed] [Google Scholar]
- 31.Chasan-Taber L, Schmidt MD, Roberts DE, Hosmer D, Markenson G, Freedson PS. Development and validation of a pregnancy physical activity questionnaire. Med Sci Sports Exerc. 2004 Oct;36(10):1750–60. doi: 10.1249/01.mss.0000142303.49306.0d. [DOI] [PubMed] [Google Scholar]
- 32.Spielberger CD. State-Trait anxiety inventory. Corsini Encyclopedia of Psychology. 1996.
- 33.Hickey CA, Cliver SP, Goldenberg RL, McNeal SF, Hoffman HJ. Relationship of psychosocial status to low prenatal weight gain among nonobese black and white women delivering at term. Obstet Gynecol. 1995 Aug;86(2):177–83. doi: 10.1016/0029-7844(95)00161-j. [DOI] [PubMed] [Google Scholar]
- 34.Spielberger CD, Gorsuch RL, Lushene RE. Te’cnicus Especialistas Asociados (TEA) Madrid: 1982. Manual STAI. cuestionario de ansiedad estado rasgo. [Google Scholar]
- 35.Jadresic E, Araya R, Jara C. Validation of the Edinburgh postnatal depression scale (EPDS) in Chilean postpartum women. J Psychosom Obstet Gynaecol. 1995 Dec;16(4):187–91. doi: 10.3109/01674829509024468. [DOI] [PubMed] [Google Scholar]
- 36.Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry. 1987 Jun;150:782–6. doi: 10.1192/bjp.150.6.782. [DOI] [PubMed] [Google Scholar]
- 37.Rich-Edwards JW, Kleinman K, Abrams A, Harlow BL, McLaughlin TJ, Joffe H, et al. Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Community Health. 2006 Mar;60(3):221–7. doi: 10.1136/jech.2005.039370. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Insaf TZ, Fortner RT, Pekow P, Dole N, Markenson G, Chasan-Taber L. Prenatal stress, anxiety, and depressive symptoms as predictors of intention to breastfeed among Hispanic women. J Womens Health (Larchmt) 2011 Aug;20(8):1183–92. doi: 10.1089/jwh.2010.2276. [DOI] [PubMed] [Google Scholar]
- 39.Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ. 2001 Aug 4;323(7307):257–60. doi: 10.1136/bmj.323.7307.257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Yonkers KA, Ramin SM, Rush AJ, Navarrete CA, Carmody T, March D, et al. Onset and persistence of postpartum depression in an inner-city maternal health clinic system. Am J Psychiatry. 2001 Nov;158(11):1856–63. doi: 10.1176/appi.ajp.158.11.1856. [DOI] [PubMed] [Google Scholar]
- 41.Misra DP, O’Campo P, Strobino D. Testing a sociomedical model for preterm delivery. Paediatr Perinat Epidemiol. 2001 Apr;15(2):110–22. doi: 10.1046/j.1365-3016.2001.00333.x. [DOI] [PubMed] [Google Scholar]
- 42.Alder J, Fink N, Bitzer J, Hosli I, Holzgreve W. Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern Fetal Neonatal Med. 2007 Mar;20(3):189–209. doi: 10.1080/14767050701209560. [DOI] [PubMed] [Google Scholar]
- 43.Rondo PH, Ferreira RF, Nogueira F, Ribeiro MC, Lobert H, Artes R. Maternal psychological stress and distress as predictors of low birth weight, prematurity and intrauterine growth retardation. Eur J Clin Nutr. 2003 Feb;57(2):266–72. doi: 10.1038/sj.ejcn.1601526. [DOI] [PubMed] [Google Scholar]
- 44.Curry MA, Burton D, Fields J. The prenatal psychosocial profile: A research and clinical tool. Res Nurs Health. 1998 Jun;21(3):211–9. doi: 10.1002/(sici)1098-240x(199806)21:3<211::aid-nur4>3.0.co;2-k. [DOI] [PubMed] [Google Scholar]
- 45.Hedegaard M, Henriksen TB, Sabroe S, Secher NJ. Psychological distress in pregnancy and preterm delivery. BMJ. 1993 Jul 24;307(6898):234–9. doi: 10.1136/bmj.307.6898.234. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Da Costa D, Larouche J, Dritsa M, Brender W. Variations in stress levels over the course of pregnancy: Factors associated with elevated hassles, state anxiety and pregnancy-specific stress. J Psychosom Res. 1999 Dec;47(6):609–21. doi: 10.1016/s0022-3999(99)00064-1. [DOI] [PubMed] [Google Scholar]
- 47.Lara M, Gamboa C, Kahramanian MI, Morales LS, Bautista DE. Acculturation and Latino health in the united states: A review of the literature and its sociopolitical context. Annu Rev Public Health. 2005;26:367–97. doi: 10.1146/annurev.publhealth.26.021304.144615. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Alvidrez J. Ethnic variations in mental health attitudes and service use among low-income African American, Latina, and European American young women. Community Ment Health J. 1999 Dec;35(6):515–30. doi: 10.1023/a:1018759201290. [DOI] [PubMed] [Google Scholar]
- 49.Ojeda VD, Bergstresser SM. Gender, race-ethnicity, and psychosocial barriers to mental health care: An examination of perceptions and attitudes among adults reporting unmet need. J Health Soc Behav. 2008 Sep;49(3):317–34. doi: 10.1177/002214650804900306. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Nguyen HT, Clark M, Ruiz RJ. Effects of acculturation on the reporting of depressive symptoms among Hispanic pregnant women. Nurs Res. 2007 May-Jun;56(3):217–23. doi: 10.1097/01.NNR.0000270027.97983.96. [DOI] [PubMed] [Google Scholar]
- 51.Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: A systematic review. Am J Obstet Gynecol. 2010 Jan;202(1):5–14. doi: 10.1016/j.ajog.2009.09.007. [DOI] [PMC free article] [PubMed] [Google Scholar]