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. 2022 Apr 13;79(6):600–609. doi: 10.1001/jamapsychiatry.2022.0597

Association of COVID-19 and Endemic Systemic Racism With Postpartum Anxiety and Depression Among Black Birthing Individuals

Wanjikũ F M Njoroge 1,2,3,4,✉, Lauren K White 1,2,4, Rebecca Waller 4,5, Markolline Forkpa 6, Megan M Himes 1,2,4, Kadina Morgan 7, Jakob Seidlitz 1,2,4, Barbara H Chaiyachati 4,8,9,10, Ran Barzilay 1,2,4, Sara L Kornfield 1,11, Julia Parish-Morris 1,2, Yuheiry Rodriguez 5, Valerie Riis 12, Heather H Burris 8,10, Michal A Elovitz 12, Raquel E Gur 1,2,4
PMCID: PMC9008565  PMID: 35416928

This cohort study assesses the association of the structural racism/COVID-19 syndemic with postpartum mental health of Black birthing individuals.

Key Points

Question

With the emergence of the COVID-19 pandemic, a catastrophic adverse event that has disproportionately impacted Black communities, layered on top of deep-rooted historical inequities (ie, syndemic), how has the postpartum mental health of Black birthing individuals been affected?

Findings

In this cohort study of 151 Black participants, perinatal syndemic exposure was associated with negative postpartum mental health outcomes. Specifically, more negative COVID-19 experiences and higher racism scores were associated with increased risk for postpartum depression and anxiety.

Meaning

Black birthing individuals already face significant challenges throughout the peripartum period, with adverse associations with mental health, which worsened during the COVID-19 pandemic.

Abstract

Importance

The intersection of endemic structural racism and the global health crisis secondary to the COVID-19 pandemic represents a syndemic, defined as the aggregation of 2 or more endemic and epidemic conditions leading to adverse repercussions for health. Long-standing inequities have placed Black individuals at disproportionate risk for negative postpartum mental health outcomes. Studies are urgently needed to understand how the COVID-19 pandemic has added to this risk (eg, syndemic associations).

Objective

To examine the association between the syndemic and the postpartum mental health of Black birthing individuals.

Design, Setting, and Participants

A longitudinal cohort of Black birthing individuals were followed up from pregnancy (April 17 to July 8, 2020) through the early postpartum period (August 11, 2020, to March 2, 2021) from urban university medical center prenatal clinics. Pregnant Black participants were recruited via email and completed 2 online surveys.

Main Outcomes and Measures

Composite variables capturing negative experiences of the COVID-19 pandemic and racism (structural racism [general], structural racism [neighborhood], and interpersonal racism) were created. Logistic regressions examined main and interactive associations between these variables and postpartum depression (Edinburgh Postnatal Depression Scale) and anxiety (Generalized Anxiety Disorder 7-item scale).

Results

The mean (SD) age of 151 Black participants was 30.18 (5.65) years. The association between higher negative COVID-19 pandemic experiences and postpartum depression may be influenced by experiences of interpersonal racism and general systemic racism. Negative COVID-19 pandemic experiences were associated with greater likelihood of screening positive for depression only at higher levels of systemic racism (odds ratio, 2.52; 95% CI, 1.38-4.60) and interpersonal racism (odds ratio, 1.90; 95% CI, 1.04-3.48) but not at lower levels of systemic or interpersonal racism. Similarly, negative COVID-19 experiences were associated with anxiety only at higher levels of interpersonal racism (odds ratio, 1.85; 95% CI, 0.86-4.01) but not at lower levels of interpersonal racism. Overall, 44 (29%) met screening criteria for postpartum depression and 20 (13%) for postpartum anxiety.

Conclusions and Relevance

In this longitudinal cohort study of Black birthing individuals, the experience of the syndemic was associated with negative postpartum mental health. Associations between interpersonal racism, structural racism, and negative COVID-19 pandemic experiences were associated with greater risk for postpartum depression and anxiety. Research is needed to address how systemic racism perturbs biobehavioral pathways to magnify associations between acute stressors and mental health. Such research can inform the creation of effective, culturally informed preventive interventions to improve the postpartum mental health of Black individuals.

Introduction

The COVID-19 pandemic has exposed our limited knowledge of how current experiences of acute adversity act in concert with long-standing disparities to affect mental health. In the US, the COVID-19 pandemic has disproportionately impacted Black communities,1 who have experienced higher rates of infection, morbidity and mortality,2,3 unemployment,4 housing and food insecurity,2 and adverse mental health outcomes.5,6 This crisis—the coupling of the COVID-19 pandemic and underlying racialized historical and social inequities—has been conceptualized as a syndemic, defined as the aggregation of 2 or more endemic and epidemic conditions leading to adverse repercussions for health.7,8,9 Specifically, researchers have leveraged the original syndemic framework by Singer10 to understand the health consequences arising from the COVID-19 pandemic exacerbating preexisting inequitable endemic factors.8,9,11 In leveraging this framework, we aimed to examine how the joint associations of structural and interpersonal racism (2 endemic conditions) and the COVID-19 pandemic (epidemic condition) contributed to postpartum anxiety and depression in Black individuals.

Before the COVID-19 pandemic, Black birthing individuals had documented disparate reproductive health experiences compared with non-Latinx White peers that are linked to racism,12 including obstetric racism (eg, beliefs and practices that harm the reproducing Black body),13 higher rates of untreated mental health disorders, including postpartum depression,14 and 3 times greater likelihood of perinatal complications15 and pregnancy-related mortality.16,17 During the COVID-19 pandemic, Black individuals have also faced particular difficulties, including more worry about COVID-19,18 food and job insecurity,4 challenges during pregnancy and postdelivery,19 and mental health adversity.20 Our data, collected early in the COVID-19 pandemic, showed that compared with non-Latinx White participants, pregnant Black participants reported higher rates of depression and anxiety. Black participants also endorsed more COVID-19–specific worries, including worries about giving birth and childcare.18 While studies have begun to explore the factors affecting birthing individuals during the COVID-19 pandemic,18,21 a paucity of evidence exists from studies that have used a syndemic framework7 to explore the intersection of race,21 racism, and COVID-1922 on the postpartum mental health of Black individuals.18,23,24

Historically, race has been confounded with racism, resulting in the use of phenotypic appearance as a major variable in illness and health.8 The context in which individuals live, work, and play has largely been ignored, resulting in failures to acknowledge that health disparities are secondary to endemic racist systems and barriers.25 Structural racism, defined as “practices that maintain or exacerbate unfair inequalities in power, resources or underlying systemic racist conditions,”26 is embedded within experiences of health care, housing, employment, and education.27 These experiences confer negative health consequences for Black individuals, which the COVID-19 pandemic has exacerbated. For example, in the 1930s, the Home Owners’ Loan Corporation (HOLC) created a systematic appraisal that graded neighborhoods based on quality of housing, proximity to industry, and characteristics of residents in the neighborhood.28 These grades commonly redlined Black communities, deeming them high-risk to mortgage lenders.29 Redlining created restrictive covenants where Black families could live, which undermined their ability to build wealth29,30,31,32 and left a persistent and quantifiable legacy of negative health effects.28,33 Additionally, interpersonal or personally mediated racism represents prejudiced assumptions assigned to an individual’s abilities, motives, aptitude, and intentions based solely on race.34 Interpersonal racism confers heightened states of psychological and physiological stress, which has been linked to poor health outcomes.35

The clinical care that Black individuals receive during pregnancy represents a vital determinant of long-term health and is susceptible to both structural and interpersonal racism.26,36,37 More broadly, pregnancy can be a vulnerable period for psychological well-being,38 and studies have established negative trajectories of mental health among parents during the COVID-19 pandemic.39 Thus, when considering the COVID-19 pandemic in the context of postpartum mental health in Black birthing individuals,40 it is imperative to understand how multiple types of racism are associated with negative experiences. We assessed Black participants from a prospective longitudinal study to explore how the syndemic was associated with postpartum mental health. Specifically, we developed multidimensional measures of racism and negative COVID-19 pandemic experiences during the peripartum period (eg, syndemic) and explored associations with risk for postpartum depression and anxiety.

Methods

Participants

This observational study followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline41 and included Black participants from a longitudinal cohort study examining the perinatal period during the COVID-19 pandemic.18,23 Participants from all gestational ages who received prenatal care at 1 of 2 urban hospitals in the University of Pennsylvania Health System in Philadelphia were recruited by email, without exclusionary criteria. The study was approved by the university institutional review board. After obtaining written informed consent, participants completed an online REDCap survey about their experiences of the COVID-19 pandemic. Data were also collected on childbirth through electronic medical records and a follow-up online REDCap survey completed during the postpartum period. Participant race (African American/Black, Asian, Latina [not otherwise specified], Native Hawaiian/Pacific Islander, White, declined, other, and unknown) and ethnicity (Hispanic/Latina, non-Hispanic/non-Latina, declined, unknown) data were collected from the electronic medical records.

The pregnancy survey (mean [SD] gestational age, 25.3 [7.8] weeks) was completed during a statewide stay-at-home order, a period of high community spread of COVID-19 (April 17 to July 8, 2020). The postpartum survey (mean [SD] gestational age, 12.7 [5.5] weeks) was completed between August 11, 2020, and March 2, 2021. Participants completed each survey in about 20 minutes, although not all survey sections were completed by all participants. Figure 1 presents recruitment flowchart and attrition, and eTable 1 in the Supplement provides comparison of Black and non-Latinx White individuals, which were the 2 groups powered for further analysis owing to sample size. Participants received $25 gift cards for completing the postpartum survey.

Figure 1. Recruitment and Attrition Flow Diagram From Larger Cohort.

Figure 1.

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When comparing the Black persons in the current sample (with usable data across all time points) with Black individuals who were eligible for the postpartum survey but did not complete, those lost to attrition were younger (t255 = –3.61; P < .001) and had lower socioeconomic scores (t254 = 2.84; P < .001). The 2 groups did not differ on their prenatal depression status or prenatal anxiety status. For the pregnancy survey, we recruited from 3966 individuals, and 1173 (30%) completed the survey. For the postpartum survey, we recruited 1089 individuals of which 833 (78%) completed.

Measures

COVID-19 Pandemic Variables

At both assessments, participants were asked about 3 COVID-19–related stressors: how the COVID-19 pandemic had affected their lives (eg, job loss, knew someone who had passed away from COVID-19 complications). Participants also completed 4 items assessing how the COVID-19 pandemic had impacted their birthing and postpartum experience (postpartum survey) and if they were worse off financially because of the pandemic (postpartum survey). Participants rated their worries about 6 general COVID-19 stressors42 (pregnancy and postpartum surveys) and 4 COVID-19 stressors specific to pregnancy (pregnancy survey) (eTable 2 in the Supplement).

Racism Variables

Structural Racism

Information from electronic medical records and participant report was used to assess income inequality (below vs above $20 000 annually), education (no college vs partial college graduate degree), insurance type (private vs public/Medicaid), relationship status (married/living with partner vs other),43 parity, and house ownership (own vs other). Additionally, a HOLC-informed Philadelphia measure of structural racism–based redlining was used based on prior digitized HOLC boundaries.44 Each participant received a risk grade from A (minimal) to D (hazardous) based on their street address.44 A census-based neighborhood socioeconomic status composite variable45 was also created using census-based geocoding of neighborhood-based variables (eg, percentage of residence in poverty, percentage married, percentage with <high school education, median family income) based on participant zip codes. Neighborhoods were blocked into census groups, generally containing 600 to 3000 persons.

Interpersonal Racism

Participants completed 2 scales: the 10-item Everyday Discrimination Scale46,47 and 6-item Major Experiences of Discrimination Scale.46,48

Prenatal and Postpartum Mental Health Measures

Prenatal anxiety was assessed using the Generalized Anxiety Disorder 7-item scale,49 and prenatal depression was assessed using the Patient Health Questionnaire 2.50 Postpartum anxiety was assessed using the Generalized Anxiety Disorder 7-item scale, and postpartum depression was assessed using a 9-item Edinburgh Postnatal Depression Scale.51,52 We removed item 10, which assesses self-harm, given the difficulty of monitoring self-harm endorsements in online surveys. Consistent with prior studies, we used clinical cutoffs of 10 or higher for postpartum depression52,53 and 11 or higher for postpartum anxiety.54

Analytic Strategy

Data reduction techniques were used to create composites to capture experiences of the COVID-19 pandemic and racism. First, to create a summary score reflecting negative pandemic experiences, all COVID-19–related items (detailed above) were summed together. Variables were recoded such that 1 indicated negative experiences and 0 indicated absence/neutral COVID-19 experiences. For items rated on a Likert scale (eg, COVID-19 pandemic worries), endorsement of higher values (eg, moderate, a lot, a great deal) were recoded as 1, with other response options (eg, a little, not at all) coded as 0 (eTable 2 in the Supplement provides frequencies for each response option prior to creating binary scores). For other items (eg, positive COVID-19 test), a yes response was coded as 1 and no as 0. A composite factor was created by summing all items, with higher scores reflecting more negative COVID-19 pandemic experiences. Second, to capture the multidimensional experience of racism, all racism variables were subjected to Exploratory Factor Analysis55 in Mplus56 using the mean- and variance-adjusted weighted least squares (wlsmv) estimator57 and oblimin rotation. Items with fewer than 4 response categories (including binary items) were treated as ordinal in the analysis; all others were treated as continuous. Additionally, the number of factors (3) was determined by parallel analysis with Glorfeld correction58 at a 0.95 threshold using the ‘psych’ package in R version 2.1.3 (R Foundation).59

Next, a series of logistic regression analyses examined the associations of negative COVID-19 pandemic experiences and racism with postpartum depression and anxiety. In each regression model, data were entered in 3 blocks. Block 1 included maternal age, parity, gestational weeks at prenatal assessment, and weeks post partum at the postpartum survey. In block 2, we entered the negative COVID-19 pandemic experience and racism factors to examine their unique associations with postpartum outcomes. To reduce multicollinearity across the racism and COVID-19 pandemic factors, all factors were regressed out of each other. In block 3, we entered 2-way associations between the pandemic factor with each racism factor, which together represented syndemic measures. To probe significant interactions, logistic regressions were rerun at high and low levels of the racism factor scores (median split). Supplemental analyses examined (1) models only using the redlining measure (HOLC grades) and perceived discrimination as measures of racism, controlling for socioeconomic status and (2) models using only COVID-19 worries and the 3 racism variables. Cronbach α were acceptable for all scales (eTable 3 in the Supplement). Two-sided P values were significant at .05 or less.

Results

A total of 151 Black participants (5 also identified as Latinx/Hispanic) were analyzed. The mean (SD) gestational age was 25.3 (7.8) weeks (range, 10-39 weeks).

Negative COVID-19 Pandemic Experiences

Table 1 presents summary statistics for variables that contributed to the negative COVID-19 pandemic experiences factor. For the 6 general COVID-19 worries, 87% (n = 132) of participants endorsed at least 1 significant worry (eg, ≥moderate) at the pregnancy assessment and 71% (n = 107) endorsed at least 1 significant worry at the postpartum survey. For pregnancy-related COVID-19 worries, 91% (n = 137) endorsed at least 1 significant worry. For delivery-related and postpartum-related pandemic worries, 81% (n = 121) endorsed at least a moderate concern for at least 1 item. The negative COVID-19 pandemic experiences factor (summing across all 27 pandemic-related variables) yielded a mean (SD) score of 14.1 (5.9) (skewness, –0.18; kurtosis, –0.89; range, 2-25; eFigure in the Supplement).

Table 1. Demographics and Racism- and COVID-19–Related Variables.

Characteristic No./total No. (%)
Maternal age, mean (SD) [range], ya 30.18 (5.65) [18 to 41]
Neighborhood SES, mean (SD) [range]a 0.48 (0.80) [–2.60 to 2.08]
Everyday discrimination scale score, mean (SD) [range]b 11.22 (9.58) [0 to 39]
Major experience scale score, mean (SD) [range]b 1.37 (1.43) [0 to 6]
Postpartum depression (EPDS score), mean (SD) [range]a,c 6.46 (5.73) [0 to 21]
Postpartum anxiety (GAD-7 score), mean (SD) [range]a,d 4.33 (4.91) [0 to 21]
Parity (>1)c 90/151 (60)
Relationship status (not married/living with partner)e
Pregnancy survey 96/151 (64)
Postpartum survey 67/151 (44)
Income (<$20 000 annually)f 51/151 (34)
Education (<college degree)g 86/151 (57)
Insurance (public/Medicaid) 88/151 (58)
House ownership (do not own) 102/151 (68)
HOLC grades (<B) 89/117 (59)
Positive COVID-19 test result (self-report) 10/139 (7)
Know someone who passed away from COVID-19 41/150 (27)
COVID-19 pandemic job loss (including decrease hours/pay) 90/150 (60)
Worse off financially at postpartum survey (≥moderately worse off) 62/150 (41)
Significant general COVID-19 worry (≥moderate worry for at least 1 item)
Pregnancy survey 132/151 (87)
Postpartum survey 107/150 (71)
Significant pregnancy-related COVID-19 worry at pregnancy survey (≥moderate worry for at least 1 item) 137/151 (91)
Significant birth and postpartum negative COVID-19 experience at postpartum survey (≥moderate effects for at least 1 item) 121/150 (81)
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Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; GAD-7, Generalized Anxiety Disorder 7-item scale; HOLC, Home Owners’ Loan Corporation; SES, socioeconomic status.

a

n = 151.

b

n = 148.

c

Parity mean (range), 1.34 (0-9); gravidity mean (range), 3.47 (1-12). For children, this sample ranged from 0 to 9 (mean, 2.35) living with them.

d

Clinical threshold for GAD-7 was 11 or higher; 13% (n = 20) of the sample screened positive for postpartum anxiety.

e

Relationship status options were single, partnered/married but not living together, partnered/married and living together, divorced/separated, widowed, or other.

f

Overall, 33.8% (n = 51) of participants reported a household income of less than $20 000, 41.7% (n = 63) reported household income of $20 000 to less than $60 000, 13.9% (n = 21) reported an income of between $60 000 and less than $100 000, and 10.6% (n = 16) reported income above $100 000.

g

Overall, 27.8% (n = 42) of participants obtained a high school degree, 34.4% (n = 52) completed trade school/apprenticeship or some college, 18.5% (n = 28) obtained a bachelor’s degree, and 14.6% (n = 22) obtained a graduate level degree.

Systemic and Interpersonal Racism

Table 1 presents descriptive statistics for each of the racism variables. Two participants (1.3%) received a HOLC risk grade of A; 26 (17.2%), grade B; 38 (25.2%), grade C; and 51 (33.8%), grade D (Figure 2). HOLC grades were missing from 34 participants. The Exploratory Factor Analysis suggested the existence of 3 latent factors (eTable 4 in the Supplement): factor 1, systemic racism (general), captured individual-level systemic racism (income inequality, education, insurance); factor 2, systemic racism (neighborhood), reflected broader neighborhood level systemic racism (HOLC grades, neighborhood socioeconomic status, relationship status); and factor 3, interpersonal racism, captured perceived discrimination (Major Experiences of Discrimination Scale and Everyday Discrimination Scale scores).

Figure 2. Plot of Sample’s Locations on the Home Owners’ Loan Cooperation (HOLC) Redlining Map of Philadelphia, Pennsylvania.

Figure 2.

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HOLC grades, a Philadelphia measure of structural racism–based redlining, are displayed. The risk scoring scheme ranged from A (minimal, green) to D (hazardous, red). Adapted via the Creative Commons Attribution-ShareAlike 2.0 Generic License (CC BY-SA 2.0).

The Syndemic and Postpartum Depression

Overall, 44 participants (29%) screened positive for postpartum depression. Logistic regression revealed that more negative COVID-19 pandemic experiences (odds ratio [OR], 1.88; 95% CI, 1.22-2.88) and higher interpersonal racism (OR, 1.60; 95% CI, 1.05-2.36) were independently associated with higher likelihood of screening for postpartum depression (Table 2). There were also significant associations between negative COVID-19 experiences and both systemic racism (general) and interpersonal racism. Negative COVID-19 pandemic experiences were significantly associated with postpartum depression among participants who reported high levels of systemic racism (general) (OR, 2.52; 95% CI, 1.38-4.60) but not low systemic racism (general) (OR, 1.03; 95% CI, 0.59-1.78; Figure 3A). Negative COVID-19 pandemic experiences were also associated with postpartum depression specifically among participants reporting high interpersonal racism (OR, 1.90; 95% CI, 1.04-3.48) but not low interpersonal racism (OR, 1.26; 95% CI, 0.72-2.21; Figure 3B). The associations (of COVID-19 pandemic experiences and interpersonal racism) remained significant after controlling for prenatal depression (eTable 5 in the Supplement).

Table 2. Logistic Regression Examining the Associations of COVID-19 and Racism With Postpartum Depression and Anxiety in Black Birthing Individualsa.

Factor B (SE) Wald statisticb P value Odds ratio (95% CI)
Syndemic associations with postpartum depression
Block 1
Maternal age –0.05 (0.04) 1.55 .21 0.95 (0.88-1.03)
Parity, first pregnancy (reference, yes) –0.29 (0.43) 0.46 .50 0.75 (0.32-1.74)
Gestational weeks at pregnancy survey –0.02 (0.02) 0.93 .34 0.98 (0.93-1.03)
Postpartum weeks at postpartum survey 0.05 (0.03) 2.21 .14 1.05 (0.98-1.12)
Block 2
COVID-19 pandemic associations 0.63 (0.22) 8.34 <.001 1.88 (1.22-2.88)
Systemic racism
General –0.24 (0.39) 0.38 .54 0.79 (0.37-1.69)
Neighborhood –0.54 (0.37) 2.05 .15 0.59 (0.28-1.22)
Interpersonal racism 0.47 (0.21) 5.19 .02 1.60 (1.07-2.39)
Block 3
COVID-19 pandemic × systemic racism
General 0.68 (0.35) 3.67 .055 NA
Neighborhood 0.47 (0.37) 1.62 .20 NA
COVID-19 pandemic × interpersonal racism 0.65 (0.27) 5.73 .02 NA
Syndemic associations with postpartum anxiety
Block 1
Maternal age –0.02 (0.05) 0.21 .65 0.98 (0.88-1.08)
Parity, first pregnancy (reference, yes) –0.22 (0.57) 0.15 .70 0.80 (0.26-2.45)
Gestational weeks at pregnancy survey –0.02 (0.03) 0.27 .61 0.98 (0.92-1.05)
Postpartum weeks at postpartum survey 0.05 (0.04) 1.70 .19 1.05 (0.97-1.14)
Block 2
COVID-19 pandemic associations 0.49 (0.29) 2.93 .09 1.64 (0.93-2.87)
Systemic racism
General –0.58 (0.51) 1.33 .25 0.56 (0.21-1.51)
Neighborhood –0.52 (0.49) 1.16 .28 0.59 (0.23-1.54)
Interpersonal racism 0.39 (0.26) 2.24 .13 1.48 (0.89-2.47)
Block 3
COVID-19 pandemic × systemic racism
General 0.67 (0.45) 2.24 .13 NA
Neighborhood 0.45 (0.49) 0.87 .35 NA
COVID-19 pandemic × interpersonal racism 1.03 (0.44) 5.44 .02 NA
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Abbreviation: NA, not applicable.

a

eTable 4 in the Supplement report on linear regression findings using continuous measures of postpartum depression and anxiety. Analyses using the redlining variable as a represenatation for racism (eTable 7 in the Supplement) and using only COVID-19 distress/worries as a proxy for negative pandemic experiences (eTable 8 in the Supplement) are in the Supplement.

b

The df for all was 1.

Figure 3. Joint Associations of the COVID-19 Pandemic and Racism (ie, the Syndemic) With Postpartum Depression and Anxiety.

Figure 3.

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Negative COVID-19 pandemic experiences were only associated with postpartum depression when participants reported high levels of structural racism (general) and interpersonal racism (odds ratio [OR], 2.52; 95% CI, 1.38-4.60 and OR, 1.90; 95% CI, 1.04-3.48, respectively), but not at low levels (OR, 1.03; 95% CI, 0.59-1.78 and OR, 1.26; 95% CI, 0.72-2.21, respectively). Negative COVID-19 pandemic experiences were only associated with postpartum anxiety when participants reported high levels of interpersonal racism (OR, 1.85; 95% CI, 0.86-4.01) but not low levels (OR, 0.94; 95% CI, 0.43-2.02).

The Syndemic and Postpartum Anxiety

A total of 20 participants (13%) met screening criteria for postpartum anxiety. There were no main associations of COVID-19 pandemic experiences or racism with risk for postpartum anxiety. However, as with postpartum depression, there was a significant association between negative COVID-19 pandemic experiences and interpersonal racism. Negative pandemic experiences were associated with postpartum anxiety for those reporting high interpersonal racism (OR, 1.85; 95% CI, 0.86-4.01) but not low levels (OR, 0.94; 95% CI, 0.43-2.02; Figure 3C). The associations remained significant after controlling for prenatal anxiety (eTable 5 in the Supplement).

Discussion

No epidemic has impacted the global community for such a protracted period of time as the COVID-19 pandemic.60 Because the COVID-19 pandemic is ongoing, understanding its disproportional association with vulnerability of Black birthing individuals is critical.61 Historically, Black individuals have been more vulnerable to develop postpartum depression compared with non-Latinx White counterparts62 but are less likely than other racial and ethnic groups to receive treatment.14,63 Studies conducted during the COVID-19 pandemic have similarly reported that more than one-third of Black pregnant individuals report levels of anxiety and depression that are clinically significant.64 Our focus on Black birthing individuals, drawn from a longitudinal study examining the association of the COVID-19 pandemic with peripartum experiences, engenders a deeper understanding of structural racism that is persistently negatively associated with mental health in Black communities in the US.65 Consistent with other recent reports, 29% of our sample met screening criteria for postpartum depressive symptoms.66,67

These estimates highlight the possibility that the COVID-19 pandemic, when combined with structural endemic racism, has created syndemic forces that have worsened conditions for Black communities.8,9,11 In addressing this question among peripartum Black individuals, we hypothesized that the syndemic would have created extra burden and increased risk of postpartum depression and anxiety.40 In line with our hypotheses, worse experiences during the COVID-19 pandemic, interpersonal racism, and living in an area of greater historical redlining, were all uniquely associated with postpartum depression (eTable 7 in the Supplement). Moreover, significant associations between racism and adverse postpartum mental health outcomes were magnified with more negative COVID-19 pandemic experiences. Specifically, individuals with more negative COVID-19 experiences combined with higher interpersonal and systemic general racism scores were at highest risk of meeting screening criteria for postpartum depression and anxiety. These findings are commensurate with the growing literature linking racism with maternal health and well-being,68 which COVID-19 has worsened.

The findings extend data on health inequities and deepen understanding of Black birthing individuals’ disparate experiences during the syndemic. Our understanding and prevention of future syndemics can be viewed through a public health framework with need for wide-reaching changes that target larger structural factors that contribute to adverse mental health outcomes, including postpartum depression and anxiety, in Black individuals. Importantly, Black individuals face significant challenges and disadvantages during pregnancy and after delivery, with adverse associations with maternal mental health, which have only worsened during the COVID-19 pandemic.

We have articulated the specific challenges faced by Black individuals and, in the face of the ongoing COVID-19 pandemic, are hopeful that the field can meet this moment by collaborating across disciplines to ensure that those most at risk have equitable access to immediate assessment throughout the peripartum period; ensuring rapid and equitable treatment; and maintaining continued vigilance postdelivery. Furthermore, we urgently need to engage larger numbers of Black participants in research efforts and investigate how different forms of racism might be differentially associated with behavioral and mental health. If we are able to collectively work toward these goals, we can effectively support Black birthing individuals’ mental health in 2022 and beyond.

Limitations

The study has several limitations. First, the sample is relatively small and there was attrition of Black participants from pregnancy to postpartum assessments. Although participants lost to follow-up did not report higher depression or anxiety in pregnancy, our findings may underestimate associations between negative COVID-19 experiences, racism, and risk for depression and anxiety. Second, because of our sample size, we assessed separate outcome measures of postpartum depression and anxiety, which represents only a snapshot of how the syndemic could be associated with mental health of Black birthing individuals (eg, larger samples could more fully explore depression and anxiety associations). We also did not screen for other mental health disorders. Third, we found no main associations of the COVID-19 experience or racism variables with the clinical screening measure for anxiety. However, the pattern of findings was similar to that for depression risk and both COVID-19 experiences and interpersonal racism were significantly associated with anxiety in models using a continuous symptom measure (eTable 6 in the Supplement). Overall, given the lower rate of participants meeting criteria for postpartum anxiety (20 [13%]) relative to depression, we may have been underpowered to detect associations using a binary screening measure. Alternatively, COVID-19 pandemic experiences and different dimensions of racism (eg, structural vs interpersonal) could differentially influence postpartum anxiety vs depression. Fourth, we used self-report surveys for our clinical measures, necessitating replication with comprehensive diagnostic assessments. Fifth, race and ethnicity assessments were based on electronic medical records, which is less accurate than patients self-identifying.69 Finally, we did not compare syndemic experiences among a non-Black comparison group. However, by limiting the sample, we were fully able to explore the depth and diversity of the mental health and reproductive experiences of Black individuals in the midst of a global pandemic.

Conclusions

In this longitudinal cohort study of Black birthing individuals, experience of the syndemic was associated with negative postpartum mental health. Long-standing structural inequities have been negatively associated with every aspect of Black individuals’ lives from neighborhood quality to nutrition, medical care, and related services. These findings underscore the importance of early detection of prenatal mood disorders and point to an urgent need for policy developments to mitigate downstream mental health effects of COVID-19, which may be disproportionately associated with Black birthing individuals. The results suggest that the key to better serving Black individuals includes an improved understanding of the intertwining issues that many of the participants faced, namely, that structural racism produces a cascade of linked inequities surrounding wealth, wages, housing, educational attainment, and mental health.

Supplement.

eTable 1. Means and Rates of Racism and Pandemic-related Variables for Black (n=151) and non-Latinx White Participants (n=571)

eTable 2. Response Rates for Endorsement of Each Response Option for Likert Response Pandemic-Related Variables that were Recoded to a Dichotomous Variable

eTable 3. Internal Consistency of Key Study Scales

eTable 4. Factor Analysis examining Factors of Racism

eTable 5. Logistic Regression Examining the effects of the Pandemic and Racism on Postpartum Depression and Anxiety in Black Women controlling for prenatal depression and anxiety

eTable 6. Linear Regression Examining the effects of the Pandemic and Racism on Postpartum Depression and Anxiety in Black Women

eTable 7. Logistic Regression Examining the effects of the Pandemic, Redlining, and Interpersonal Racism on Postpartum Depression and Anxiety in Black Women

eTable 8. Logistic Regression Examining the effects of the Pandemic Worries and Racism on Postpartum Depression and Anxiety in Black Birthing Individuals

eFigure. Histogram of the Negative Pandemic Experiences Summary Variable

Click here for additional data file. (329.8KB, pdf)

References

  • 1.Tai DBG, Shah A, Doubeni CA, Sia IG, Wieland ML. The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States. Clin Infect Dis. 2021;72(4):703-706. doi: 10.1093/cid/ciaa815 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Do DP, Frank R. Unequal burdens: assessing the determinants of elevated COVID-19 case and death rates in New York City’s racial/ethnic minority neighbourhoods. J Epidemiol Community Health. 2020;75(4):321-326. doi: 10.1136/jech-2020-215280 [DOI] [PubMed] [Google Scholar]
  • 3.US Census Bureau COVID-19 Site . Accessed January 12, 2022. https://covid19.census.gov/
  • 4.Selden TM, Berdahl TA. COVID-19 and racial/ethnic disparities in health risk, employment, and household composition. Health Aff (Millwood). 2020;39(9):1624-1632. doi: 10.1377/hlthaff.2020.00897 [DOI] [PubMed] [Google Scholar]
  • 5.Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic–United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049-1057. doi: 10.15585/mmwr.mm6932a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Sher L. The impact of the COVID-19 pandemic on suicide rates. QJM. 2020;113(10):707-712. doi: 10.1093/qjmed/hcaa202 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Gravlee CC. Systemic racism, chronic health inequities, and COVID-19: a syndemic in the making? Am J Hum Biol. 2020;32(5):e23482. doi: 10.1002/ajhb.23482 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Courtin E, Vineis P. COVID-19 as a syndemic. Front Public Health. 2021;9:763830. doi: 10.3389/fpubh.2021.763830 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Horton R. Offline: COVID-19 is not a pandemic. Lancet. 2020;396(10255):874. doi: 10.1016/S0140-6736(20)32000-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Singer M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inq Creat Sociol. 1994;24:99-110. [Google Scholar]
  • 11.Rod MH, Hulvej Rod N. Towards a syndemic public health response to COVID-19. Scand J Public Health. 2021;49(1):14-16. doi: 10.1177/1403494820982862 [DOI] [PubMed] [Google Scholar]
  • 12.Rosenthal L, Earnshaw VA, Moore JM, et al. Intergenerational consequences: women’s experiences of discrimination in pregnancy predict infant social-emotional development at 6 months and 1 year. J Dev Behav Pediatr. 2018;39(3):228-237. doi: 10.1097/DBP.0000000000000529 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Scott KA, Davis D. Obstetric racism: naming and identifying a way out of black women’s adverse medical experiences. Am Anthropol. 2021;123(3):681-684. doi: 10.1111/aman.13559 [DOI] [Google Scholar]
  • 14.House TS, Alnajjar E, Mulekar M, Spiryda LB. Mommy meltdown: understanding racial differences between Black and White women in attitudes about postpartum depression and treatment modalities. J Clin Gynecol Obstet. 2020;9(3):37-42. doi: 10.14740/jcgo664 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Olson DM, Severson EM, Verstraeten BS, Ng JW, McCreary JK, Metz GA. Allostatic load and preterm birth. Int J Mol Sci. 2015;16(12):29856-29874. doi: 10.3390/ijms161226209 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Arnett DAM. Maternal mortality rates in African-American women in the United States: a narrative review [thesis]. Published online May 2015. Accessed January 12, 2022. https://cardinalscholar.bsu.edu/handle/123456789/200996
  • 17.Petersen EE, Davis NL, Goodman D, et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423-429. doi: 10.15585/mmwr.mm6818e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Gur RE, White LK, Waller R, et al. The disproportionate burden of the COVID-19 pandemic among pregnant Black women. Psychiatry Res. 2020;293:113475. doi: 10.1016/j.psychres.2020.113475 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Yoshikawa H, Wuermli AJ, Britto PR, et al. Effects of the global coronavirus disease-2019 pandemic on early childhood development: short- and long-term risks and mitigating program and policy actions. J Pediatr. 2020;223:188-193. doi: 10.1016/j.jpeds.2020.05.020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Pachter LM, Coll CG. Racism and child health: a review of the literature and future directions. J Dev Behav Pediatr. 2009;30(3):255-263. doi: 10.1097/DBP.0b013e3181a7ed5a [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Blitz MJ, Rochelson B, Prasannan L, et al. Racial and ethnic disparity and spatiotemporal trends in severe acute respiratory syndrome coronavirus 2 prevalence on obstetrical units in New York. Am J Obstet Gynecol MFM. 2020;2(4):100212. doi: 10.1016/j.ajogmf.2020.100212 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Brandt JS, Hill J, Reddy A, et al. Epidemiology of coronavirus disease 2019 in pregnancy: risk factors and associations with adverse maternal and neonatal outcomes. Am J Obstet Gynecol. 2021;224(4):389.e1-389.e9. doi: 10.1016/j.ajog.2020.09.043 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Kornfield SL, White LK, Waller R, et al. Risk And resilience factors influencing postpartum depression and mother-infant bonding during COVID-19. Health Aff (Millwood). 2021;40(10):1566-1574. doi: 10.1377/hlthaff.2021.00803 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Liu CH, Koire A, Erdei C, Mittal L. Unexpected changes in birth experiences during the COVID-19 pandemic: Implications for maternal mental health. Arch Gynecol Obstet. Published online November 1, 2021. doi: 10.1007/s00404-021-06310-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Njoroge WFM, Forkpa M, Bath E. Impact of racial discrimination on the mental health of minoritized youth. Curr Psychiatry Rep. 2021;23(12):81. doi: 10.1007/s11920-021-01297-x [DOI] [PubMed] [Google Scholar]
  • 26.Flanagin A, Frey T, Christiansen SL; AMA Manual of Style Committee . Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA. 2021;326(7):621-627. doi: 10.1001/jama.2021.13304 [DOI] [PubMed] [Google Scholar]
  • 27.Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76. doi: 10.2105/AJPH.2015.302903 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Aaronson D, Faber J, Hartley D, Mazumder B, Sharkey P. The long-run effects of the 1930s HOLC “redlining” maps on place-based measures of economic opportunity and socioeconomic success. Reg Sci Urban Econ. 2021;86:103622. doi: 10.1016/j.regsciurbeco.2020.103622 [DOI] [Google Scholar]
  • 29.Mitchell B, Franco J. HOLC “redlining” maps: the persistent structure of segregation and economic inequality. National Community Reinvestment Coalition. Published March 20, 2018. Accessed January 12, 2022. https://ncrc.org/holc/
  • 30.Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212-1215. doi: 10.2105/AJPH.90.8.1212 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Geronimus AT, Hicken M, Keene D, Bound J. “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States. Am J Public Health. 2006;96(5):826-833. doi: 10.2105/AJPH.2004.060749 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Berry OO, Londoño Tobón A, Njoroge WFM. Social determinants of health: the impact of racism on early childhood mental health. Curr Psychiatry Rep. 2021;23(5):23. doi: 10.1007/s11920-021-01240-0 [DOI] [PubMed] [Google Scholar]
  • 33.Compton MT, Shim RS. The social determinants of mental health. Focus. 2015;13(4):419-425. doi: 10.1176/appi.focus.20150017 [DOI] [Google Scholar]
  • 34.Slaughter-Acey JC, Sealy-Jefferson S, Helmkamp L, et al. Racism in the form of micro aggressions and the risk of preterm birth among black women. Ann Epidemiol. 2016;26(1):7-13.e1. doi: 10.1016/j.annepidem.2015.10.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40(1):105-125. doi: 10.1146/annurev-publhealth-040218-043750 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race lens to relationship-centered care in pregnancy and childbirth: an antidote to structural racism. Birth. 2020;47(1):3-7. doi: 10.1111/birt.12462 [DOI] [PubMed] [Google Scholar]
  • 37.Paradies Y, Truong M, Priest N. A systematic review of the extent and measurement of healthcare provider racism. J Gen Intern Med. 2014;29(2):364-387. doi: 10.1007/s11606-013-2583-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.van Bussel JCH, Spitz B, Demyttenaere K. Women’s mental health before, during, and after pregnancy: a population-based controlled cohort study. Birth. 2006;33(4):297-302. doi: 10.1111/j.1523-536X.2006.00122.x [DOI] [PubMed] [Google Scholar]
  • 39.Patrick SW, Henkhaus LE, Zickafoose JS, et al. Well-being of parents and children during the COVID-19 pandemic: a national survey. Pediatrics. 2020;146(4):e2020016824. doi: 10.1542/peds.2020-016824 [DOI] [PubMed] [Google Scholar]
  • 40.Lemke MK, Brown KK. Syndemic perspectives to guide black maternal health research and prevention during the COVID-19 pandemic. Matern Child Health J. 2020;24(9):1093-1098. doi: 10.1007/s10995-020-02983-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative . Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806-808. doi: 10.1136/bmj.39335.541782.AD [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Barzilay R, Moore TM, Greenberg DM, et al. Resilience, COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers. Transl Psychiatry. 2020;10(1):291. doi: 10.1038/s41398-020-00982-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Raley RK, Sweeney MM, Wondra D. The growing racial and ethnic divide in U.S. marriage patterns. Future Child. 2015;25(2):89-109. doi: 10.1353/foc.2015.0014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Nelson R, Winling L, Marciano R, Connolly N. Mapping Inequality. Accessed January 12, 2022. https://dsl.richmond.edu/panorama/redlining/
  • 45.Moore TM, Martin IK, Gur OM, et al. Characterizing social environment’s association with neurocognition using census and crime data linked to the Philadelphia Neurodevelopmental Cohort. Psychol Med. 2016;46(3):599-610. doi: 10.1017/S0033291715002111 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Williams DR, Gonzalez HM, Williams S, Mohammed SA, Moomal H, Stein DJ. Perceived discrimination, race and health in South Africa. Soc Sci Med. 2008;67(3):441-452. doi: 10.1016/j.socscimed.2008.03.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Williams DR, Yu Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: socio-economic status, stress and discrimination. J Health Psychol. 1997;2(3):335-351. doi: 10.1177/135910539700200305 [DOI] [PubMed] [Google Scholar]
  • 48.Sternthal MJ, Slopen N, Williams DR. Racial disparities in health: how much does stress really matter? Du Bois Rev. 2011;8(1):95-113. doi: 10.1017/S1742058X11000087 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. doi: 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]
  • 50.Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348-353. doi: 10.1370/afm.1139 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Cox J. Use and misuse of the Edinburgh Postnatal Depression Scale (EPDS): a ten point ‘survival analysis’. Arch Womens Ment Health. 2017;20(6):789-790. doi: 10.1007/s00737-017-0789-7 [DOI] [PubMed] [Google Scholar]
  • 52.Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150(6):782-786. doi: 10.1192/bjp.150.6.782 [DOI] [PubMed] [Google Scholar]
  • 53.Wisner KL, Parry BL, Piontek CM. Clinical practice: postpartum depression. N Engl J Med. 2002;347(3):194-199. doi: 10.1056/NEJMcp011542 [DOI] [PubMed] [Google Scholar]
  • 54.Mossman SA, Luft MJ, Schroeder HK, et al. The Generalized Anxiety Disorder 7-item scale in adolescents with generalized anxiety disorder: signal detection and validation. Ann Clin Psychiatry. 2017;29(4):227-234A. [PMC free article] [PubMed] [Google Scholar]
  • 55.Asparouhov T, Muthén B. Exploratory structural equation modeling. Struct Equ Modeling. 2009;16(3):397-438. doi: 10.1080/10705510903008204 [DOI] [Google Scholar]
  • 56.Muthen LK, Muthen BO. Mplus User’s Guide. 7th ed. Muthen & Muthen; 1998. [Google Scholar]
  • 57.Muthen B, Du Toit SH, Spisic D. Robust inference using weighted least squares and quadratic estimating equations in latent variable modeling with categorical and continuous outcomes. Psychometrika. 1997;75:1-45. [Google Scholar]
  • 58.Glorfeld LW. An improvement on Horn’s parallel analysis methodology for selecting the correct number of factors to retain. Educ Psychol Meas. 1995;55(3):377-393. doi: 10.1177/0013164495055003002 [DOI] [Google Scholar]
  • 59.Revelle W. Psych: procedures for psychological, psychometric, and personality research. Accessed January 13, 2022. https://CRAN.R-project.org/package=psych
  • 60.The Covid-19 tracker. STAT. Published March 26, 2020. Accessed January 12, 2022. https://www.statnews.com/2020/03/26/covid-19-tracker/
  • 61.Mollard E, Kupzyk K, Moore T. Postpartum stress and protective factors in women who gave birth in the United States during the COVID-19 pandemic. Womens Health (Lond). 2021;17:17455065211042190. doi: 10.1177/17455065211042190 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Bauman BL, Ko JY, Cox S, et al. Vital signs: postpartum depressive symptoms and provider discussions about perinatal depression–United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;69(19):575-581. doi: 10.15585/mmwr.mm6919a2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Kozhimannil KB, Trinacty CM, Busch AB, Huskamp HA, Adams AS. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011;62(6):619-625. doi: 10.1176/ps.62.6.pss6206_0619 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 64.Perzow SED, Hennessey EP, Hoffman MC, Grote NK, Davis EP, Hankin BL. Mental health of pregnant and postpartum women in response to the COVID-19 pandemic. J Affect Disord Rep. 2021;4:100123. doi: 10.1016/j.jadr.2021.100123 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Ford CL, Airhihenbuwa CO. Critical race theory, race equity, and public health: toward antiracism praxis. Am J Public Health. 2010;100(S1)(suppl 1):S30-S35. doi: 10.2105/AJPH.2009.171058 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Aremu B, Hill PD, McNeal JM, Petersen MA, Swanberg D, Delaney KR. Implementation of trauma-informed care and brief solution-focused therapy: a quality improvement project aimed at increasing engagement on an inpatient psychiatric unit. J Psychosoc Nurs Ment Health Serv. 2018;56(8):16-22. doi: 10.3928/02793695-20180305-02 [DOI] [PubMed] [Google Scholar]
  • 67.Yan H, Ding Y, Guo W. Mental health of pregnant and postpartum women during the coronavirus disease 2019 pandemic: a systematic review and meta-analysis. Front Psychol. 2020;11:617001. doi: 10.3389/fpsyg.2020.617001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Geronimus AT. The weathering hypothesis and the health of African-American women and infants: evidence and speculations. Ethn Dis. 1992;2(3):207-221. [PubMed] [Google Scholar]
  • 69.Gianfrancesco MA, Tamang S, Yazdany J, Schmajuk G. Potential biases in machine learning algorithms using electronic health record data. JAMA Intern Med. 2018;178(11):1544-1547. doi: 10.1001/jamainternmed.2018.3763 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

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

Supplementary Materials

Supplement.

eTable 1. Means and Rates of Racism and Pandemic-related Variables for Black (n=151) and non-Latinx White Participants (n=571)

eTable 2. Response Rates for Endorsement of Each Response Option for Likert Response Pandemic-Related Variables that were Recoded to a Dichotomous Variable

eTable 3. Internal Consistency of Key Study Scales

eTable 4. Factor Analysis examining Factors of Racism

eTable 5. Logistic Regression Examining the effects of the Pandemic and Racism on Postpartum Depression and Anxiety in Black Women controlling for prenatal depression and anxiety

eTable 6. Linear Regression Examining the effects of the Pandemic and Racism on Postpartum Depression and Anxiety in Black Women

eTable 7. Logistic Regression Examining the effects of the Pandemic, Redlining, and Interpersonal Racism on Postpartum Depression and Anxiety in Black Women

eTable 8. Logistic Regression Examining the effects of the Pandemic Worries and Racism on Postpartum Depression and Anxiety in Black Birthing Individuals

eFigure. Histogram of the Negative Pandemic Experiences Summary Variable

Click here for additional data file. (329.8KB, pdf)

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