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. 2022 May 12;26(6):1194–1202. doi: 10.1007/s10995-022-03404-7

Stressful life events and social support among pregnant Marshallese women

Cari A Bogulski 1, Don E Willis 1, Christina A Williams 1, Britni L Ayers 1, Jennifer A Andersen 1, Pearl A McElfish 1,✉
PMCID: PMC9095441  PMID: 35551586

Abstract

Introduction

Women from racial and ethnic minority groups in the United States are disproportionately likely to experience adverse perinatal outcomes such as preterm birth, low birthweight infants, and infant mortality. Previous research has demonstrated that exposure to stressful life events and social support may influence perinatal outcomes. Although studies have documented stressful life events and social support for the general United States population and minority groups, less is known about the experiences of Pacific Islander women in the United States, and no prior studies have documented these experiences in Marshallese Pacific Islander women.

Methods

The present study examined data collected from pregnant Marshallese women (n = 67) in northwest Arkansas participating in a women’s health program using descriptive analyses (means, standard deviations, proportions).

Results

Results indicated a high prevalence of three stressful life events: experiencing a family member going into the hospital (35.8%), someone close to them dying (29.9%), and being unable to pay bills (53.7%). Food insecurity was higher than previously reported for pregnant women or Pacific Islanders (83.7%). Social support was high among the sample. A majority of women reported receiving help with daily chores (86.6%), help when sick (88.1%), and support on how to deal with personal problems (85.1%).

Discussion

This study is the first to document the prevalence of stressful life events and social support in a sample of pregnant Marshallese women living in the United States. The findings provide important information to guide efforts to reduce adverse perinatal outcomes in a Pacific Islander population.

Keywords: Pregnancy, Maternal health, Social determinants of health, Stress, Pacific Islander, Marshallese social support

Significance

What is already known on this subject?

Previous research has found disparities in adverse perinatal outcomes for racial and ethnic minority women living in the United States. Evidence suggests stressful life events predict adverse perinatal outcomes, but social support may provide some protection from these outcomes.

What this study adds

Although previous studies have examined the association between stress, social support, and adverse perinatal outcomes for Black and Hispanic women, very few have examined the experiences of Pacific Islander women. This study adds to this literature and is the first to report prevalence of stressful life events and social support in a Marshallese Pacific Islander population in the United States.

Introduction.

In the United States (US), public health efforts have contributed to the reduction in adverse perinatal outcomes (Centers for Disease Control and Prevention 2021a, 2021b). Despite these efforts, racial and ethnic minority inequities in perinatal outcomes persist (Centers for Disease Control and Prevention 2021b, 2021a; Willis et al., 2014). Social determinants of health have been identified as contributing factors (Amjad et al., 2019; Giurgescu, 2017; Healthypeople.gov, 2019; Thoma et al., 2019), and research demonstrates stressful life events may be a contributing factor to adverse perinatal outcomes (Harville et al., 2010; Hux & Roberts, 2015; Mendez-Figueroa et al., 2019; Oyarzo et al., 2012; Traylor et al., 2020). Stress exposure across the life course activates physiological responses and accelerates biological aging, undermining health generally (Danese & McEwen, 2012). Acute and chronic stress have been associated with a variety of adverse perinatal outcomes such as preterm birth, preeclampsia, infant morbidity, and low birthweight infants (Vianna et al., 2011; Wadhwa et al., 2011). In 2010, data from the Centers for Disease Control Pregnancy Risk Assessment Monitoring System (PRAMS) found 75% of women reported at least one stressful event during their pregnancy (Burns et al., 2015). The most common stressors included moving, serious illness of a family member, and inability to pay bills (Burns et al., 2015). Racial and ethnic minority women are often at risk for multiple stressful life events during pregnancy (Lu & Chen, 2004; Silveira et al., 2013; Zhao et al., 2015). The risk of exposure to stress during pregnancy is higher for low-income women of color (Hatch & Dohrenwend, 2007; Koning & Ehrenthala, 2019), including financial struggles, job loss or unemployment, food insecurity, domestic violence, and homelessness (Borders et al., 2007; Braveman et al., 2010).

Research has documented the disparities in stressful life events for pregnant Black and Hispanic women (Brunst et al., 2014; Dominguez, 2008; Grobman et al., 2018; Lefmann et al., 2017), but less is known about stressful life events and social support for Pacific Islander women (Schempf et al., 2010). Pacific Islanders are the second-fastest growing population in the US (Hixson et al., 2012). Arkansas has had especially high growth, with the Pacific Islander population increasing 252% between 2000 and 2010 (Arkansas Department of Education Data Center, 2016; Arkansas Department of Health & Arkansas Vital Records Office, 2015). Pacific Islanders are underrepresented in research, and available research often aggregates data across Pacific Islanders and Asian Americans, obscuring disparities (Park et al., 2009; Ro & Yee, 2010; Roehr, 2010; Schempf et al., 2010; Srinivasan & Guillermo, 2000; Working Group of the Applied Research Center & the National Council of Asian Pacific Americans 2013). Data available include limited studies demonstrating that Pacific Islander women experience higher prevalence of preterm birth and lower birthweight infants and are also more likely to experience preeclampsia, primary cesarean delivery, excessive gestational weight gain, and gestational diabetes mellitus (Chang et al., 2015; Chang et al., 2010; Choi, 2008; Hawley et al., 2014; Utah Department of Health, 2009; Nembhard et al., 2019; Schempf et al., 2010; Shen et al., 2005; Todd & Peabody, 2004).

The majority of Pacific Islanders in Arkansas are Marshallese migrants from the Republic of the Marshall Islands, where the US tested nuclear weapons between 1946 and 1958 (Arkansas Department of Education Data Center, 2016; Arkansas Department of Health & Arkansas Vital Records Office, 2015; Barker, 2012; McElfish et al., 2015; United States Census Bureau, 2010a, 2010b). Tests exposed islanders to significant levels of nuclear radiation (Barker, 2012; Guyer, 2001; Pollock, 2002). Studies have demonstrated health problems affecting exposed individuals and changes in Marshallese health behaviors (Barker, 2012; Gittelsohn et al., 2003; McElfish et al., 2016; McLennan & Ulijaszek, 2015). Previous analyses of birth records (n = 2,488) documented the following among Marshallese living in Arkansas: 15% of Marshallese women received no prenatal care (compared to 1.6% women nationally); half do not receive prenatal care visits during their first trimester (compared to 22.9% nationally); 19% of Marshallese infants were born preterm (compared to 9.6% nationally); and 15% of Marshallese infants were low birthweight (compared to 8.3% nationally; Nembhard et al., 2019; Osterman & Martin, 2018). Despite evidence of adverse perinatal outcomes for Marshallese women, no research explores stressful life events among Marshallese or other Pacific Islander pregnant women. The present study fills this gap in the literature by examining the prevalence of stressful life events and social support among pregnant Marshallese women.

Methods.

Data Sources and Participants.

Data were collected from the enrollment survey for a women’s health program offered by the University of Arkansas for Medical Sciences. Both pregnant and non-pregnant women take part in the program; however, only pregnant women are included in the study. Participants provided verbal consent for data collection at the time of enrollment. The data collection portion of the women’s health program was conducted in accord with prevailing ethical principles and was determined by the University of Arkansas for Medical Sciences Institutional Review Board to be exempt (#239466). Sixty-seven pregnant Marshallese women completed the program’s enrollment survey between July 2019 and January 2021.

Measures and Data Collection.

Care coordinators administered questions to participating clients and recorded responses in REDCap (Research Electronic Data Capture; Harris et al., 2009; Harris et al., 2019). Stressful life events were measured using the Modified Life Events Inventory 14-item scale (Newton et al., 1979) as utilized in PRAMS (Shulman et al., 2018), and social support was measured using an abbreviated Medical Outcomes Study social support survey (Sherbourne & Stewart, 1991), with those reporting “all of the time” or “most of the time” as having social support. A validated 2-item food insecurity assessment was also added in December 2019 as part of quality improvement; therefore, these items were not administered to all participants (Hager et al., 2010). Additional measures collected and analyzed (e.g., health insurance status; father/partner involvement; Special Supplemental Nutrition Program for Women, Infants, and Children [WIC] and Supplemental Nutrition Assistance Program [SNAP] needs assessment; and housing insecurity) were assessed using questions adapted from PRAMS (Shulman et al., 2018).

Data Analysis.

Descriptive statistics, including means and standard deviations for continuous variables and proportions for categorical variables, are presented to characterize participants. Analyses included participant demographics and the domains of interest: stressful life events, social support, health insurance status, father/partner involvement, WIC/SNAP needs assessments, housing insecurity, and food insecurity. All analyses were conducted using R/RStudio (R Core Team, 2019; RStudio Team, 2018).

Results.

Participants had a mean age of 28.2 (SD = 6.6) at enrollment in the program, and 42.2% of participants reported being uninsured. A majority of participants were married, a member of an unmarried couple, or living with a partner (77.3%) and had a high school degree/GED or less (83.6%). Participants reported an average household size (adults and children) of 6.1 (SD = 2.8). A majority of participants reported needing, but not having applied for, WIC (71.6%) and SNAP (59.7%). Several participants reported already receiving or having applied for WIC (17.9%) and SNAP (17.9%) (Table 1).

Table 1.

Sociodemographic characteristics of pregnant Marshallese Healthy Start participants (n = 67)

N (%) or Mean ± SD
Age 28.2 ± 6.6
Household Size (n = 64) 6.1 ± 2.8
Marital Status at Enrollment (N = 66) a
Single/Never married 15 (22.7)
Married/A member of an unmarried couple/Living with partner 51 (77.3)
Divorced/Separated 0 (0)
Widowed 0 (0)
Education a
Less than high school 23 (34.3)
High school graduate or GED completed 33 (49.3)
Some college/vocational school 10 (14.9)
Bachelor’s degree/College graduate 1 (1.5)
More than college/Graduate or professional school 0 (0)
Insurance at Enrollment (n = 64) a,b
Insured 37 (57.8)
Uninsured 27 (42.2)
Household Income (n = 65) a
Less than $20,000 18 (27.7)
More than $20,000 45 (69.2)
Don’t know 2 (3.1)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Needs Assessment
Receiving 11 (16.4)
Have applied for 1 (1.5)
Need 48 (71.6)
Not applicable 7 (10.4)
Supplemental Nutrition Assistance Program (SNAP) Needs Assessment
Receiving 9 (13.4)
Have applied for 3 (4.5)
Need 40 (59.7)
Not applicable 15 (22.4)
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aQuestion changed by funding agency in May 2020. Responses have been collapsed and re-coded.

bThe health insurance question allowed for multiple response options. Responses have been collapsed and re-coded.

A majority of participants were food insecure (83.7%). None of the participants reported home ownership, and almost all reported renting or sharing a home (97%). Over one-third (37.3%) of pregnant Marshallese women reported having a concern about housing; of those, 84% reported unstable housing due to non-payment of rent or past due rent, and 80% reported concern with non-payment of utilities or utility shut-off (Table 2).

Table 2.

Food and housing insecurity (n = 67)

N (%)
Food Insecurity (n = 43)
Food insecure 36 (83.7)
Food secure 7 (16.3)
Housing Status
Owns or shares home, condominium, or apartment 0 (0)
Rents or shares own home or apartment 65 (97)
Lives in public housing 0 (0)
Lives with parent or family member 2 (3)
Homeless 0 (0)
Some other arrangement 0 (0)
Has Housing Concern
Yes 25 (37.3)
No 39 (58.2)
Don’t know 3 (4.5)
Housing Concerns (n = 25)
Received an eviction notice 0 (0)
Non-payment of rent or past due rent 21 (84)
Unable to pay future rent because lost housing subsidy, job, or other income source 0 (0)
Non-payment of utilities or utility shut-off 20 (80)
Housekeeping concerns (failure to maintain cleanliness of the unit) 2 (8)
Housing is or will be condemned 0 (0)
Friend or family member being evicted or threatened with eviction 0 (0)
Threat of abuse by partner, family member, or other 0 (0)
Being discharged or service is being terminated 0 (0)
Personal conflict with others 0 (0)
Other health or safety concerns 0 (0)
Other lease violation(s) 0 (0)
Other 1 (4)
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More than three-fourths of participants reported one or more stressful life events (76.2%), and over half reported at least two stressful life events in the past twelve months (55.3%). A majority of participants reported having experienced problems paying the rent, mortgage, or other bills (53.7%), and 21% of participants reported moving to a new address. Over one-third of participants reported having a close family member who was very sick and had to go into the hospital (35.8%), and 30% reported having someone very close to them die. For social support, a majority of participants reported having someone available to help with daily chores (86.6%), help if they were sick (88.1%), or turn to for suggestions about how to deal with a personal problem (85.1%). Almost all participants (92.5%) reported having a supportive partner (Table 3).

Table 3.

Stressful life events and social support (n = 67)

N (%) or Mean ± SD
Total Stressful Life Events (out of 14) 1.7 ± 1.3
Total Stressful Life Events (out of 14)
0 16 (23.9)
1 14 (20.9)
2 20 (29.9)
3 or more 17 (25.4)
Stressful Life Events
A close family member was very sick and had to go into the hospital 24 (35.8)
I got separated or divorced from my husband or partner 4 (6)
I moved to a new address 14 (20.9)
I was homeless or had to sleep outside, in a car, or in a shelter 0 (0)
My husband/partner or parent/guardian lost his or her job 8 (11.9)
I lost my job even though I wanted to go on working 1 (1.5)
My husband/partner, parent/guardian, or I had a cut in work hours or pay 5 (7.5)
I was apart from my husband/partner or parent/guardian due to military deployment or extended work-related travel 0 (0)
I argued with my husband/partner or parent/guardian more than usual 0 (0)
My husband/partner or parent/guardian said he or she didn’t want me to be pregnant (n = 66) 0 (0)
I had problems paying the rent, mortgage, or other bills 36 (53.7)
My husband/partner, parent/guardian, or I went to jail 0 (0)
Someone very close to me had a problem with drinking or drugs 0 (0)
Someone very close to me died 20 (29.9)
If You Needed it, How Often is Someone Available to…? (responded “all of the time” or “most of the time”
Provide temporary financial support 24 (35.8)
Do something enjoyable with you (n = 66) 32 (48.5)
Help with daily chores 58 (86.6)
Help you if you were sick 59 (88.1)
Turn to for suggestions about how to deal with a personal problem 57 (85.1)
Father/Partner Involvement a 62 (92.5)
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aQuestion responses changed by funding agency in May 2020. Presented are the number and percentage of participants who reported “Involved in my pregnancy and supportive of me” or “Involved in my pregnancy and supportive of me and the child I’m carrying.”

Discussion.

This study examined the prevalence of stressful life events and social support among pregnant Marshallese women living in Arkansas. Pregnant Marshallese women face many stressful life events stemming from socioeconomic and health inequities while also reporting strong social support within and among families. Participants reported a high prevalence of family members being hospitalized (35.8%), someone close to them dying (29.9%), and being unable to pay bills (53.7%). The proportions for these three specific stressful life events were higher in this study than in any racial/ethnic subpopulations reported in a larger PRAMS study (Lu & Chen, 2004; see Limitations for possible effects of the COVID-19 pandemic).

Until recently, unequal death exposure has been an overlooked source of racial/ethnic health disparities in the US (Umberson et al., 2017). The exposure to death through the loss of a loved one is one of the most stressful life events people experience, leading to a potential loss of resources, including social support. The loss of resources alters one’s social environment in ways that may lead to additional stressful events (Pearlin et al., 2005; Umberson, 2017). The accumulation of stressful events across the life course have been shown to activate physiological responses that may lead to adverse perinatal outcomes (Danese & McEwen, 2012; Hux et al., 2014; Vianna et al., 2011; Wadhwa et al., 2011).

Many of the pregnant Marshallese women reported social support in the form of receiving help with daily chores (86.6%), receiving help when sick (88.1%), and having someone to turn to for suggestions about how to deal with personal problems (85.1%). Although social support has been documented as generally protective against negative health outcomes and as important resources for coping with stress (Umberson & Karas Montez, 2010), reviews of this literature reveal the somewhat limited benefits of social support (Thoits, 1995). Marshallese women in this study reported high levels of both stressful life events and high levels of social support, raising questions about the capacity of social support to cope with stressful events in a population that faces multiplicative stressors.

The prevalence of food insecurity among participants was extremely high (83.7%). This reported level of food insecurity is much higher than has been documented during pregnancy in other populations including Pacific Islanders living the US. Prior to the COVID-19 pandemic, 10.5% of the US population was estimated to be food insecure (Coleman-Jensen et al., 2020), and a study of Behavioral Risk Factor Surveillance System data showed 33.6% of pregnant Pacific Islanders in Hawaii were food insecure (Stupplebeen, 2019). Moreover, only 16.4% and 13.4% of participants reported currently receiving WIC and SNAP benefits, respectively. Our results indicate 71.6% of participants needed to apply for WIC benefits, and 59.7% needed to apply for SNAP benefits but had not done so. These findings demonstrate pregnant women may need more assistance in the application process for benefits, helping to alleviate food insecurity during pregnancy.

Housing was also a concern for many participants (37.3%), and more than half (53.7%) of participants reported worrying about paying the rent, mortgage, or other bills. Previous studies have found 44.8–46% of adults living in Hawaii worried about paying rent and other bills (Pobutsky et al., 2015; Stupplebeen, 2019), so a higher proportion in Arkansas is surprising, given Hawaii has the highest cost of living in the US (1st ) and Arkansas has the second-lowest (50th ) (US Department of Commerce, Bureau of Economic Analysis, 2020).

Lack of reported health insurance was also notably high (42.2%) in the sample relative to other groups of Pacific Islanders living in the US (Park et al., 2018). However, the lack of insurance is similar to the previously-reported proportion of uninsured Marshallese adults in Arkansas (46.4%) (McElfish et al., 2017). Prior to early 2021, Marshallese adults living in the US were not eligible to receive Medicaid benefits unless they were pregnant due to their Compact of Free Association (COFA) migrant status (McElfish et al., 2015). Of particular concern is that almost half of pregnant Marshallese women in Arkansas report they are uninsured despite being eligible for Medicaid. The results indicate a need for additional efforts to assist with Medicaid applications, both for currently pregnant women and for the Marshallese community as a whole as they become eligible for Medicaid benefits.

Limitations.

Results should be interpreted with limitations in mind. The study sample size was small, and all women in the sample are part of a women’s health program; therefore, the results of this study may not be generalizable to other Pacific Islanders or to Marshallese residing outside of Arkansas. Although data were collected from pregnant participants, participants varied in their gestational age during data collection, which may introduce variability in experiences of social support and stressful life events. Additionally, though measured using an abbreviated Medical Outcomes Study social support survey (Sherbourne & Stewart, 1991), social support was adapted and abbreviated by a nationally-convened Collaborative Improvement and Innovation Network specific to the women’s health program and, thus, cannot be scored and compared to previous studies utilizing the original scale. Of additional importance is acknowledging the potential effects of COVID-19 in this study, as approximately one-third of participants were enrolled during or after March 2020 (n = 22). The COVID-19 pandemic may have had an effect on both the number of stressful life events and amount of social support received during this time period. The Marshallese have experienced disproportionately high rates of COVID-19 infection, hospitalization, and death from COVID-19 (Center et al., 2020). Despite these limitations, this study is the first to document stressful life events and social support among Marshallese pregnant women residing in the US.

Policy Implications.

Using research findings to assist communities is an important part of the community-engaged participatory approach (Chen et al., 2010; Purvis et al., 2017). In addition to contributing new knowledge, insights from this study can inform public health interventions for the Marshallese community. We find that Marshallese women experience several specific stressful life events immediately prior to or during pregnancy, including high prevalence of family health stress, financial and housing instability, food insecurity, lack of health insurance, and lack of WIC and SNAP support. The University of Arkansas for Medical Sciences women’s health program addresses numerous concerns identified in this study and provides Marshallese care coordinators to help pregnant Marshallese women: (1) enroll in health insurance; (2) utilize health insurance; and (3) connect with resources such as WIC, SNAP, and food pantries. This study also revealed high levels of family support in the Marshallese community. Previous studies have indicated health behavior interventions incorporating a family model is highly effective among Pacific Islander communities (McElfish et al., 2021; McElfish et al., 2019). Future interventions should incorporate group or family-centric models for pregnant Pacific Islander women.

Conclusion.

This study is the first to document stressful life events and social support among pregnant Marshallese women. The findings show evidence of the considerable economic, social, and health challenges these women face. The findings also show strong evidence of the ability of the highly collectivistic and family-oriented Marshallese culture to provide strong social support within their community (Yeary et al., 2017). The high levels of both stressful life events and social support indicate need for further study to better understand the capacity of social support to protect against stressful life events during pregnancy.

Acknowledgments

None.

Authors’ contributions

CAB performed all analyses, finalized edits for the entire article, and worked with CAW and DEW to create initial framing of the article based on analyses; DEW provided edits throughout and worked with CAB and CAW to help create initial framing of the article based on analyses; CAW provided edits throughout, provided feedback on framing and analyses, worked with CAB and DEW to help create initial framing of the article based on analyses, and performed the first draft of the literature review on social support and stress; BLA provided edits throughout, performed the first draft of the literature review on women’s health and Marshallese/Pacific Islander background, and provided the first draft of policy implications; JAA provided edits and feedback on framing and analyses; PAM provided edits throughout and guiding framing of the article at every step.

Funding

The study was supported by a Health Resources and Services Administration Healthy Start Award [#1 H49MC32729-01-00] and a Centers for Disease Control and Prevention Racial and Ethnic Approaches to Community Health Award [#5 NU58DP006595-03-00]. Additional support was provided by a University of Arkansas for Medical Sciences Translational Research Institute grant from the National Center for Advancing Translational Sciences of the National Institutes of Health [# U54 TR001629 and #UL1 TR003107] and a University of Arkansas for Medical Sciences Translational Research Institute grant through the National Center for Advancing Translational Sciences of the National Institutes of Health [#KL2 TR003108]. The work was also partially supported by the National Institute of General Medical Sciences of the National Institutes of Health [#5 P20GM109096]. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

Availability of data and material

Not applicable.

Code availability

All analyses were conducted using R/RStudio.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

The data collection portion of the women’s health program was conducted in accord with prevailing ethical principles and was determined by the University of Arkansas for Medical Sciences Institutional Review Board to be exempt (#239466).

Consent to participate

Participants provided verbal consent for data collection at the time of enrollment.

Consent for publication

Not applicable.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Cari A. Bogulski, Email: cbogulski@uams.edu

Don E. Willis, Email: dewillis@uams.edu

Christina A. Williams, Email: cawilliams2@uams.edu

Britni L. Ayers, Email: blayers@uams.edu

Jennifer A. Andersen, Email: jaandersen@uams.edu

Pearl A. McElfish, Email: pamcelfish@uams.edu

References

  1. Amjad S, MacDonald I, Chambers T, Osornio-Vargas A, Chandra S, Voaklander D, Ospina MB. Social determinants of health and adverse maternal and birth outcomes in adolescent pregnancies: A systematic review and meta-analysis. Paediatric and Perinatal Epidemiology. 2019;33(1):88–99. doi: 10.1111/ppe.12529. [DOI] [PubMed] [Google Scholar]
  2. Arkansas Department of Education Data Center . Springdale School District Enrollment by Race, 2016–2017. In. Little Rock, AR: Arkansas Department of Education; 2016. [Google Scholar]
  3. Arkansas Department of Health, & Arkansas Vital Records Office . Unpublished birth records data: Arkansas resident births born to Marshallese mothers, 2009–2013. In. Little Rock, AR: Arkansas Department of Health; 2015. [Google Scholar]
  4. Barker, H. (2012). Bravo for the Marshallese: Regaining Control in a Post-Nuclear, Post-Colonial World. Cengage Learning
  5. Borders AEB, Grobman WA, Amsden LB, Holl JL. Chronic stress and low birth weight neonates in a low-income population of women. Obstetrics & Gynecology. 2007;109(2):331–338. doi: 10.1097/01.AOG.0000250535.97920.b5. [DOI] [PubMed] [Google Scholar]
  6. Braveman P, Marchi K, Egerter S, Kim S, Metzler M, Stancil T, Libet M. Poverty, near-poverty, and hardship around the time of pregnancy. Maternal and Child Health Journal. 2010;14(1):20–35. doi: 10.1007/s10995-008-0427-0. [DOI] [PubMed] [Google Scholar]
  7. Brunst KJ, Enlow MB, Kannan S, Carroll KN, Coull BA, Wright RJ. Effects of prenatal social stress and maternal dietary fatty acid ratio on infant temperament: Does race matter? Epidemiology. 2014;4(4):167. doi: 10.4172/2161-1165.1000167. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Burns ER, Farr SL, Howards PP, Centers for Disease Control and Prevention Stressful life events experienced by women in the year before their infants’ births–United States, 2000–2010. MMWR Morb Mortal Wkly Rep. 2015;64(9):247–251. [PMC free article] [PubMed] [Google Scholar]
  9. Centers for Disease Control and Prevention (2021a). Maternal and Infant Health. Retrieved April 12th from https://www.cdc.gov/reproductivehealth/MaternalInfantHealth/
  10. Centers for Disease Control and Prevention (2021b). Reproductive Health. Retrieved April 12th from https://www.cdc.gov/reproductivehealth/maternal-mortality/disparities-pregnancy-related-deaths/infographic.html
  11. Center KE, Da Silva J, Hernandez AL, Vang K, Martin DW, Mazurek J, James AE. Multidisciplinary Community-Based Investigation of a COVID-19 Outbreak Among Marshallese and Hispanic/Latino Communities - Benton and Washington Counties, Arkansas, March-June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(48):1807–1811. doi: 10.15585/mmwr.mm6948a2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Chang AL, Hurwitz E, Miyamura J, Kaneshiro B, Sentell T. Maternal risk factors and perinatal outcomes among pacific islander groups in Hawaii: a retrospective cohort study using statewide hospital data. BMC Pregnancy Childbirth. 2015;15:239. doi: 10.1186/s12884-015-0671-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Chang AL, Soon R, Kaneshiro B. The prevalence of gestational diabetes among Micronesians in Honolulu. Hawaii Med J. 2010;69(5 Suppl 2):4–6. [PMC free article] [PubMed] [Google Scholar]
  14. Chen PG, Diaz N, Lucas G, Rosenthal MS. Dissemination of results in community-based participatory research. Am J Prev Med. 2010;39(4):372–378. doi: 10.1016/j.amepre.2010.05.021. [DOI] [PubMed] [Google Scholar]
  15. Choi J. Seeking health care: Marshallese migrants in Hawai’i. Ethnicity & Health. 2008;13(1):73–92. doi: 10.1080/13557850701803171. [DOI] [PubMed] [Google Scholar]
  16. Coleman-Jensen, A., Rabbitt, M. P., Gregory, C. A., & Singh, A. (2020). Household Food Security in the United States in 2019 (ERR-275). United States Department of Agriculture, Economic Research Service.
  17. Danese A, McEwen BS. Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiology & Behavior. 2012;106(1):29–39. doi: 10.1016/j.physbeh.2011.08.019. [DOI] [PubMed] [Google Scholar]
  18. Dominguez TP. Race, racism, and racial disparities in adverse birth outcomes. Clin Obstet Gynecol. 2008;51(2):360–370. doi: 10.1097/GRF.0b013e31816f28de. [DOI] [PubMed] [Google Scholar]
  19. Gittelsohn J, Haberle H, Vastine A, Dyckman W, Palafox N. Macro- and microlevel processes affect food choice and nutritional status in the Republic of the Marshall Islands. The Journal Of Nutrition. 2003;133(1):310S–313S. doi: 10.1093/jn/133.1.310S. [DOI] [PubMed] [Google Scholar]
  20. Giurgescu C. Social determinants of maternal health and birth outcomes. The American Journal of Maternal/Child Nursing. 2017;42(1):7. doi: 10.1097/NMC.0000000000000303. [DOI] [PubMed] [Google Scholar]
  21. Grobman, W. A., Parker, C. B., Willinger, M., Wing, D. A., Silver, R. M., Wapner, R. J. … Reddy (2018). & Eunice Kennedy Shriver National Institute of Child Health and Human Development Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) Network. Racial disparities in adverse pregnancy outcomes and psychosocial stress. Obstetrics and Gynecology, 131(2), 328–335. 10.1097/AOG.0000000000002441 [DOI] [PMC free article] [PubMed]
  22. Guyer RL. Radioactivity and rights: Clashes at Bikini Atoll [Nuclear Effects] American Journal of Public Health. 2001;91(9):1371–1376. doi: 10.2105/AJPH.91.9.1371. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hager ER, Quigg AM, Black MM, Coleman SM, Heeren T, Rose-Jacobs R, Frank DA. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26–32. doi: 10.1542/peds.2009-3146. [DOI] [PubMed] [Google Scholar]
  24. Harris P, Taylor R, Thielke R, Payne J, Gonzalez N, Conde J. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Infrom. 2009;42(2):377–381. doi: 10.1016/j.jbi.2008.08.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, Consortium R. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208. doi: 10.1016/j.jbi.2019.103208. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Harville EW, Boynton-Jarrett R, Power C, Hyppönen E. Childhood hardship, maternal smoking, and birth outcomes: a prospective cohort study. Arch Pediatr Adolesc Med. 2010;164(6):533–539. doi: 10.1001/archpediatrics.2010.61. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Hatch SL, Dohrenwend BP. Distribution of traumatic and other stressful life events by race/ethnicity, gender, SES and age: A review of the research. American Journal of Community Psychology. 2007;40(3–4):313–332. doi: 10.1007/s10464-007-9134-z. [DOI] [PubMed] [Google Scholar]
  28. Hawley NL, Brown C, Nu’usolia O, Ah-Ching J, Muasau-Howard B, McGarvey ST. Barriers to adequate prenatal care utilization in American Samoa. Matern Child Health J. 2014;18(10):2284–2292. doi: 10.1007/s10995-013-1368-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Healthypeople.gov (2019). Maternal, Infant, and Child Health. Retrieved February 4th from https://www.healthypeople.gov/2020/leading-health-indicators/infographic/maternal-infant-and-child-health
  30. Hixson, L., Hepler, B., & Kim, M. (2012). The Native Hawaiian and Other Pacific Islander population 2010. Retrieved April 12th from http://www.census.gov/prod/cen2010/briefs/c2010br-12.pdf
  31. Hux VJ, Catov JM, Roberts JM. Allostatic load in women with a history of low birth weight infants: The National Health and Nutrition Examination Survey. Journal of Women’s Health. 2014;23(12):1039–1045. doi: 10.1089/jwh.2013.4572. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Hux VJ, Roberts JM. A potential role for allostatic load in preeclampsia. Matern Child Health J. 2015;19(3):591–597. doi: 10.1007/s10995-014-1543-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Koning SM, Ehrenthala DB. Stressor landscapes, birth weight, and prematurity at the intersection of race and income: Elucidating birth contexts through patterned life events. SSM - Population Health. 2019;8:100460. doi: 10.1016/j.ssmph.2019.100460. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Lefmann T, Combs-Orme T, Orme JG. Examining the inter-correlated effects of low income, life stress, and race on birth outcomes: A representative state study. Social Work in Health Care. 2017;56(6):450–469. doi: 10.1080/00981389.2017.1316811. [DOI] [PubMed] [Google Scholar]
  35. Lu MC, Chen B. Racial and ethnic disparities in preterm birth: the role of stressful life events. American Journal of Obstetrics and Gynecology. 2004;191(3):691–699. doi: 10.1016/j.ajog.2004.04.018. [DOI] [PubMed] [Google Scholar]
  36. McElfish, P., Boyers, J., Purvis, R., O’Connor, B., Carleton, A., Bing, W. … Riklon, S. (2021). Family Model Diabetes Self-Management and Support in Faith-Based Organizations in the Republic of the Marshall Islands Study Protocol. Contemporary Clinical Trials Communication, 21, 100710. 10.1016/j.conctc.2021.100710 [DOI] [PMC free article] [PubMed]
  37. McElfish P, Hallgren E, Henry L, Ritok M, Rubon-Chutaro J, Kohler P. Health beliefs of Marshallese regarding type 2 diabetes. American Journal of Health Behavior. 2016;40(1):248–257. doi: 10.5993/AJHB.40.2.10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. McElfish P, Hallgren E, Yamada S. Effect of US health policies on health care access for Marshallese migrants. Am J Public Health. 2015;105(4):637–643. doi: 10.2105/AJPH.2014.302452. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. McElfish P, Rowland B, Long C, Hudson J, Piel M, Buron B, Warmack T. Diabetes and hypertension in Marshallese adults: Results from faith-based health screenings. J Racial Ethn Health Disparities. 2017;4(6):1042–1050. doi: 10.1007/s40615-016-0308-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. McElfish PA, Purvis RS, Esquivel MK, Sinclair KA, Townsend C, Hawley NL, Kaholokula JK. Diabetes Disparities and Promising Interventions to Address Diabetes in Native Hawaiian and Pacific Islander Populations. Curr Diab Rep. 2019;19(5):19. doi: 10.1007/s11892-019-1138-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. McLennan A, Ulijaszek S. Obesity emergence in the Pacific islands: why understanding colonial history and social change is important. Public Health Nutr. 2015;18(8):1499–1505. doi: 10.1017/S136898001400175X. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Mendez-Figueroa H, Chauhan SP, Tolcher MC, Shamshirsaz AA, Sangi-Haghpeykar H, Pace RM, Aagaard K. Peripartum Outcomes Before and After Hurricane Harvey. Obstet Gynecol. 2019;134(5):1005–1016. doi: 10.1097/AOG.0000000000003522. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Nembhard WN, Ayers BL, Collins RT, Shan X, Rabie NZ, Chang D, McElfish PA. Adverse Pregnancy and Neonatal Outcomes Among Marshallese Women Living in the United States. Matern Child Health J. 2019;23(11):1525–1535. doi: 10.1007/s10995-019-02775-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Newton RW, Webster PAC, Binu PS, Maskrey N, Phillips AB. Psychosocial stress in pregnancy and its relation to the onset of premature labour. British Medical Journal. 1979;2(6187):411–413. doi: 10.1136/bmj.2.6187.411. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Osterman, M. J. K., & Martin, J. A. (2018). Timing and adequacy of prenatal care in the United States, 2016. National Vital Statistics Reports, 67(3), 1–14. [PubMed]
  46. Oyarzo C, Bertoglia P, Avendaño R, Bacigalupo F, Escudero A, Acurio J, Escudero C. Adverse perinatal outcomes after the February 27th 2010 Chilean earthquake. J Matern Fetal Neonatal Med. 2012;25(10):1868–1873. doi: 10.3109/14767058.2012.678437. [DOI] [PubMed] [Google Scholar]
  47. Park C, Bruan K, Horiuchi B, Tottori C, Onaka A. Longevity disparities in multiethnic Hawai’i: An analysis of 2000 life tables. Public Health Rep. 2009;124(4):579–584. doi: 10.1177/003335490912400415. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Park JJ, Humble S, Sommers BD, Colditz GA, Epstein AM, Koh HK. Health insurance for Asian Americans, Native Hawaiians, and Pacific Islanders under the Affordable Care Act. JAMA Internal Medicine. 2018;178(8):1128–1129. doi: 10.1001/jamainternmed.2018.1476. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Pearlin LI, Schieman S, Fazio EM, Meersman SC. Stress, health, and the life course: Some conceptual perspectives. Journal of Health and Social Behavior. 2005;46(2):205–219. doi: 10.1177/002214650504600206. [DOI] [PubMed] [Google Scholar]
  50. Pobutsky AM, Baker KK, Reyes-Salvail F. Investigating Measures of Social Context on 2 Population-Based Health Surveys, Hawaii, 2010–2012. Prev Chronic Dis. 2015;12:E221. doi: 10.5888/pcd12.150319. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Pollock NJ. Health transitions, fast and nasty: The case of Marshallese exposure to nuclear radiation. Pacific Health Dialog. 2002;9(2):275–282. [PubMed] [Google Scholar]
  52. Purvis R, Abraham T, Long C, Stewart M, Warmack T, McElfish P. Qualitative study of participants’ perceptions and preferences regarding research dissemination. American Journal of Bioethics. 2017;8(2):69–74. doi: 10.1080/23294515.2017.1310146. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. R Core Team (2019). R: A language and environment for statistical computing. In R Foundation for Statistical Computing. https://www.R-project.org/
  54. Ro M, Yee A. Out of the shadows: Asian Americans, Native Hawaiians, and Pacific Islanders. Am J Public Health. 2010;100(5):776–778. doi: 10.2105/AJPH.2010.192229. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Roehr B. Asians and Pacific Islanders in US need greater prominence in research. BMJ. 2010;340:c2495. doi: 10.1136/bmj.c2495. [DOI] [PubMed] [Google Scholar]
  56. RStudio Team (2018). RStudio: Integrated Development for R. In RStudio, Inc. http://www.rstudio.com/
  57. Schempf A, Mendola P, Hamilton B, Hayes D, Makuc D. Perinatal outcomes for Asian, Native Hawaiian, and other Pacific Islander Mothers of single and multiple race/ethnicity: California and Hawaii, 2003–2005. American Journal of Public Health. 2010;100(5):877–887. doi: 10.2105/AJPH.2009.177345. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Shen JJ, Tymkow C, MacMullen N. Disparities in maternal outcomes among four ethnic populations. Ethnicity & Disease. 2005;15(3):492–497. [PubMed] [Google Scholar]
  59. Sherbourne CD, Stewart AL. The MOS social support survey. Social Science & Medicine. 1991;32(6):705–714. doi: 10.1016/0277-9536(91)90150-B. [DOI] [PubMed] [Google Scholar]
  60. Shulman HB, D’Angelo DV, Harrison L, Smith RA, Warner L. The pregnancy risk assessment monitoring system (PRAMS): Overview of design and methodology. American Journal of Public Health. 2018;108(10):1305–1313. doi: 10.2105/AJPH.2018.304563. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Silveira ML, Pekow PS, Dole N, Markenson G, Chasan-Taber L. Correlates of high perceived stress among pregnant Hispanic women in Western Massachusetts. Maternal and Child Health Journal. 2013;17(6):1138–1150. doi: 10.1007/s10995-012-1106-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Srinivasan S, Guillermo T. Toward improved health: disaggregating Asian American and Native Hawaiian Pacific Islander data. American Journal of Public Health. 2000;90(11):1731–1734. doi: 10.2105/AJPH.90.11.1731. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Stupplebeen DA. Housing and Food Insecurity and Chronic Disease Among Three Racial Groups in Hawai’i. Prev Chronic Dis. 2019;16:E13. doi: 10.5888/pcd16.180311. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Thoits, P. A. (1995). Stress, coping, and social support processes: Where are we? What next? Journal of Health and Social Behavior, Spec No, 53–79. 10.2307/2626957 [PubMed]
  65. Thoma ME, Drew LB, Hirai AH, Kim TY, Fenelon A, Shenassa ED. Black–white disparities in preterm birth: Geographic, social, and health determinants. American Journal of Preventive Medicine. 2019;57(5):675–686. doi: 10.1016/j.amepre.2019.07.007. [DOI] [PubMed] [Google Scholar]
  66. Todd WA, Peabody JW. Maternal predictors of infant health outcomes among Hawaiians. Hawaii Med J. 2004;63(2):40–44. [PubMed] [Google Scholar]
  67. Traylor, C. S., Johnson, J. D., Kimmel, M. C., & Manuck, T. A. (2020). Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review. American Journal of Obstetrics & Gynecology MFM, 2(4), 100229. 10.1016/j.ajogmf.2020.100229 [DOI] [PMC free article] [PubMed]
  68. Umberson D. Black deaths matter: Race, relationship loss, and effects on survivors. Journal of Health and Social Behavior. 2017;58(4):405–420. doi: 10.1177/0022146517739317. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Umberson D, Karas Montez J. Social relationships and health: A flashpoint for health policy. Journal of Health and Social Behavior. 2010;51(1):S54–S66. doi: 10.1177/0022146510383501. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Umberson D, Olson JS, Crosnoe R, Liu H, Pudrovska T, Donnelly R. Death of family members as an overlooked source of racial disadvantage in the United States. Proceedings of the National Academy of Sciences of the United States of America. 2017;114(5):915–920. doi: 10.1073/pnas.1605599114. [DOI] [PMC free article] [PubMed] [Google Scholar]
  71. United States Census Bureau (2010a). Profile of general population and housing characteristics: 2010, Benton County, Arkansas. Retrieved April 12th from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml
  72. United States Census Bureau (2010b). Profile of general population and housing characteristics: 2010, Washington County, Arkansas. Retrieved April 12th from http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml
  73. US Department of Commerce, Bureau of Economic Analysis (2020). Real Personal Income by State and Metropolitan Area, 2019. Retrieved March 18th from https://www.bea.gov/news/2020/real-personal-income-state-and-metropolitan-area-2019
  74. Utah Department of Health (2009). Utah Health Disparities Summary: Pacific Islanders. Retrieved April 12th from https://www.health.utah.gov/disparities/data/ohd/archives/PacificIslanderFactSheet.pdf
  75. Vianna P, Bauer ME, Dornfeld D, Chies JA. Distress conditions during pregnancy may lead to pre-eclampsia by increasing cortisol levels and altering lymphocyte sensitivity to glucocorticoids. Med Hypotheses. 2011;77(2):188–191. doi: 10.1016/j.mehy.2011.04.007. [DOI] [PubMed] [Google Scholar]
  76. Wadhwa PD, Entringer S, Buss C, Lu MC. The contribution of maternal stress to preterm birth: issues and considerations. Clin Perinatol. 2011;38(3):351–384. doi: 10.1016/j.clp.2011.06.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  77. Willis E, McManus P, Magallanes N, Johnson S, Majnik A. Conquering racial disparities in perinatal outcomes. Clin Perinatol. 2014;41(4):847–875. doi: 10.1016/j.clp.2014.08.008. [DOI] [PubMed] [Google Scholar]
  78. Working Group of the Applied Research Center & the National Council of Asian Pacific Americans (2013). Best Practices: Researching Asian Americans, Native Hawaiians and Pacific Islanders. Retrieved March 11th from https://depts.washington.edu/sphnet/wp-content/uploads/2013/01/BestPracticesAANHPI.pdf
  79. Yeary K, Aitaoto N, Sparks K, Ritok-Lakien M, Hudson J, Goulden P, Mcelfish P. Cultural adaptation of diabetes self-management education for Marshallese residing in the United States: Lessons learned in curriculum development. Progress in Community Health Partnerships: Research, Education and Action. 2017;11(3):253–261. doi: 10.1353/cpr.2017.0030. [DOI] [PMC free article] [PubMed] [Google Scholar]
  80. Zhao Y, Kershaw T, Ettinger AS, Higgins C, Lu MC, Chao SM. Association between life event stressors and low birth weight in African American and White populations: Findings from the 2007 and 2010 Los Angeles Mommy and Baby (LAMB) Surveys. Maternal and Child Health Journal. 2015;19(10):2195–2205. doi: 10.1007/s10995-015-1734-x. [DOI] [PubMed] [Google Scholar]

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