Financial stress as a mediator of the association between maternal childhood adversity and infant birth weight, gestational age, and NICU admission | BMC Public Health

We undertook an analysis to test the hypothesis that maternal ACEs scores increased the risk of financial stress during pregnancy, which in turn increased the likelihood of NICU admission, earlier gestational age at birth, and lower infant birth weight. This study demonstrated that maternal exposure to ACEs is indirectly associated with earlier infant gestational age at birth and lower infant birth weight through increased financial stress during pregnancy. There was no evidence to suggest that maternal exposure to ACEs is directly or indirectly associated with infant probability of a stay in the NICU. These findings elucidate one pathway through which intergenerational stress affects children at the earliest stages of development and present an opportunity for researchers and policy makers to improve prenatal care in ways that are tenable and affordable.

Contrary to our findings, extant evidence supports a direct association between maternal exposure to ACEs and numerous birth outcomes, including low birth weight and early gestational age [14, 25,26,27]. However, these published findings may not be comparable to our data as the median number of ACEs reported by mothers in the present study was low (0; IQR = 0–2), and prior studies note associations with adverse birth outcomes at high (e.g., 3+, 6+) levels of adversity [6, 28]. It is possible that this direct association is observed only at high levels of adversity that affect maternal functioning longer throughout the lifecourse. Regarding financial stress, prior research demonstrates a link between financial strain during pregnancy and low infant birth weight [16]. In our study, we found direct associations between financial stress and both infant gestational age and weight at birth, but not NICU admission. This may be due, in part, to how we operationalized financial stress. Most studies testing the association between financial stress and birth outcomes use indicators of socioeconomic resources such as employment status, annual income, and education [25, 26, 29]. Here, we operationalized financial stress based on its perceived impact using five indicators reflecting the severity of specific material hardships (e.g., difficulty paying bills), which may provide more sensitivity to detect mothers experiencing financial strain.

Our finding that financial stress during pregnancy mediated the association between maternal exposure to ACEs and earlier infant gestational age and weight at birth underscores the intergenerational impact of ACEs and immediate impact of financial strain on children. Moreover, this presents an opportunity to intervene during a critical period of prenatal development. Evidence suggests that financial stress during pregnancy negatively affects birth outcomes through lack of affordability and subsequent engagement in prenatal care [15] and/or through increased psychosocial stressors, including anxiety and depression [16]. All mothers in the current study had access to, and were receiving, prenatal care, so it is likely that ACEs indirectly contributed to earlier gestational age through the various stressors that come with living under financial stress. Although socioeconomic factors (e.g., employment, annual income) may be difficult to adjust in the short term to relieve financial stress, options exist to improve mothers’ psychosocial wellbeing and prevent adverse birth outcomes.

There are several empirically supported means through which researchers and policy makers can support mothers experiencing financial stress and associated stressors during pregnancy. The Family Foundations [30] intervention is one way in which families experiencing financial stress can be supported, particularly given that short-term changes in socioeconomic status may be infeasible. Family Foundations is a universal, evidence-based intervention, delivered to first-time parents during and after pregnancy to increase cooperative co-parenting, that has been associated with better parent mental health (including perceived financial stress), birth outcomes (e.g., birth weight) [31], and parent-child relations [30]. By enhancing parents’ communication and support, mothers may experience less psychosocial stress, including stress related to finances, thus reducing the risk of adverse birth outcomes.

Alternative measures for supporting both first-time and existing parents include (but are not limited to) child tax credits, extension of Medicaid coverage from 60 days to a full year post-partum [32], paid parental leave, and guaranteed income programs. Evidence suggests that child tax credits, for example, are an effective anti-poverty strategy, reducing food insecurity in the short-term [33] and improving maternal mental health, specifically among single mothers [34]. Although empirical evidence is limited in the US, guaranteed income programs also represent an alternative approach to assisting expecting mothers. For example, the Abundant Birth Project [35] in San Francisco seeks to provide an income supplement to Black and Pacific Islander pregnant women in an effort to decrease stress and improve infant and mother outcomes. The evaluation study of this project is currently underway. Combined with evidence-based interventions, these policies provide multiple angles by which to reduce the financial burden and associated stressors for expecting mothers, which in turn has the potential to improve birth outcomes and infant health.

The present study had several strengths, including a racially and ethnically diverse sample of expecting mothers and temporal ordering of events that aids in establishing causation. There are, however, several limitations to consider when interpreting these results. First, we were not able to adjust for all possible confounders, namely mother’s childhood socioeconomic status, which presents a major potential confounder of the exposure-mediator and exposure-outcome relationships [36]. Second, overall levels of ACEs (and financial stress) were low-to-moderate in this sample; the ACE measure included in this study also did not include racialized experiences and other relevant adversities. Recent evidence shows that, among Black mothers, additional ACEs (e.g., perceived racism, neighborhood safety) contribute to poor health outcomes (e.g., depression) [37]. It is possible that the present associations are underestimated due to exclusion of these experiences for mothers from minoritized racial and ethnic groups. This study also was limited in that mothers self-reported on tobacco use throughout pregnancy and social desirability bias could have affected our findings. Similarly, our results are subject to shared-method bias with mothers reporting on both their ACEs and financial stress during pregnancy.