More than one-half of pregnant women experience some level of anxiety symptoms (
Meades and Ayers, 2011
), with 20%–35% of women reporting high anxiety or evidence of an anxiety disorder (Fawcett et al., 2019
; Koelewijn et al., 2017
; Nakić Radoš et al., 2018
). Experiencing anxiety during pregnancy is associated with pregnancy complications (Kurki et al., 2000
; Tomfohr-Madsen et al., 2019
), postnatal depressive symptoms (Coelho et al., 2011
), adverse fetal and neonatal development—including preterm birth, low birth weight (Rondó et al., 2003
; Rose et al., 2016
; Uguz et al., 2019
), and impaired fetal growth (Henrichs et al., 2010
)—and longer term adverse developmental outcomes (Irwin et al., 2020
). One of the largest contributors to maternal anxiety is experiencing stress during pregnancy, and prenatal anxiety is a salient risk factor for postpartum anxiety (Aris-Meijer et al., 2019
; - Aris-Meijer J.
- Bockting C.
- Stolk R.
- Verbeek T.
- Beijers C.
- van Pampus M.
- Burger H.
What if pregnancy is not seventh heaven? The influence of specific life events during pregnancy and delivery on the transition of antenatal into postpartum anxiety and depression.
International Journal of Environmental Research and Public Health. 2019; 16: 2851
Huizink et al., 2017
). Postpartum anxiety can lead to disruption of the mother–infant bond and problems with breastfeeding and sleep, as well as long-term adverse effects on child well-being and risk for psychopathology (Fallon et al., 2016
; Field, 2018
; Prenoveau et al., 2017
; Tietz et al., 2014
). Living through large-scale stressful events such as natural disasters (King and Laplante, 2005
; Tees et al., 2010
), terrorist attacks (Maslow et al., 2016
), health emergencies (Preis et al., 2020a
; Preis et al., 2020b
), and other catastrophic emergencies may increase the risk for developing maternal anxiety symptoms. The novel coronavirus disease-2019 (COVID-19) pandemic has been shown to increase anxiety symptoms on a global scale (Salari et al., 2020
).Some populations experience more prenatal anxiety than others. Latinas report some of the highest levels of anxiety symptoms (20%–36%) (
Lara-Cinisomo et al., 2019
) compared with the general population (15%–20%) (Fairbrother et al., 2016
), and they are one of the fastest-growing populations in the United States—a trend driven by high birth rates rather than immigration (Stepler and Brown, 2016
). Additionally, although Latinas may experience the aforementioned large-scale stressful events, they also are exposed to various daily psychosocial and sociocultural stressors that may predispose them to anxiety symptoms during the perinatal period (i.e., pregnancy to the first year after childbirth). Latinas are disproportionately likely to have low socioeconomic status (- Stepler R.
- Brown A.
Statistical Portrait of Hispanics in the United States.
Pew Research Center,
Washington, DC2016
https://www.pewresearch.org/hispanic/2016/04/19/2014-statistical-information-onhispanics-in-united-states/
Date accessed: November 15, 2020
Bernstein, 2007
; - Bernstein R.
Minority population tops 100 million.
www.census.gov/Press-Release/www/releases/archives/population/010048.html
Date: 2007
Date accessed: November 19, 2020
Stepler and Brown, 2016
; - Stepler R.
- Brown A.
Statistical Portrait of Hispanics in the United States.
Pew Research Center,
Washington, DC2016
https://www.pewresearch.org/hispanic/2016/04/19/2014-statistical-information-onhispanics-in-united-states/
Date accessed: November 15, 2020
Williams et al., 2010
), less access to insurance (American College of Obstetricians and Gynecologists (ACOG), 2017
; Rutledge and McLaughlin, 2008
), and barriers to prenatal care (Osterman and Martin, 2011
). Additionally, sociocultural stressors such as acculturative stress, the psychological distress associated with the process of adapting to a new culture (Berry, 2006
), and perceived discrimination have been associated with elevated anxiety trajectories across pregnancy (Preciado and D’Anna-Hernandez, 2017
). This commentary highlights the complex factors that increase the risk of perinatal anxiety among immigrant and U.S.-born Latinas during the pandemic and provides recommendations to address those risk factors to ensure their short- and long-term well-being.The global pandemic of COVID-19 has resulted in devastating rates of illness and death in the United States and across the globe (
World Health Organization, 2020
). By early February 2021, the United States had reported more than 449,000 deaths in the United States alone, with significant racial/ethnic inequities (Centers for Disease Control and Prevention, 2021a
). The CDC data indicate that Latino Americans represent 20.7% of COVID-19 cases (where race/ethnicity data are available) and 38% of COVID-19 age-adjusted deaths, but comprise only 19.4% of the (age-standardized) U.S. population (Centers for Disease Control and Prevention, 2021b
; Centers for Disease Control and Prevention
CDC COVID data tracker: United States COVID-19 cases and deaths by state.
CDC COVID data tracker: United States COVID-19 cases and deaths by state.
https://covid.cdc.gov/covid-data-tracker/#cases_casesinlast7days
Date: 2021
Date accessed: February 5, 2021
Centers for Disease Control and Prevention, 2021c
). Since the start of the pandemic, Latinos in the United States have experienced the greatest increase in COVID-19–related deaths (53.6%), which is nearly five times the increase seen in non-Latino White Americans (11.9%) (Centers for Disease Control and Prevention
Data on COVID-19 during pregnancy: severity of maternal illness.
Data on COVID-19 during pregnancy: severity of maternal illness.
https://covid.cdc.gov/covid-data-tracker/#pregnant-population
Date: 2021
Date accessed: February 5, 2021
Rossen et al., 2020
). More than 10% of pregnant Latina women were exposed to the coronavirus during summer 2020, as measured by antibody total levels, which was five times the rate of White women in a Philadelphia-based study (- Rossen L.
- Branum A.
- Ahmad F.
- Sutton P.
- Anderson R.
Excess deaths associated with COVID-19, by age and race and ethnicity — United States, January 26–October 3, 2020. MMWR Morbidity Mortality Weekly Report.
www.cdc.gov/mmwr/volumes/69/wr/mm6942e2.htm?s_cid=mm6942e2_w
Date: 2020
Date accessed: February 5, 2021
Flannery et al., 2020
). In early February 2021, a CDC report showed that pregnant Latinas had the highest number (n = 14,423 [31.5%]) of positive COVID-19 cases compared with non-White racial and ethnic groups in the United States (Centers for Disease Control and Prevention, 2021d
). Both Black and Latino people face increased risks of coronavirus exposure because structural racism and discrimination have limited their housing and employment prospects in ways that make it harder for them to follow recommendations for physical distancing. Black and Latino people are more likely to live in crowded conditions and have jobs deemed essential, including in transportation and food service (Shah et al., 2020
), and they are less often permitted to work from home (U.S. Bureau of Labor Statistics, 2019
).U.S. Bureau of Labor Statistics
Economic news release.
Economic news release.
US Bureau of Labor Statistics,
2019
https://www.bls.gov/opub/mlr/2020/article/ability-to-work-from-home.htm
Date accessed: February 5, 2021
For immigrant Latinos in particular, racism, discrimination, and fear of deportation have also increased under the current sociopolitical climate (
Williamson and Gelfand, 2019
). These factors contribute to worse mental health (- Williamson V.
- Gelfand I.
Trump and racism: What do the data say?.
www.brookings.edu/blog/fixgov/2019/08/14/trump-and-racism-what-do-the-data-say/
Date: 2019
Date accessed: February 5, 2021
Williams, 2018
) and decreased access to care among marginalized communities (Martinez et al., 2015
). Recent studies have shown a significant and positive association between current immigration policies and anxiety in Latina women compared with men (Becerra et al., 2020
). Some communities even reported fearing deportation more than COVID-19 (- Becerra D.
- Hernandez G.
- Porchas F.
- Castillo J.
- Nguyen V.
- Perez González R.
Immigration policies and mental health: Examining the relationship between immigration enforcement and depression, anxiety, and stress among Latino immigrants.
Journal of Ethnic & Cultural Diversity in Social Work. 2020; 2 9: 43-59
Alvarado, 2020
). A previous study showed that deportation fears were significantly associated with an increased risk of anxiety in prenatal Latinas (Lara-Cinisomo et al., 2019
). Furthermore, Latina women have been particularly vulnerable to job loss during the pandemic, as 11% remain unemployed as of October 2020—more than double the pre-pandemic rate—despite national September employment gains for all other groups (Ewing-Nelson, 2020
). All of these psychosocial stressors may lead to increased mental health disorders among Latina women. A June CDC survey of more than 5,000 participants indicated that reporting at least one adverse mental and behavioral health symptom was highly prevalent among Latinos during the pandemic (51.9%), and 18.6% had suicidal thoughts in the last 30 days (- Ewing-Nelson C.
Four times more women than men dropped out of the labor force in September. National Women's Law Center.
https://nwlc.org/wp-content/uploads/2020/10/september-jobs-fs1.pdf
Date: 2020
Date accessed: February 5, 2021
Czeisler et al., 2020
). Thus, for Latina mothers, the combined effects of disproportionately higher rates of COVID-19 and subsequent effects on socioeconomic conditions may exacerbate ongoing immigrant and minority-related stressors, leading to a potentially higher risk of mental health disorders in the future.Recommendations for Clinical Practice
Early detection and intervention can help address the mental health needs of immigrant and U.S.-born perinatal Latinas, but distancing measures to reduce COVID-19 transmission may limit opportunities to evaluate them for anxiety. Fears about contagion and deportation may also decrease health care system contact in Latina mothers, particularly among immigrant and undocumented women. Although assessing anxiety symptoms can be quick when using effective screeners that are available in English and Spanish, such as the State-Trait Anxiety Inventory (
Spielberger et al., 1971
, Spielberger et al., 1983
) and the Generalized Anxiety Disorder 7- and 2-item versions (García-Campayo et al., 2010
; Plummer et al., 2016
), health care professionals may have limited time owing to other medical demands related to the pandemic. Therefore, we recommend a multipronged approach that can be cost effective, increase reach, and promote help-seeking behaviors.For instance, by using reliable and credible information, public health and health care professionals can provide clear and concrete information using social media about anxiety, including the presentation of symptoms, how anxiety can be detected, and information on where to seek help. Indeed, a recent commentary suggested using social media to reduce anxiety during a pandemic (
Wiederhold, 2020
). However, prior research has shown that health messages must use culturally relevant language, originate from trusted sources, and aim to reach patients using trusted media outlets (Clayman et al., 2010
). Latinos “less comfortable” speaking English have been shown to have lower use of internet, radio, and weekly newspapers compared with Latinos more comfortable with English (Clayman et al., 2010
), and others have found lower levels of media trust in Latinos compared with non-Latino White people (Monforti and Marichal, 2014
). However, a recent report shows a surge in the use of social media since the COVID-19 pandemic for Latinos compared with non-Latinos (Acevedo, 2020
). Therefore, we encourage public health professionals and health care providers to use social media to provide psychoeducation about anxiety that targets English- and Spanish-speaking immigrant and U.S.-born perinatal Latina women. We also encourage health care providers working directly or indirectly through other patient contacts (e.g., pediatric visits) to provide these women with resources regarding anxiety symptoms, prevention, and treatment options.- Acevedo N.
Latinos rely more on social media as a coronavirus lifeline, Nielsen report finds.
www.nbcnews.com/news/latino/latinos-rely-more-social-media-coronavirus-lifeline-nielsen-report-finds-n1235968
Date: 2020
Date accessed: February 25, 2021
In addition to providing psychoeducation regarding anxiety, we urge public health professionals and health care providers to be aware of the stressors, such as increased deportation efforts and heightened racial profiling of Latinos (
Becerra et al., 2020
; - Becerra D.
- Hernandez G.
- Porchas F.
- Castillo J.
- Nguyen V.
- Perez González R.
Immigration policies and mental health: Examining the relationship between immigration enforcement and depression, anxiety, and stress among Latino immigrants.
Journal of Ethnic & Cultural Diversity in Social Work. 2020; 2 9: 43-59
Lara-Cinisomo et al., 2019
), that may increase Latinas’ risk. Therefore, we recommend that health care providers remind perinatal Latina women about patient confidentiality and boundaries that protect patient information (e.g., The Health Insurance Portability and Accountability Act) and when information about the patient requires further action, such as when a woman discloses suicidal thoughts. We also recommend frequent screening for anxiety symptoms throughout the perinatal period to ensure early detection and appropriate referral and treatment (Gregory et al., 2020
) and decrease the negative effects of anxiety on the fetus and child (Field, 2017
).Although early detection and reliable information about anxiety can help to inform women about the risk of anxiety, research must also assess the factors that increase perinatal Latinas’ risk during the pandemic. Research that evaluates the unique and combined effects of psychosocial factors (e.g., financial strain), cultural stressors (e.g., acculturative stress), sociopolitical stressors (e.g., deportations), and socioeconomic changes owing to the pandemic on anxiety symptoms in this population is needed. Several research teams have developed measures that are specific to the pandemic (
Briggs-Gowan et al., 2020
; Drury et al., 2020
) and we encourage researchers to collaborate to ensure a comprehensive understanding of how these factors affect mental health and to foster the development of responsive and appropriate early interventions and treatments.Recommendations for Research
To elucidate the effects of the pandemic on anxiety symptoms among perinatal Latinas, we recommend an increase in federal funding to ensure research teams have the necessary resources to develop measures, gather data across sites, and analyze data promptly. We urge the National Institutes of Health and other federal funding agencies to provide emergency and timely funding to investigators, particularly those of Latino origin with established records of research working with Latino communities, to conduct culturally and linguistically appropriate studies. Because Latinas are not a monolithic group, researchers should examine how the pandemic has affected the various subgroup of Latinas in the United States. Of the 14 largest Latino subgroups in the United States, Mexicans comprise the largest proportion at 64.9% (
Motel and Patten, 2012
; - Motel S.
- Patten E.
The 10 Largest Hispanic origin groups: Characteristics, rankings, top counties.
www.pewresearch.org/hispanic/2012/06/27/the-10-largest-hispanic-origin-groups-characteristics-rankings-top-counties/
Date: 2012
Date accessed: February 24, 2021
Stepler and Brown, 2016
). Although Latinos share a language and many cultural values, the 2020 Presidential election showed that political views and voting behaviors are not homogenous (- Stepler R.
- Brown A.
Statistical Portrait of Hispanics in the United States.
Pew Research Center,
Washington, DC2016
https://www.pewresearch.org/hispanic/2016/04/19/2014-statistical-information-onhispanics-in-united-states/
Date accessed: November 15, 2020
Sonneland, 2020
). Latino subgroups also differ in key demographic characteristics that have implications for exposure to structural, psychosocial, and sociopolitical stressors, such as employment security owing to immigration status. Therefore, we encourage researchers and clinicians to be mindful of these differences when exploring how best to study and address the mental health needs of perinatal Latinas in the United States.- Sonneland H.K.
Chart: How U.S. Latinos voted in the 2020 Presidential election.
www.as-coa.org/articles/chart-how-us-latinos-voted-2020-presidential-election
Date: 2020
Date accessed: February 25, 2021
Policy-Related Recommendations
Because policies at the local, state, and federal levels can, directly and indirectly, affect the well-being of mothers, we recommend the following policies to reduce and address anxiety in immigrant and U.S.-born perinatal Latinas in the United States. First, additional funding must be allocated to support the growing need for mental health providers owing to the negative effects of the pandemic on mental health. Local, state, and federal resources should be directed to support bilingual and diversity-trained mental health professionals who are prepared to address the unique and complex mental health needs of perinatal Latinas during a pandemic. For instance, rather than requiring states to provide matching funds for interpreters, such as required for Medicaid recipients, the federal government should earmark specific funds for those services because state resources may be depleted meeting other patient needs. Also, the Health Resources and Services Administration should make existing grant funds for language access services more accessible to small and large health care providers. Second, we recommend increased funding to enable mental health providers and community workers to reach out to and serve vulnerable communities where large numbers of perinatal Latinas who are essential workers reside so they have accessible services, potentially through added telehealth services. For example, the Health Resources and Services Administration Telehealth Network Grant Program should be expanded to support urban and rural regions in the country. This factor is particularly important, given perinatal Latinas' exposure to high-risk jobs and competing family demands. Third, state and federal officials should increase the enforcement of safe workplace standards to ensure that employers are limiting workers’ risks of virus exposure, and consider adopting new COVID-19 occupational health standards, like California, Michigan, Oregon, and Virginia have done (
Michaels and Wagner, 2020
). Federal agencies such as the Occupational Safety and Health Administration and the CDC should develop tools and recommendations to protect workers from exposure to the coronavirus and not rely on existing standards (Michaels and Wagner, 2020
). Fourth, COVID-19 legislation should provide stimulus packages to all who are eligible, regardless of whether they are in mixed status families, where some family members are U.S. citizens and others are not. The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) excluded mixed status families (Migration Policy Institute, 2020
; Migration Policy Institute
Mixed-status families ineligible for CARES Act Federal pandemic stimulus checks.
Mixed-status families ineligible for CARES Act Federal pandemic stimulus checks.
www.migrationpolicy.org/content/mixed-status-families-ineligible-pandemic-stimulus-checks
Date: 2020
Date accessed: February 24, 2021
National Immigration Forum N. I., 2020
), exposing 16.2 million people in the United States to more economic hardship and distress because an estimated 37% of unauthorized immigrants are parents to U.S.-born children (National Immigration Forum, N. I.
Fact sheet: Mixed status families and COVID-19 economic relief.
Fact sheet: Mixed status families and COVID-19 economic relief.
https://immigrationforum.org/article/mixed-status-families-and-covid-19-economic-relief/
Date: 2020
Date accessed: February 25, 2021
Passell and Taylor, 2010
). In one example of a solution, a COVID-19 stimulus payment introduced by Republican senators known as the Coronavirus Assistance for American Families (CAAF) Act (S.4381) would allow for economic relief payments to individuals with a social security number in mixed status homes (- Passell J.S.
- Taylor P.
III. Household structure; Mixed families.
www.pewresearch.org/hispanic/2010/08/11/iii-household-structure-mixed-families/
Date: 2010
Date accessed: February 21, 2021
Cassidy et al., 2020
). If passed, this legislation could help an estimated 26.6 million adult Latino U.S. citizens and 17.3 million child U.S. citizens living in mixed status households (- Cassidy B.
- Daines S.
- Romney M.
- Rubio M.
The Coronavirus Assistance for American Families Act.
www.daines.senate.gov/imo/media/doc/Coronavirus%20Assistance%20for%20American%20Families%20Act_Bill%20Text.pdf
Date: 2020
Date accessed: February 5, 2021
Asad, 2020
).Immediate changes to immigration policy are also critical for the well-being of Latinos in general and perinatal Latinas specifically. In addition to providing much-needed financial relief, we urge elected officials to halt deportations and reunite families separated at the U.S.–Mexico border. Our research shows that deportation threats increase anxiety in prenatal women and those effects are likely to persist for many years (
Lara-Cinisomo et al., 2019
). Deportations also threaten the safety and health of immigrants because of the increased risk of exposure to COVID-19 in already poorly managed detention centers (Keller and Wagner, 2020
).Conclusions
Like many perinatal women, immigrant and U.S.-born Latinas encounter various stressors that increase their risk for perinatal anxiety, and the pandemic has increased the risk in women across the globe (
Durankuş and Aksu, 2020
; Liu et al., 2020
; Salehi et al., 2020
). Latinas in the United States have also had to endure racist attacks encouraged by the Trump administration, separations of families at the U.S.–Mexico border, increased deportation threats, elevated exposure to the coronavirus, and unequal access to federal funding under laws such as the CARES Act. As the Biden–Harris administration begins implementing its policy priorities, we urge all elected officials to provide much-needed resources to clinicians working directly with perinatal Latinas, researchers working to understand the effects of the pandemic on these women, and the perinatal Latinas who are fighting to keep themselves and their families safe on all fronts.Acknowledgments
Sandraluz Lara-Cinisomo would like to thank the University of Illinois at Urbana-Champaign, United States for its support of this article.
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Biography
Sandraluz Lara-Cinisomo, PhD, is an Assistant Professor at the University of Illinois at Urbana-Champaign. Her research focuses on addressing mental health disparities in racially and ethnically diverse women as well as military populations.
Biography
Kimberly D'Anna-Hernandez, PhD, is a neuroscientist with expertise in mental health and biomarkers. She has a well-established record of research focused on the negative effects of discrimination and acculturative stress on maternal mental health in mothers of Mexican descent.
Biography
Amy L. Non, PhD, is a genetic anthropologist whose research focuses on how the biological embedding of stress may contribute to racial health disparities. She leads a study of stress about epigenetic and hair cortisol variation in Mexican immigrant mothers and their children.
Article info
Publication history
Published online: April 20, 2021
Accepted:
March 10,
2021
Received in revised form:
February 25,
2021
Received:
October 30,
2020
Footnotes
Conflicts of interest: The authors do not have any conflicts of interest to disclose.
Identification
Copyright
© 2021 Jacobs Institute of Women's Health. Published by Elsevier Inc.
