In early 2020, the spread of severe acute respiratory syndrome coronavirus 2 (known as COVID-19) resulted in significant economic turmoil globally . The United States experienced a stock market drop more significant than the Great Crash of 1929  and in April 2020 unemployment rates peaked at 14.8% . The pandemic has exacerbated labor market inequity, as racial and ethnic minorities have been disproportionately impacted [3, 4], along with women .
Researchers have highlighted the ways in which women are uniquely impacted by outbreaks. For example, women bear a larger burden of unpaid emotional labor and also comprise the majority of the caregiver workforce (e.g., healthcare workers; domestic workers) in the United States [5, 6]. Women are also more vulnerable to the psychological impacts associated with pandemics, face barriers to sexual and reproductive healthcare, and experience increased incidences of intimate partner violence [5, 7]. Further, the financial impacts of pandemics take longer for women to recover from ; scholars expect this to be true for the COVID-19 pandemic as well [5, 8].
As Zhang & Ma point out, most studies exploring the impact of COVID-19 on women have focused on the general population . However, pregnant women face additional stressors during natural disasters. During the COVID-19 pandemic, pregnant women have experienced increased uncertainty about the effects of the virus on maternal and perinatal health, and concerns about receiving medical treatment due to potential health risks. Women are also particularly vulnerable to increased financial stress and mental health symptomology . Although several studies have documented the increased financial strain pregnant women have experienced as a result of COVID-19 [9, 10, 11], examining factors associated with this financial strain has not been their primary purpose. As such, the purpose of this study was to explore factors associated with pregnant women’s experiences of material hardship during the COVID-19 pandemic.
Financial Strain and Pregnancy
Approximately 56% of people living in poverty in the United States are women and 31% are children . Braveman and colleagues analyzed data from the Center for Disease Control’s Pregnancy Risk Assessment Monitoring System and found that over 50% of women in the sample were poor or near poor during their pregnancy based on the U.S. federal poverty level . Further, 60% of these low income women experienced at least one hardship (e.g., job loss; homelessness; domestic violence; food insecurity).
Pregnancy, itself, may cause increased financial stress, as mothers and families prepare for additional expenses related to child care. Women may also experience financial losses during pregnancy as a result of employment changes . Although some women choose to stop working, others are penalized by their employers for becoming pregnant or having a newborn; women are sometimes fired or lose out on opportunities for promotion as a result [15, 16]. During high risk pregnancies, women may be prescribed bed-rest prior to delivery, therefore further restricting their income generating activities and potentially causing additional household expenses (e.g., childcare costs) .
Although not often discussed, financial strain poses significant health risks to maternal and child health. For example, one study among pregnant women in South Africa found food insecurity was associated with depression, substance dependence, and anxiety . Another study conducted in the United States found that financial strain was positively associated with depressive symptoms, anxiety, perceived stress, and pregnancy-specific distress, and negatively associated with birth weight; depression mediated the relationship between financial strain and birth weight .
Financial stress is also associated with intimate partner violence. Intimate partner violence refers to a pattern of coercive behaviors used by one intimate partner to control another . Coercive tactics can be physical, sexual, psychological, or economic in nature. Intimate partner violence is associated with a range of negative health consequences including mental health issues [21, 22], reproductive health challenges [21, 23], traumatic brain injury , and chronic health conditions . The relationship between financial insecurity and intimate partner violence is bidirectional; it serves as a risk factor for intimate partner violence perpetration  and for survivors it also serves as a primary barrier to leaving an abusive relationship [27, 28]. Although pregnancy functions as a protective factor for a sub-sample of women, for other survivors’ intimate partner violence may begin or persist during pregnancy . Survivors have reported ways in which financial requests (e.g., asking for money to pay for pregnancy-related expenses) have precipitated abusive incidents; the financial strains associated with pregnancy have also kept pregnant women financially dependent on their abusive partners [14, 15]. The association between financial stress and intimate partner violence is particularly concerning, as intimate partner violence is also associated with a range of negative pregnancy-related outcomes including low birth weight, small for gestational age, perinatal death, and preterm birth [30, 31, 32].
Increased Stress During COVID-19 Pandemic
The COVID-19 pandemic has exacerbated the financial stress of women and created unique challenges for pregnant women in particular. Overall, the pandemic has decreased the financial security of families. Since the COVID-19 pandemic began, over one-third of women have been laid off, furloughed, or received pay cuts . Given that health insurance is often linked to employment in the United States, job loss may also result in lost health insurance coverage . This may be particularly stressful for pregnant women, who have ongoing healthcare needs. In addition to un- or underemployment, financial stress has also been made worse by highly unpredictable financial markets . Further, the financial insecurity caused by COVID-19 has forced some to utilize their savings, which now makes families more vulnerable to other unexpected financial hardships that may emerge .
The news media has highlighted ways in which the COVID-19 pandemic has made women’s experiences with economic abuse worse. Economic abuse is a form of intimate partner violence in which one intimate partner interferes with the other’s ability to access or acquire financial resources in order to increase their dependency . In the United States, stimulus checks (approximately $600 per person) were provided to taxpayers making up to $150,000 for married couples and $75,000 for individuals; these stimulus checks were administered through bank direct deposit, by check, or in the form of a debit card . However, these funds have been inaccessible to some women in abusive relationships. For example, the funds were directly deposited into their partners’ accounts, so women were unable to retrieve the money. In other instances, the checks were stolen by their partners or women who had recently left their abusive partners were afraid of having their mail forwarded to them, out of concerns their partner might be able to locate them . As a result, women have lost access to a critical source of funding.
Women’s financial situations have been further strained by their emotional labor. Lock-down orders implemented to mitigate the risks of spreading COVID-19 have resulted in the closure of nurseries and schools, which has increased women’s caretaking responsibilities at home. In addition to caring for their children, many women also have to look after older persons in their families as well, as this population is at increased risk for the virus and traditional health services are overwhelmed . Historically, these responsibilities have had a significant impact on women’s participation in the job market; women experience great lifetime wage penalties due to their caregiving responsibilities and may lose employment opportunities and promotions due to their emotional labor at home . The pandemic is further exacerbating this gender gap, as scholars have already begun to highlight how these caretaking responsibilities are disproportionately incurred by women and have hindered their ability to work as productively as their male counterparts [39, 40].
Further, as a result of the sex-segregated workforce in the United States, women’s jobs tend to pay lower wages and put them in employment positions that may not be amenable to working from home [5; 41]. For example, women are more likely to work in roles that require close, prolonged contact with COVID-19 patients; work that cannot be completed remotely and also makes women more vulnerable to contracting the virus themselves . Given these and other barriers to financial security that women face as a result of pandemics, it takes women even longer to financially recover from outbreaks and other natural disasters than men [6, 8].
As a result of the significant stress women have experienced as a result of the COVID-19 pandemic, it is not surprising that researchers have reported a decline in mental health, including increased depression, anxiety, and posttraumatic stress disorder (see Almeida et al. for a review) . This has also been found to be true of pregnant women, who are already considered high risk for mental disorders given their prevalence during the perinatal period .
Globally, several studies have looked at the impact of COVID-19 on the emotional well-being of pregnant women. Researchers found that pregnant women have had higher levels of depression [43, 44, 45], anxiety [43, 44], posttraumatic stress disorder  and increased thoughts of self-harm . Factors that have contributed to elevated stress levels include concerns about exposure to the virus when visiting medical facilities and uncertainty about what impacts the virus could have on their pregnancy, disruptions to reproductive healthcare, and fears around the effects of virus prophylaxis and treatment [5, 47]. These concerns are not unfounded; Ellington et al. found that pregnant women are at greater risk for severe illness from COVID-19 than non-pregnant women .
Scholars have also identified an association between pandemic-related financial strain and mental health concerns for pregnant women. Zhang & Ma found that pregnant women in their sample reported the impact of COVID-19 on their stress to be moderate to severe; stressors included finances, work, and increased responsibilities at home . Thayer and Gildner reported that COVID-19 related financial stress was associated with increased likelihood of depression, even after controlling for income . Preis et al. found that 45.8% of pregnant women in their sample lost income due to the pandemic and this income loss was associated with both pregnancy preparedness stress and perinatal infection stress .
Rates of intimate partner violence have also increased during the COVID-19 pandemic [49, 50, 51]. Although most studies examining the women’s intimate partner violence experiences during the pandemic have focused on the general population, a small number studies have looked specifically at the experiences of pregnant women. Naghizadeh and colleagues found one-third of their sample of 250 pregnant women seeking services at an obstetrics clinic in Iran reported experiencing intimate partner violence and those who had experienced abuse reported lower mental health quality of life . Similarly, a study of 885 pregnant women in South Africa found approximately 12% of women fit the criteria to be classified as having probable common mental health disorders; a higher percentage of these women reported anxiety about being infected with COVID, were severely food insecure during the lockdown and had experienced either psychological, physical, or sexual abuse by an intimate partner .
In summary, although financial stress is not uncommon among pregnant women, the COVID-19 pandemic has greatly exacerbated financial insecurity among women and their families. The impacts of financial stress are wide-ranging, including negative health sequelae and increased risk of intimate partner violence, which are also either directly or indirectly associated with a range of negative maternal and child health outcomes. Some studies have explored the impact of financial strain among pregnant women during the COVID-19 pandemic, but fewer have look specifically at the factors most associated with women’s experiences with material hardship. As such, this study sought to answer two primary research questions: (1) To what extent did pregnant womxn in this sample experience material hardship during the past one year? (2) What factors were most associated with womxn’s experiences with material hardship in the past one year? The term “womxn” is used in the presentation of study findings because participants were never asked to specify their gender identity. This spelling is more inclusive of transgender women and nonbinary people.