Food insecurity was very common in this large, representative sample of California women with household incomes below 400% of the federal poverty guidelines; greater than a third of women reported either marginal food security or being food insecure during pregnancy. Furthermore, this study found food insecurity was seldom the only severe maternal hardship faced by pregnant women. As expected, prevalence of food insecurity during pregnancy was higher among low-income women; however, food insecurity was reported among women with household incomes as high as 300–400% of the federal poverty guidelines. This may suggest that federal, state and local assistance programs should relax strict income criteria for program participation. During pregnancy, many families experience dynamic employment and financial changes2. Women from low-income households as well as those who were not married, lived in larger families, and reported additional maternal hardships were associated with greater risk for food insecurity.
Similar to those who reported low or very low food security, women who reported marginal food security during pregnancy were less educated, had lower-income, were not married, and more likely to report maternal hardships compared to their food secure counterparts. These results support the notion that women facing marginal food security are not only distinct from women who are fully food secure but have vulnerabilities comparable to those experienced by women reporting food insecurity 3,5,24, and therefore marginal food security should be assessed, monitored, and addressed in addition to food insecurity 25, especially during pregnancy.
While it is unsurprising that food insecurity is associated with an array of maternal hardships, the prevalence and magnitude of the cooccurrences has not been previously measured. The vast majority of women who experienced marginal, low or very low food security reported one or more additional maternal hardships. Most notable were depressive symptoms, job loss, lack of practical support, and intimate partner violence as these were among the most prevalent and were associated with all levels of food insecurity. At greatest risk were the over seven percent of women who reported very low food security during pregnancy. This group had the highest prevalence of all maternal hardships reported. These findings suggest that pregnant women experiencing food insecurity not only face a threat to their nutritional status but also to their overall well-being and the health of their fetus. The strong and consistent association between levels of food security and number of maternal hardships, independent of demographic and socioeconomic factors, may suggest that food security status is a reflection of major adverse life events and could be used for screening for additional social needs.
A causal relationship between food security status and severe maternal hardships was not the focus of this analysis and is difficult to determine; causal direction cannot be inferred. However, the strong association between food security status and severe maternal hardships suggest that both must be addressed during prenatal care, nutritional services, and other social services. An excellent example of organized screening efforts are guidelines from the American Academy of Pediatrics (AAP) 26 and the American College of Obstetrics and Gynecology (ACOG) 27 that promote screening and referrals for social determinants of health, food security, maternal depression, maternal hardships, and to bolster emotional, physical and social support, although consistency of screening implementation is not known. The California Department of Public Health also recommends that providers screen for these social issues and food security during pregnancy within the comprehensive Initial and Trimester Assessment and Care Plan Program 28 through the Comprehensive Perinatal Services Program. The current AAP policy statement encourages pediatricians to promote food security for all families with young children in pediatric settings by screening for food insecurity and other social needs at routine health maintenance visits as well as to advocate at the local, state and federal level for policies and programs that support acquisition of nutritious foods for all families pediatrics 29. These guidelines for screening must be instituted as a standard of care within the prenatal care setting to ensure social needs of pregnant women are being met. Until we have an effective preventive approach, we must put in place and bolster routine screening and referral services—not just at public hospitals/clinics but at most prenatal care sites, and nutrition programs like Women, Infant and Children Supplemental Nutrition Program (WIC) should have the resources to screen and provide referrals on a wide range of maternal hardships. Social policies could address the attendant stress-related outcomes and mental and somatic health consequences that result from these severe maternal hardships by ensuring enrollment in safety net programs and designing new interventions, as done in other industrialized countries, to shield pregnant women from falling into or worsening their poverty condition.30 Points of interventions and referral must be identified to assist with communication among programs.
Our cross-sectional analysis may have been subject to selection bias, as the severely food insecure women and the women who faced the most hardships may have consistently chosen not to participate in the survey. Our analysis would subsequently underestimate the prevalence of food insecurity in pregnancy and potentially its co-occurrence with additional hardships. Additionally, our data is roughly eight years old and examines only Californian women which reduces its generalizability. However, state representative data on pregnant women and hardships is difficult to procure, and has not been subsequently analyzed. Additionally, while have been changes in the California economy, it is unclear if the relationships between food insecurity and hardships would change drastically over time. A key strength of this study, is it is the first to our knowledge that measured maternal hardships in pregnancy in a representative sample and examined the co-occurrence of hardships with food security status. While this paper did not seek to nor identify causal relationships between food security status and these various hardships, by measuring and highlighting the co-occurrence of food insecurity and hardships, this paper contextualizes pregnant women in California for programs that aim to help them.
Public Health Implications
Targeted screening for severe maternal hardships is necessary to identify needed services and provide referrals, especially among socioeconomically disadvantaged maternity populations. An example of the importance of real time screening is the Prenatal Risk Overview, a screening mechanism created by the Minneapolis Health Department that was used to assess the prevalence of psychological risk during pregnancy among low-income women seeking prenatal service in four community clinics 31. Use of this screener between 2005 and 2007 identified high frequency of psychological risk among pregnant women: 75% had a lack of social support, 48% housing instability, 32% food insecurity, 25% drug use, 23% smoking and alcohol use, 18% depression, 9% physical/sexual abuse and 7% partner violence. Sixty percent were classified as high risk in one or more domains. Research has found that among African-Americans, each additional negative life event has been associated with lower gestational age, and higher levels of event distress were associated with lower birth weight 16. Therefore, the number of hardships faced is itself a predictor of adverse outcomes, over and above the nature of any particular hardship. More work is needed to help pregnant women address each of the several maternal hardships that they may face during pregnancy.
Food insecurity is a very common adverse pregnancy condition, and has been associated with financial hardship, stress and mental health, as well as poor nutrition. Food insecurity has persisted at the same levels for the last decade 4,11, suggesting that food insecurity must be addressed with multifactorial strategies 3. Federal programs that address food insecurity and well-being are more critical than ever when one in every three pregnant women of moderate- or low-income face food insecurity. Because food insecurity is often not an isolated problem, programs that provide services to pregnant women need to not only screen for food insecurity but other severe hardships as well, to bolster referrals and help inform future interventions. Strategies must address social inequities and eliminating root causes of health disparities. Interventions are needed that go beyond acute situations and change the cycle of poverty, food insecurity, hardship and health outcomes for future generations.