Sage Journals: Discover world-class research

Abstract

Background:

Anxiety during pregnancy is a prevalent but underemphasized mental health concern with downstream impacts on the entire family unit. Quality social support is strongly related to mental well-being and provides a promising strategy to prevent and manage prenatal anxiety.

Methods:

This convergent mixed-methods study used a cross-sectional survey and interviews to: (1) Quantitatively investigate what adverse social determinants of health and multi-level sources of social support are most predictive of prenatal anxiety and (2) Qualitatively examine different types of social support that may buffer prenatal anxiety among a sample of pregnant women experiencing socioeconomic disadvantage.

Results:

Hierarchical linear regressions revealed that race and food insecurity were predictive of prenatal anxiety and that social support from friends/peers was most protective against prenatal anxiety. Integration of quantitative survey data and qualitative interview data suggested that emotional support was most protective among this sample of pregnant women.

Discussion:

The results of this study highlight opportunities for adaptations of prenatal peer support programs to include a focus on mitigating food insecurity and promoting emotional support from peers in order to most effectively buffer prenatal anxiety among underresourced pregnant women.

Keywords

maternal mental health peer support prenatal anxiety social support well-being

Prenatal anxiety is an often-overlooked public health concern with lasting effects on the health and well-being of families.¹ Approximately 20% of prenatal individuals meet the clinical criteria for anxiety,² and the adverse impacts are not isolated to pregnancy. Prenatal anxiety has been associated with increased risk of poor physical and mental health outcomes for the mother and baby (i.e., preeclampsia, hemorrhage, fetal death, preterm birth, or a low birthweight).³ The multigenerational impacts of prenatal anxiety extend beyond birth experience, negatively affecting the development of the child^4,5 and health care costs for the family.^6,7 One study on the economic burden of perinatal mood and anxiety disorders (PMADs) from conception to 5 years postpartum estimated that untreated PMADs can cost a mother-child dyad more than $30,000.⁷

Because both biological and social determinants of health contribute to the risk and severity of mental health challenges,⁸ prenatal anxiety disproportionately impacts women of low socioeconomic status (SES).^8,9 Unmet psychological needs and systemic inequities such as insufficient access to quality health care, food insecurity, housing- and transportation-related strain, and discrimination influence this disparity.^10,11 Given that individuals of low SES with prenatal anxiety are more likely to deliver preterm and have adverse prenatal health outcomes,^8,12 there is a need for effective interventions to buffer associations between adverse social determinants of health (e.g., food insecurity, poverty) and prenatal anxiety in low-income populations.¹³ Thus far, literature on the prevalence and treatment of prenatal anxiety is insufficient, with most focusing on prenatal depression or grouping depression and anxiety together as prenatal mood and anxiety disorders.^9,13,14 The prevalence and far-reaching effects of prenatal anxiety and the disproportionate impact on vulnerable communities emphasize the critical importance of identifying tailored evidence-based strategies to prevent and treat this mental health disorder.^12,15

Social support provides a promising strategy to prevent and manage prenatal anxiety due to its strong connection to improved psychological health.¹⁶ It is well established that appropriate social support is associated with lower anxiety and depression.^17–19 In prenatal individuals specifically, perceived social support has been shown to predict prenatal anxiety, possibly due to its ability to mitigate stress.^20,21 Similarly, lack of social support is associated with increased risk of prenatal anxiety.²² In those with low social support, prenatal stress was shown to increase poorer infant temperament,²³ which could further contribute to anxiety risk. In contrast, ample social support and social networks are associated with better labor and infant health outcomes (i.e., babies with higher Apgar scores and birth weight).²⁴ There is a lack of evidence around the types and sources of social support that are most protective against prenatal anxiety specifically.^16,22 To effectively leverage social support as a prevention strategy for prenatal anxiety, more research is needed to understand the specific types and sources of social support that are most protective for low-SES prenatal women.^16,20,21

The connection between social support and anxiety in low-income prenatal populations can be explained in part by the stress-buffering model, which posits that social support provides emotional, informational, or tangible resources to help individuals cope with stress and reduce its psychological impacts.²⁵ Emotional support involves perceptions of empathy and reassurance, fostering a sense of belonging and connection. Informational support provides advice and guidance to inform decision-making and help individuals navigate stressors. Tangible support includes material assistance to alleviate stressors, such as financial resources.²⁵ Thus far, most of the research with the buffering model has focused on non-prenatal populations,²⁶ and the evidence on functional aspects of social support and prenatal anxiety is mixed. For instance, informational and emotional support from health professionals have both been shown to protect against prenatal anxiety,²² but there is also some evidence to support tangible resources, such as financial assistance and help with childcare, as critical for prenatal health outcomes.²⁴ The application of the stress-buffering model may help to elucidate both the external sources of stress as well as how types and sources of social support may buffer prenatal anxiety among low-SES women.

Additionally, consideration of how social support may operate at multiple levels of influence could inform promising preventative strategies to mitigate prenatal mental health disparities. The socio-ecological model is a systems-level framework that describes how health and behavior are shaped by the dynamic interactions across the individual-, interpersonal-, organizational-, community- and policy-levels.²⁷ When considering prenatal anxiety, a multi-level approach can capture how personal factors (i.e., knowledge, attitudes, self-efficacy) interact with social relationships, organizational settings, and community norms to shape behaviors and outcomes.^28,29 Existing literature supports that family and partner social support is especially protective for depression and anxiety.^15,17,30 Poor-quality partner relationships are an established risk factor for prenatal anxiety.³¹ Outside of familial support, support from other mothers has also been shown to buffer against prenatal anxiety.²² Additionally, perceived social support from health care providers is a predictor of prenatal depression, but there is a lack of evidence on its relationship to prenatal anxiety.²² Though existing literature highlights the value of social support for mitigating risk, particularly within socioeconomically disadvantaged communities,^9,32 evidence around what specific types and sources of social support are most protective for this population is lacking.

Further investigation is needed to understand how adverse social determinants of health are contributing to the disproportionate prenatal anxiety rates in low-income communities.³³ Identifying protective factors for prenatal anxiety can inform effective prevention and treatment and mitigate the host of associated negative outcomes.¹⁴ To address these gaps, the following convergent parallel mixed-methods study seeks to answer the following questions: (1) What specific social determinants are most predictive of prenatal anxiety? (2) What multilevel sources of social support (family/friend/significant other, community/neighborhood) are most protective against prenatal anxiety? and (3) What types of social support (emotional, informational, and tangible) help to mitigate anxiety among this sample of prenatal individuals?

Methods

Participants

All procedures were approved by the Colorado Multiple Institutional Review Board (IRB #: 22-1725). This study is a part of a larger longitudinal mixed-methods study examining perinatal anxiety, well-being, and biopsychosocial mechanisms to inform a nature-based therapeutic program. Pregnant individuals in the United States were recruited using non-probability purposive sampling techniques between June of 2023 and September of 2024 from two sources: (1) two targeted health care clinics in Colorado and 2) Prolific Academic. Eligibility criteria were: (1) >6 weeks pregnant, (2) at least 18 years of age, (3) english-speaking, and (4) experiencing socioeconomic disadvantage. Participants were classified as experiencing socioeconomic disadvantage if they endorsed low-income status (defined in one of five ways: Medicaid recipient, participation in federal assistance programs, household income <250% Federal Poverty Line, no- or partial-insurance, subjective experience of high financial stress), if they endorsed low educational attainment (less than a college degree), or if they endorsed both factors. There were no exclusion criteria. Prolific Academic is an online research platform that provides the recruitment and management of participants for online research. The platform provides high-quality data collection and is used by researchers globally to recruit diverse and representative samples. Prolific Academic recruited a representative sample of pregnant women across the United States.³⁴ Of the full sample, 55% were recruited from Colorado clinics, and 45% were recruited from Prolific. Demographic differences between the samples were explored; only education was statistically significant, with the Prolific sample reporting higher education than the Colorado sample.

Procedures

The study consent and surveys were administered via Research Electronic Data Capture (REDCap).³⁵ REDCap is a secure, web-based application designed to support data capture for research studies. Individuals were asked to complete up to four surveys across the prenatal period: (1) first or second trimester, (2) third trimester, (3) 6 weeks postpartum, (4) 12 weeks postpartum. Each survey took approximately 20 minutes to complete, and participants received a $20 electronic gift card for each survey completion. The second timepoint for analyses in the present study, as social support in the 3^rd trimester has been identified as critical to protect against postpartum mood and anxiety disorders.^36,37

The qualitative data were obtained from a subset of survey participants from clinics in Colorado who indicated interest in participating in an interview. Convenience sampling was used to recruit participants via email or phone. Semi-structured interviews were conducted over Zoom or phone based on preference and lasted 30–60 minutes. The qualitative interview guide was based on the self-determination theory framework and included questions about psychological-, social-, and community-level resources that promote mental well-being. Questions explored how these multilevel resources may protect against perinatal anxiety. An example question was: “What types of supports have helped you thus far and how have they helped you in your pregnancy?” Please see the Supplementary Appendix for more details on the interview guide. Participants received a $20 electronic gift card sent via email after the interview was completed.

Instruments

The 125-item survey used at each timepoint assessed sociodemographic factors and social determinants of health (e.g., food insecurity, unmet basic needs), prenatal mental health outcomes (e.g., anxiety), and types and sources of psychosocial resources (i.e., self-efficacy, optimism, social support) using validated instruments. Sociodemographic characteristics were operationalized via the following variables: age (continuous), ethnicity (non-Hispanic vs. Hispanic), race (White, Black or African American, American Indian or Alaskan Native, Asian or Pacific Islander, or other), highest level of education (some high school, completed high school, associate’s degree, some college, completed college, and beyond college), and total household income (continuous). Food insecurity was operationalized via 2 one-item yes(1)/no(0) questions: (1) During the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money to buy food? and (2) Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. Unmet basic needs were evaluated via a one-item question with eight response options and a check all that apply option: In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Example responses include clothing, utilities, childcare, and medicine.

The primary outcome investigated in this study was assessed using the generalized anxiety disorder (GAD)-7 scale, which is a 7-item reliable brief measure of anxiety (α = 0.89) (Spitzer et al., 2006). Anxiety was assessed as a continuous variable for all analyses. Sources of social support were assessed via the Multidimensional Scale of Perceived Social Support (MSPSS). This MSPSS is a 12-item scale that measures three sources of social support (friends/peers, family, significant other) on a 7-point Likert scale (1 = very strongly disagree, 7 = very strongly agree). The tool shows an internal consistency of 0.90–0.94 in a prenatal sample.³⁸ A sample item is “I get the emotional help & support I need from my family.”³⁸

Quantitative data analysis

To explore the primary research question, all quantitative variables of interest were examined for missing data and multivariate outliers. Percent missingness ranged from 0% to 14.9%; however, Little’s Missing Completely At Random test³⁹ provided evidence that data were missing completely at random (X²(214) = 242.65, p = .09), so the full information maximum likelihood estimator was used to account for all available data. First, we exported data from REDCap to SPSS Software Version 29.0⁴⁰ and investigated univariate distributions (means, standard deviations, and graphical displays), bivariate associations between all key continuous variables, and assumptions of normality, linearity, and homoskedasticity between all key variables.⁴¹ We conducted hierarchical linear regression modeling to explore our first two research questions. First, sociodemographic characteristics and social determinants of health were added to the model to predict anxiety (continuous). Next, sources of social support (e.g., family, friends/peers, significant other) were added to block 2 and community/neighborhood support was added to block 3. R2 and adjusted R2 values, and corresponding p-values for each block are presented, as well as parameter estimates, standard errors, and p-values for the final model. Alpha (α) was set at 0.05.

Qualitative data analysis

Qualitative data were analyzed using a phenomenological approach to explore pregnant participants’ lived experiences. Thematic analysis was used to systematically group the data and identify key themes and patterns. Inductive and deductive coding strategies were used; inductive coding captured novel themes in the data, and deductive coding captured social support based on the MSPSS and established types of social support (emotional, informational, and tangible). The data were further iteratively explored to shed insight into the types and sources of social support that helped participants cope with stress and anxiety during pregnancy.

Results

The demographics of the final quantitative and qualitative samples (n = 248 and n = 23, respectively) can be seen in Table 1. Approximately 24% of the quantitative sample reported a total household income level that was below the federal poverty level, while about half made between $35,000 and $99,999 per year. Note that participants only had to endorse one indicator of low-SES to be included in the study. About half of the sample (52%) did not have a college degree; 23% had completed college, and 19% had gone on to additional education after college. Most of the sample (83%) were White, 12% were Black or African American, 5% were Asian or Pacific Islander, 3% were American Indian or Alaskan Native, and 5% reported “other.” The majority of participants were Hispanic (80%), and the food insecurity rate across the sample was about 42%. The most prevalent unmet social need was health care, with nearly 20% of the sample reporting inadequate access to health care.

Table 1.

Demographics of Final Analytical Samples (Quantitative Sample n = 248; Qualitative Sample n = 23)

	Quantitative(n = 248)		Qualitative(n = 23)
	M	SD	M	SD
Age	29.7	5.5	29.8	6.08
Gestational age	29.6	5.5	14.2	6.6
	N	%	N	%
Total Household Income
<$20,000	32	13.2	10	43.4
$20,000–$34,999	26	10.7	3	13.0
$35,000–$49,999	34	14.0	1	4.3
$50,000–$74,999	54	22.2	3	13.0
$75,000–$99,999	40	16.5	3	13.0
>$100,000	57	23.4	3	16.7
Education
Some high school	6	2.5	4	17.4
Completed high school or GED	46	18.9	6	26.1
Associate degree	18	7.4	1	4.4
Some college	59	24.3	4	17.3
Completed college	68	28.0	2	8.7
Beyond college	46	18.9	5	21.7
Race
White	181	83.0	19	82.6
Black or African American	27	12.4	5	21.7
American Indian or Alaskan Native	7	3.2	2	8.7
Asian or Pacific Islander	11	5.0	3	13.0
Other	11	5.0	0	0.0
Ethnicity
Hispanic	174	79.8	13	56.5
Non-Hispanic	44	20.2	10	43.5
Food Insecurity
No	137	58.3	10	43.5
Yes	98	41.7	13	56.5
Unmet Basic Social Needs
Food	38	15.3	5	21.7
Clothing	32	12.9	4	17.3
Utilities	22	8.9	4	17.3
Childcare	16	6.5	2	8.7
Transportation	31	12.5	5	21.7
Medicine or Health care	46	18.5	8	34.7
Phone	18	7.3	3	13.0

Results from the hierarchical linear regression models examined the relationship between sources of social support and prenatal anxiety after controlling for sociodemographic factors and social determinants of health (Table 2). The final model presents the results of a hierarchical linear regression model of sociodemographic factors (Block 1: r² = .13, F(8, 187) = 4.71, p < .001), social determinants of health (Block 2: r² = .19, F(11, 184) = 5.19, p < .001), and sources of social support (Block 3: r² = .19, F(12, 183) = 4.70, p < .001) predicting prenatal anxiety. In the final model (see Block 3), race and friend support were significant, with food insecurity approaching significance (p = .07). Being White was associated with higher levels of anxiety (p < .01). After controlling for sociodemographic factors and social determinants of health, social support from friends was significantly and negatively associated with anxiety (β = −.66, p < .01).

Table 2.

Hierarchical Linear Regression Models of Social Determinants of Health and Sources of Social Support Predicting Anxiety among a Sample of Pregnant Women (n = 248)

Outcome	Model 1. Anxiety
Outcome	R-Square	Adjusted R-Square	p Value
Block 1	0.41	0.13	<0.001
Block 2	0.49	0.19	<0.001
Block 3(Final Model)	0.49	0.19	<0.001

Final Model (Block 3)	Model 1: Anxiety
Final Model (Block 3)	B	SE	p Value
Constant	15.87	3.22	<0.001
Age	−0.13	0.08	0.08
Income	−0.11	0.25	0.65
Ethnicity
Hispanic (ref)	—	—	—
Non-Hispanic	−0.44	0.41	0.28
Race
Non-White (ref)	—	—	—
White	2.43^*	0.88	0.01
Education
College Degree (ref)	—	—	—
No college degree	0.13	0.32	0.68
Unmet Basic needs	0.44	0.40	0.28
Food Insecurity
(ref)	—	—	—
At risk	2.99	1.66	0.07
Social Support
Significant other	−0.043	0.40	0.28
family	−0.35	0.35	0.32
Friend	−0.66^*	0.31	0.04
Community/neighborhood	0.04	0.06	0.47

p < 05.

Ref, reference category.

Qualitative results

The qualitative data provided in-depth insights into how social support empowered participants to successfully navigate the stressors of pregnancy. Pregnant women identified emotional, informational, and tangible resources that help them navigate stressors and anxiety during pregnancy (see Table 3).

Table 3.

Types of Social Support Experienced by Pregnant Women Based on the Stress-Buffering Model (Cohen and Wills, 1985) (n = 23)

	Definition	Quote
Emotional support	Actions that directly alleviate or prevent emotional distress (physical touch, providing a safe space for someone to express their feelings, offering comforting words, helping someone manage their emotions).	“My husband has been phenomenal and very just calming demeanor as well. I am like, ‘Aren’t you like worried?’ He’s like, ‘No,’ like, really? Hmm. OK. That’s probably really good for me. That’d be bad. We’d be feeding off each other’s anxiety. So that’s been really good, and he’s been very calm.”
		“There yeah, someone’s always available. I have a big family. I have three siblings, and A step mom and a mom and a dad. So I feel like there’s always someone available.”
Informational support	Giving advice, suggestions, or sharing knowledge to help someone solve a problems or make decisions.	“It’s helpful like hearing about people that are just now having kids or are about to have kids. So you get to hear about different experiences and then even before having a child you get to like learn about healthy behaviors and non-healthy behaviors so that you could try to change them before you have your baby.”
		“So I like to really get on like the Pinterest or like the Tick Tock or figure out how we can do different things around the house.”
Tangible support	Providing resources such as financial assistance, help with childcare, or physical items.	“And like my mom is like let me know if you need to borrow money or whatever so they are there just in case.”
		“..my family has already jumped in to offer babysitting.”

Emotional support

Emotional support was the most salient type of support based on both frequency and pertinence in the data. Quality time with partners, family, and friends/peers helped to mitigate stressors and support participant well-being. Individuals in this sample reported that knowing someone was there for them was valuable to prevent emotional distress. One participant described it this way:

“My support system like my whole family has been amazing and it makes me so happy to feel so loved like that. It has been one of my really big things.”

Emotional support from spouses and families emerged most often, though friend/peer support was instrumental in fostering an active social life, a sense of social connectedness, mitigating loneliness, and encouraging participants to get out of the house:

“I have a friend. we go out to eat here and there and that’s fun too because like it gets lonely. so it’s nice having somebody else to talk to other than your mom and your sibling.”

The insights from this sample demonstrated how emotional support served to validate, encourage, and comfort pregnant participants and could translate to reduced risk of anxiety:

“I’d say on the easier side, mainly because of the support that I have, so I have a really good community of women around me and encourage me and tell me I’m gonna be okay and say you’re enough.”

Informational support

Participants were less likely to reference informational support, such as advice or guidance, as a type of support that mitigated anxiety. That does not diminish the importance of education and accurate information related to the prenatal experience among this sample of pregnant women; many participants expressed a need for more informational support outside of what they currently had access to:

“Apps like, like pregnancy apps. They were talking about like gestational diabetes. And so I was like reading into that and it’s like, you know, what helped me because like the doctors, they just told me like, oh, you gotta come in and do this. They didn’t really explain to me like what it was or why it was caused.”

For mothers who had already had a baby, this need extended to a desire for information around what to expect during pregnancy and postpartum:

“When I felt a little down, I was like, it must be the baby blues. But when you’re sleep deprived, you’re not remembering how long those are supposed to last or not last or any of that information. I feel like more conversation around that or even discussing like is there a program available through the hospital or somewhere else to have those conversations.”

Common resources for informational support were therapists and social media. Those who had met with a therapist felt it was critically protective to their mental health. Outside of therapy, social media emerged as an easily accessible avenue for pregnant women to feel seen in their experiences and help to mitigate stress:

“I know this is going to sound really weird, but I think social media actually…like hearing other moms and some of their struggles and how they overcame those struggles… like you understand there are other people going through the same thing as you and helps you feel better.”

Tangible support

Tangible support, commonly in the form of financial assistance or help with childcare, was less prevalent in the data. When asked about financial support, some participants emphasized the emotional comfort of knowing their family was there to provide emotional support as opposed to describing the unique benefits of receiving financial support:

“And like my mom is like let me know if you need to borrow money or whatever so they are there just in case.”

Participants did acknowledge and appreciate nonmonetary tangible support such as family helping with childcare and partners helping with tasks around the house:

“And just the support from my husband. he has really, really stepped up and is very attentive to me. And so that’s really helped. A lot of my emotional and physical load has been lifted a little bit, so where I’m not all alone in it.”

As seen in the quote above, there was significant overlap between tangible support and emotional support. For example, another participant said:

“Definitely my family. tce. if I feel like I’m like slipping and going into like a negative mindset, they definitely help me out.”

Overall, it was evident that social support can be protective against mental health challenges. As one participant said, “Having a village and like that support is huge.”

Mixed methods

The mixed methods analysis of types and sources of social support displayed concordance across both quantitative and qualitative findings around the importance of social support for well-being in this sample of low-SES pregnant women (see Fig. 1). The quantitative data identified support from friends and peers as a significant predictor of prenatal anxiety, which was echoed in more detail in the qualitative data. The shared lived experiences provided by friends/peers uniquely support the emotional well-being of participants in ways that a partner or family could not:

FIG. 1.

Heat map depicting the quantitative and qualitative relationships between types of support and sources of social support among a sample of pregnant women experiencing socioeconomic disadvantage.

“And then a friend who had a baby in August, kind of people who I could also talk to about the experience and kind of what they’re going through. that’s been very helpful.” That said, there was discordance between the quantitative and qualitative data, because the qualitative data suggested that support from partners, family members, and health care providers protected the well-being of participants during pregnancy while the quantitative did not. To further triangulate the data and better understand these relationships, Pearsons correlations (r) between types of support (qualitative) and sources of support (quantitative) were explored. The strongest associations were seen between partner support and emotional (−.66) and informational support (−.61). Family support was also moderately correlated with emotional, informational, and tangible support (>.50). Friend support was also significantly correlated with each type of support, but the correlations were not as strong. This mixed-methods analysis highlighted that emotional and instrumental support from numerous sources, including friends, peers, partners, and family members, may be the most important resource for this sample of pregnant women. Overall, the integration of both data types emphasizes the complex nature of social support and the need for multilevel sources of social support to holistically care for the mental wellbeing needs of pregnant women.

Discussion

This mixed-methods study investigated unique social determinants of health that may be associated with anxiety among low-SES pregnant individuals and emphasized the value of social support, particularly emotional support, for buffering prenatal anxiety. Social support from friends and peers emerged as significantly predictive of anxiety, aligning with existing literature around social support moderating the relationship between stress and psychological health.²⁰ The findings of this study are supported by the stress-buffering model, as emotional support was shown to help prenatal participants navigate life stressors and reduce the negative psychological impacts.²⁵ The results of this study provide practical insights to inform policies, programs, and research efforts to reduce the burden of and disparities in prenatal anxiety.

We investigated associations between sociodemographic factors and social determinants of health (i.e., income, education, housing security, food security) and found that race and food security were the only indicators that were predictive of prenatal anxiety among this underresourced sample (associations between food insecurity and anxiety were approaching significance, p = .08). The finding that White women reported higher anxiety is not surprising, as GAD is typically more prevalent in White women.^42,43 In prenatal populations specifically, the risk of anxiety is higher in those with a past history of (GAD), low education, and low levels of social support.^44,45 Furthermore, though not statistically significant, the finding that food insecurity may be a critical social determinant for prenatal anxiety aligns with a recent scoping review that found prenatal women experiencing food insecurity are at higher risk for depression and anxiety.⁴⁶ Food insecurity during pregnancy contributes to poorer maternal and child outcomes, such as preterm labor, gestational diabetes, and neonatal mortality.⁴⁷ Though the heterogeneity in methodology and inadequate number of studies limits the strength of evidence, the established relationship between food insecurity and prenatal mental health warrants improved policies to connect pregnant women with resources (e.g., produce prescriptions, subsidies for purchasing nutritious foods, community outreach programs) that reduce food insecurity.⁴⁸

Next, we examined multi-level sources of social support that may buffer prenatal anxiety. In the quantitative sample, support from friends and peers was the only source of social support significantly associated with anxiety. This aligns with existing literature, which found that support from friends reduced prenatal anxiety and depression more than family support.^22,49 However, in the qualitative data, individuals shared that support from partners, parents, friends, and peers also helped to mitigate poor mental health and promote well-being. The integration of these data suggests that peer relationships may confer resilience; having support from others who understood what they were going through (i.e., moms on social media, mom friend groups, formal support groups) was informational. Nonfamilial relationships, specifically from others who have been or were pregnant, provided a critical avenue for connection, peer support, and learning. Participants valued being around others who knew what they were experiencing and could share insights in a safe space. The benefits of friendships and peer support networks for underresourced pregnant populations provide promising clinical strategies to protect against prenatal anxiety. Peer support programs are an accessible and promising strategy for preventing and treating prenatal mood disorders.^50–52 However, more work is needed to assess clinical peer support interventions for prenatal anxiety.^51,53 Given the shortage of mental health providers and limited access care for low-income populations, the effectiveness of peer support interventions for prenatal anxiety should be explored further.^53,54

We investigated unique sources of social support (i.e., informational, tangible, emotional) based on the stress-buffering hypothesis and found that emotional support was most strongly correlated with anxiety. This finding aligned with qualitative data, where emotional support was most salient (based on relevance and frequency) when participants discussed sources of support in their life. The importance of emotional support is echoed within existing literature, as emotional closeness promotes prenatal mental health⁵⁵ and sufficient emotional support from partners, family, and friends/peers can protect against prenatal anxiety.²² Outside of the prenatal population, emotional support has been seen to be more powerful than tangible support for well-being.^56,57 The importance of emotional support highlighted in this study is especially compelling considering the sample was from a low-resourced population. Even though emotional support emerged as more important to participants in our sample than tangible resources, these findings do not dimmish the need for improved access to prenatal health care in underresourced communities.^10,12 Future work should consider the interplay between tangible (e.g., financial assistance) and emotional support to better support low-income perinatal populations.

Limitations

This study has several limitations that should be considered when interpreting the results. First, the cross-sectional design prevents any causal understanding of the impact of social support on prenatal anxiety. Furthermore, since the data were only collected at one timepoint, it cannot account for fluctuations and contextual changes across the prenatal period. Therefore, it cannot be generalized across pregnancy. Next, this study used purposive sampling of women in the United States, which limits generalizability to broader populations. Future research should assess a more diverse sample longitudinally to strengthen causal inferences and better understand changes over time and across cultural contexts.

Conclusions

Despite the limitations, the mixed-methods design of this study adds uniquely to the literature by integrating lived experiences and contextualization of supports to more comprehensively elucidate the role of social support in mitigating prenatal anxiety among low-SES women. Fostering group-based emotional social support (e.g., community-based peer networks, digital peer platforms) should be considered a key part of preventing and managing prenatal anxiety. Evidence-based peer support programs present an accessible and effective approach to promote prenatal mental health, but more work needs to be done to understand how to best implement and assess interventions for prenatal anxiety.^50–52 Furthermore, this study found that food insecurity may be one of the most important unmet social needs that contributes to prenatal anxiety, highlighting the importance of enhancing clinical screening processes, referral programs, and policies. This study emphasizes the benefit of strengthening social support networks and group-based clinical practices to mitigate the broad-reaching adverse impacts of prenatal anxiety.

Ethics Approval

All procedures were approved by the Colorado Multiple Institutional Review Board.

Consent to Participate

All individuals consented to participate in this study.

Data Availability Statement

Data is available from the authors upon request.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This Work Was Supported by the National Institute on Minority Health and Health Disparities (5K01MD016928-02) And (NIH/NCATS Colorado CTSA Grant Number Ul1 TR002535).

Supplemental Material

Abbreviaitons Used

References

1. Byrnes

. Perinatal mood and anxiety disorders. The Journal for Nurse Practitioners 2018;14(7):507–513.

2. Fawcett

, Fairbrother

, Cox

, et al. The prevalence of anxiety disorders during pregnancy and the postpartum period: A multivariate Bayesian meta-analysis. J Clin Psychiatry 2019;80(4):18r12527; doi: 10.4088/JCP.18r12527

3. Accortt

, Mirocha

, Jackman

, et al. Association between diagnosed perinatal mood and anxiety disorders and adverse perinatal outcomes. J Matern Fetal Neonatal Med 2022;35(25):9066–9070.

4. Moog

, Nolvi

, Kleih

, et al. Prospective association of maternal psychosocial stress in pregnancy with newborn hippocampal volume and implications for infant social-emotional development. Neurobiol Stress 2021;15:100368.

5. Jagtap

, Jagtap

, et al. Effects of prenatal stress on behavior, cognition, and psychopathology: A comprehensive review. Cureus 2023;15(10):e47044; doi: 10.7759/cureus.47044

6. Luca

, Margiotta

, Staatz

, et al. Financial toll of untreated perinatal mood and anxiety disorders among 2017 births in the United States. Am J Public Health 2020;110(6):888–896.

7. Pisavadia

, Doungsong

, Ezeofor

, MAP ALLIANCE study team. et al. Healthcare use and costs of perinatal anxiety: A UK NHS perspective. BMC Health Serv Res 2025;25(1):1183.

8. Daalderop

, Lagendijk

, Steegers

, et al. Psychological distress during pregnancy and adverse maternal and perinatal health outcomes: The role of socioeconomic status. Int J Gynaecol Obstet 2023;163(3):920–930.

9. Best

, Ayers

, Sinesi

, MAP Study Team. et al. Socioeconomic deprivation and perinatal anxiety: An observational cohort study. BMC Public Health 2024;24(1):3183.

10.

10. Miller

, Dupree

, Monette

, et al. Health equity and perinatal mental health. Curr Psychiatry Rep 2024;26(9):460–469.

11.

11. Prady

, Endacott

, Dickerson

, et al. Inequalities in the identification and management of common mental disorders in the perinatal period: An equity focused re-analysis of a systematic review. PLoS One 2021;16(3):e0248631.

12.

12. Zivin

, Courant

. Disparities in utilization and delivery outcomes for women with perinatal mood and anxiety disorders. J Psychiatr Brain Sci 2024;9(2):e240003; doi: 10.20900/jpbs.20240003

13.

13. Nillni

, Mehralizade

, Mayer

, et al. Treatment of depression, anxiety, and trauma-related disorders during the perinatal period: A systematic review. Clin Psychol Rev 2018;66:136–148.

14.

14. Goodman

, Watson

, Stubbs

. Anxiety disorders in postpartum women: A systematic review and meta-analysis. J Affect Disord 2016;203:292–331.

15.

15. Dennis

C-L

, Falah-Hassani

, Shiri

. Prevalence of antenatal and postnatal anxiety: Systematic review and meta-analysis. Br J Psychiatry 2017;210(5):315–323.

16.

16. Bedaso

, Adams

, Peng

, et al. The relationship between social support and mental health problems during pregnancy: A systematic review and meta-analysis. Reprod Health 2021;18(1):162–123.

17.

17. Roohafza

, Afshar

, Keshteli

, et al. What’s the role of perceived social support and coping styles in depression and anxiety? J Res Medical Sci: The Official J Isfahan Univ of Medical Sci 2014;19(10):944.

18.

18. Stewart

, Patel

, McDermott

, et al. Functional and structural social support in DSM-5 mood and anxiety disorders: A population-based study. J Affect Disord 2022;308:528–534.

19.

19. Kay

, Moulson

, Vigod

, et al. The role of social support in perinatal mental health and psychosocial stimulation. Yale J Biol Med 2024;97(1):3–16; doi: 10.59249/wmge9032

20.

20. Razurel

, Kaiser

, Sellenet

, et al. Relation between perceived stress, social support, and coping strategies and maternal well-being: A review of the literature. Women Health 2013;53(1):74–99.

21.

21. Schwab-Reese

, Schafer

, Ashida

. Associations of social support and stress with postpartum maternal mental health symptoms: Main effects, moderation, and mediation. Women Health 2017;57(6):723–740.

22.

22. Sufredini

, Catling

, Zugai

, et al. The effects of social support on depression and anxiety in the perinatal period: A mixed-methods systematic review. J Affect Disord 2022;319:119–141.

23.

23. Takács

, Štipl

, Gartstein

, et al. Social support buffers the effects of maternal prenatal stress on infants’ unpredictability. Early Hum Dev 2021;157:105352.

24.

24. Collins

, Dunkel-Schetter

, Lobel

, et al. Social support in pregnancy: Psychosocial correlates of birth outcomes and postpartum depression. J Pers Soc Psychol 1993;65(6):1243–1258.

25.

25. Cohen

, Wills

. Stress, social support, and the buffering hypothesis. Psychol Bull 1985;98(2):310–357.

26.

26. DeGarmo

, Patras

, Eap

. Social support for divorced fathers’ parenting: Testing a stress‐buffering model. Fam Relat 2008;57(1):35–48.

27.

27. Sallis

, Owen

, Fisher

. Ecological models of health behavior. Health behavior and health education: Theory, research, and practice, 4th ed. Jossey-Bass; 2008:465–485.

28.

28. Kousoulis

, Goldie

. A visualization of a socio-ecological model for urban public mental health approaches. Front Public Health 2021;9:654011.

29.

29. Tyokighir

, Hervey

, Schunn

, et al. Qualitative assessment of access to perinatal mental health care: A social-ecological framework of barriers. Kans J Med 2022;15(1):48–54.

30.

30. Racine

, Plamondon

, Hentges

, et al. Dynamic and bidirectional associations between maternal stress, anxiety, and social support: The critical role of partner and family support. J Affect Disord 2019;252:19–24.

31.

31. Leach

, Poyser

, Fairweather‐Schmidt

. Maternal perinatal anxiety: A review of prevalence and correlates. Clin Psychol 2017;21(1):4–19.

32.

32. Verbeek

, Bockting

, Beijers

, et al. Low socioeconomic status increases effects of negative life events on antenatal anxiety and depression. Women Birth 2019;32(1):e138–e143.

33.

33. Blebu

, Jackson

, Reina

, et al. Social determinants among pregnant clients with perinatal depression, anxiety, or serious mental illness: Study examines co-occurring social determinants of health for people experiencing perinatal mood and anxiety disorders or serious mental illness. Health Aff (Millwood) 2024;43(4):532–539.

34.

34.Prolific. 2019; Available from: https://www.prolific.com

35.

35. Harris

, Taylor

, Thielke

, et al. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377–381; doi: 10.1016/j.jbi.2008.08.010

36.

36. Cho

, Lee

, Choi

, et al. Association between social support and postpartum depression. Sci Rep 2022;12(1):3128; doi: 10.1038/s41598-022-07248-7

37.

37. Feinberg

, Declercq

, Lee

, et al. The relationship between social support and postnatal anxiety and depression: Results from the listening to mothers in California survey. Womens Health Issues 2022;32(3):251–260.

38.

38.The Multidimensional Scale of Perceived Social Support, 52 Lawrence Erlbaum 30-41 (1988).

39.

39. Little

RJA

. A test of missing completely at random for multivariate data with missing values. J Am Stat Assoc 1988;83(404):1198–1202; doi: 10.1080/01621459.1988.10478722

40.

40. Corp

. IBM SPSS Statistics for Mac, Version 28.0. 2021. IBM Corp: Armonk, NY.

41.

41. Fife

. The eight steps of data analysis: A graphical framework to promote sound statistical analysis. Perspect Psychol Sci 2020;15(4):1054–1075.

42.

42. Asnaani

, Richey

, Dimaite

, et al. A cross-ethnic comparison of lifetime prevalence rates of anxiety disorders. J Nerv Ment Dis 2010;198(8):551–555.

43.

43. Terlizzi

, Villarroel

. Symptoms of generalized anxiety disorder among adults: United States, 2019. NCHS Data Brief 2020(378):1–8.

44.

44. Buist

, Gotman

, Yonkers

. Generalized anxiety disorder: Course and risk factors in pregnancy. J Affect Disord 2011;131(1–3):277–283; doi: 10.1016/j.jad.2011.01.003

45.

45. Luo

, Zhang

, Huang

, et al. Risk factors for depression and anxiety in pregnant women during the COVID-19 pandemic: Evidence from meta-analysis. PLoS One 2022;17(3):e0265021; doi: 10.1371/journal.pone.0265021

46.

46. Kinsey

, Caceres

, Posner

HEK

, et al. Food insecurity during pregnancy and associated perinatal outcomes: A scoping review. Epidemiol Rev 2025;47(1):mxaf001; doi: 10.1093/epirev/mxaf001

47.

47. Bell

, Nguyen

, Andreae

, et al. Associations between food insecurity in high-income countries and pregnancy outcomes: A systematic review and meta-analysis. PLoS Med 2024;21(9):e1004450; doi: 10.1371/journal.pmed.1004450

48.

48. Biete

, Biete

, Patriota

ESO

, et al. Household food insecurity and symptoms of anxiety and depression during pregnancy: Systematic review and meta-analysis. Matern Child Nutr 2025;21(1):e13714; doi: 10.1111/mcn.13714

49.

49. Hughes

, Devine

, Foley

, et al. Couples becoming parents: Trajectories for psychological distress and buffering effects of social support. J Affect Disord 2020;265:372–380; doi: 10.1016/j.jad.2020.01.133

50.

50. Baumel

, Schueller

. Adjusting an Available Online Peer Support Platform in a Program to Supplement the Treatment of Perinatal Depression and Anxiety. JMIR Ment Health 2016;3(1):e11; doi: 10.2196/mental.5335

51.

51. Fang

, Lin

, Chen

, et al. Effect of peer support intervention on perinatal depression: A meta-analysis. Gen Hosp Psychiatry 2022;74:78–87; doi: 10.1016/j.genhosppsych.2021.12.001

52.

52. Shah

, Chua

JYX

, Goh

, et al. Effectiveness of peer support interventions in improving mothers’ psychosocial well-being during the perinatal period: A systematic review and meta-analysis. Worldviews Evid Based Nurs 2024;21(6):652–664; doi: 10.1111/wvn.12747

53.

53. Huang

, Yan

, Tian

, et al. Effectiveness of peer support intervention on perinatal depression: A systematic review and meta-analysis. J Affect Disord 2020;276:788–796; doi: 10.1016/j.jad.2020.06.048

54.

54. McLeish

, Ayers

, McCourt

. Community-based perinatal mental health peer support: A realist review. BMC Pregnancy Childbirth 2023;23(1):570; doi: 10.1186/s12884-023-05843-8

55.

55. Pilkington

, Milne

, Cairns

, et al. Modifiable partner factors associated with perinatal depression and anxiety: A systematic review and meta-analysis. J Affect Disord 2015;178:165–180; doi: 10.1016/j.jad.2015.02.023

56.

56. Hill

. Quality of life and mental health among women with ovarian cancer: Examining the role of emotional and instrumental social support seeking. Psychol Health Med 2016;21(5):551–561; doi: 10.1080/13548506.2015.1109674

57.

57. Morelli

, Lee

, Arnn

, et al. Emotional and instrumental support provision interact to predict well-being. Emotion 2015;15(4):484–493; doi: 10.1037/emo0000084

Unpacking the Protective Power of Social Support in Mitigating Prenatal Anxiety Among Low-Resourced Populations: A Mixed-Methods Study

Abstract

Background:

Methods:

Results:

Discussion:

Keywords

Methods

Participants

Procedures

Instruments

Quantitative data analysis

Qualitative data analysis

Results

Qualitative results

Emotional support

Informational support

Tangible support

Mixed methods

Discussion

Limitations

Conclusions

Ethics Approval

Consent to Participate

Data Availability Statement

Footnotes

Author Disclosure Statement

Funding Information

Supplemental Material

Abbreviaitons Used

References