Financial Hardships and Mental Health

Financial difficulties, housing instability, trouble paying bills, food insecurity, and job loss, increased substantially during the COVID-19 pandemic. These hardships contribute to poor mental health through chronic stress, stigma, and trauma.⁵ Overall, 32.7% of birthing people experienced symptoms of anxiety and/ or depression during or after pregnancy. Symptoms of anxiety and/or depression were more common among those with financial hardships.

Symptoms of anxiety and/or depression were more common among those who experienced financial hardships than among those who did not

Health Insurance, Race, and Ethnicity and Mental Health

Both private health insurance and Medi-Cal cover mental health screening and treatment. Birthing people who had Medi-Cal for prenatal insurance reported depression symptoms more frequently than did those with private insurance. Anxiety symptoms were similarly high in each group. The high prevalence of these symptoms demonstrates a great need for pregnancy-related mental health services.

Symptoms of anxiety and depression by prenatal health insurance type

The chronic stress of racism is also associated with depression and other mental health concerns.⁶ Black birthing people have the highest prevalence of both anxiety and depression symptoms among all racial and ethnic groups.

Symptoms of anxiety and depression by race and ethnicity

Addressing Maternal Mental Health

​​​​​​Resources for California Families

About the Data

Methods

This data brief uses 2020 data from the Maternal and Infant Health Assessment (MIHA) survey, a statewide representative survey of individuals with a recent live birth in California, conducted annually since 1999, linked to birth certificates. The survey collects self-reported information about maternal and infant experiences before, during, and shortly after pregnancy. 

MIHA is a stratified random sample of English- or Spanish-speaking individuals. MIHA data used in this brief are weighted to be representative of California residents with a live birth from May 16, 2020 to June 15, 2020, excluding those who were younger than 15 years old at delivery, had a multiple birth greater than triplets, or had a missing address on the birth certificate. The MIHA 2020 sample size was 6,363. For more information on weighting and technical definitions, see the MIHA Technical Notes at go.cdph.ca.gov/MIHA-methods. 

Definitions

Self-reported symptoms of anxiety and depression were ascertained using an adapted four-item Patient Health Questionnaire (PHQ-4), which includes the two- item Generalized Anxiety Disorder (GAD-2) scale and the twoitem PHQ-2, which assesses symptoms of depression.¹⁴ Adaptations to the PHQ-4 for use in MIHA included (1) changing the time period from “Over the last 2 weeks” to the prenatal period ("During your pregnancy") and postpartum period ("Since your most recent birth") and (2) changing the response categories from the frequency of days in the past two weeks to a general frequency scale ("always," "often," "sometimes," "rarely," and "never").¹⁵ Measures were defined as follows: 

Anxiety symptoms – During pregnancy or since most recent birth, always or often felt nervous, anxious or on edge, or was unable to stop or control worrying.

Depression symptoms – During pregnancy or since most recent birth, always or often felt down, depressed or hopeless, or had little interest or pleasure in doing things usually enjoyed. 

Anxiety and/or depression symptoms – During pregnancy or since most recent birth, experienced either anxiety symptoms, depression symptoms, or both.

References

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5. Tracking the COVID-19 Economy’s Effects on Food, Housing, and Employment Hardships. Center on Budget and Policy Priorities, 2021.
   

6. Knifton L, Inglis G. Poverty and mental health: policy, practice and research implications. BJ Psych Bull 2020; 44(5): 193-196.

7. Paradies Y, Ben J, Denson N et al. Racism as a determinant of health: a systematic review and meta-analysis. PLOS One 2015; 10(9):e0138511.

8. Panchal N, Kamal R, Cox C, Garfield R. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation Fact Sheet, 2021.

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10. Liu J, Hung P, Alberg AJ et al. Mental health among pregnant women with COVID-19-related stressors and worries in the United States. Birth 2021; 48:470-479.

11. Cal. Assemb. B. 2193, Chapter 755 (Cal. Stat. 2018).
    

12. Parma A. New Medi-Cal Policy Expands Access to Family Therapy for Young Children. https://first5center.org/blog/newmedi- cal-policy-expands-access-to-family-therapy-for-youngchildren. Accessed May 11, 2022.

13. Misra DP, Guyer B, Allston A. Integrated perinatal health framework: A multiple determinants model with a life span approach. Am J Prev Med 2003;25(1):65-75.

14. Shim RS, Compton, MT. Addressing the social determinants of mental health: if not now, when? If not us, who? Psychiatr Serv 2018; 69:844-846.

15. Kroenke K, Spitzer RL, Williams JB, et al. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics. 2009;50(6):613-21.​​​