How Stress Shapes Maternal Health

Imagine that you’re somewhere between six and nine months pregnant. You’re still working because your job doesn’t offer paid family and medical leave (PFML), and you have to save up any sick days or vacation time you’ve earned to recover after giving birth. To make matters even more stressful, you’re having a hard time getting reasonable accommodations like lighter duty assignments, regular bathroom breaks, or a stool, despite the legal measures in place to protect you. Maybe your housing situation is precarious because rent has hit record levels of sky-high, and wages aren’t keeping up with the landlords’ markup. If you’re one of the few who can afford your rent on your wages, what will you do if you can’t work all 40, 50, and, in some states, 100 of the hours required to do so due to needing more rest and care? Maybe you’re risking getting an eviction notice because you chose to spend your limited funds on food or transportation to the doctor instead.

It all gets a bit more convoluted once your child is born. The American College of Obstetricians and Gynecologists recommends that you take six to 12 weeks off work to recover, while other organizations suggest at least six months. But again, if you don’t have PFML, this may be impossible unless you quit your job. Maybe you qualify for the unpaid Family Medical Leave Act. But there’s no guarantee of pay, so you can’t afford it. Even if you do have PFML or quit, can your family survive on one income—assuming it isn’t already? Regardless, when it’s time to secure infant care, it will cost you between eight and 19.3 percent of the median family’s income per child. Should you be part of the 50 percent of Americans who live in a child care desert, where the number of young children needing care exceeds the number of available slots with licensed providers thrice over, this battle will be even tougher.

All that stress during pregnancy will compound upon itself on top of the significant stress that pregnancy puts on a body. The strain can make it impossible to sleep. Your breathing can quicken. You could develop high blood pressure—a disease that is the primary cause of death for Black women during the pre-and post-partum period—go into labor early, deliver a low birth weight baby, or miscarry.

It sounds dire to have a child in this country because it is for many who decide to do so. However, the scenarios laid out in the previous paragraphs are only a glimpse of the way stress affects expecting, new, and seasoned parents. (We didn’t get into accessing quality healthcare, birth trauma, or fearing a negative outcome because you’re Black, for example.) Molly Dickens, a stress physiologist and maternal health advocate, is trying to make sense of this phenomenon via the Maternal Stress Project, an exploratory initiative to map and build evidence around the stressors related to modern American motherhood.

Dickens is working to paint a picture here. Her project centers around a visual map that appears to be a series of different-colored and shaped orbs with connecting lines that resemble a granddaddy spider's namesake long legs. But the arachnid-like appendages link various stressors—some of which are mentioned above—that negatively affect the health and well-being of a birthing person from pregnancy to childbirth, postpartum, and, in many instances, long after.

“I’m building an evidence bank to better describe how stress manifests as a societal issue,” says Dickens. “I want to show that we have opportunities to solve stress as it relates to women's health, maternal health, the health of birthing people, and caregivers more generally.”

Dickens and I discussed her stress map—which is confusing at first glance but makes more sense as you analyze it—why the modern American notions of self-care and individual responsibility aren’t enough to address chronic stress, how pregnancy and racism push a stressed-out body to the edge, and what policymakers could do about it.

Julia Craven: Let’s start with what stress does to the human body. I don't think people fully understand how detrimental it is.

Stress itself is not an illness; it is not a diagnosable disease that has a cure. That's why it gets tricky from a clinical perspective. But what we know is that stress affects nearly all of the systems in the body—the cardiovascular system, the reproductive system, the metabolic system, the nervous system, the immune system. When people say, ‘I got a cold because I'm stressed,’ there's truth to that. When you’re in a state of chronic stress, it is essentially initiating or exacerbating illness in the body.

On the mental health side, chronic stress has been linked to clinical anxiety, depression, and other mental health disorders. It’s connected to the cardiovascular system and exacerbates hypertension and cardiovascular disease. Stress is linked to the metabolic system, so that's why it exacerbates metabolic disorders like diabetes—especially type 2 diabetes.

Explain how pregnancy pushes all of these things to an extreme.

Pregnancy and postpartum recovery are some of the most incredible physiological events in the human body. I'm absolutely in awe of it because, as a physiologist, when you look at the changes happening in this relatively short window of time, the body is pushed to this extreme level. And if the body weren’t in a state of pregnancy, the way physiological metrics read—hormone levels, blood pressure, etc.—that body might be seen as in a “disease state” [1]. If you take any measurement of anything in the body during pregnancy and you blindly give it to a clinician, they'd be like, ‘What is happening in this body?!” But those extreme levels are important for the developing fetus, maintaining pregnancy, and preparing for birth.

When the priority of physiological changes shifts to growing and birthing a human, sometimes, the mother's health suffers as a side effect. But often, the body can go through these incredible, extreme changes and come out the other end healthy—maybe slightly changed—but still generally healthy.

This push to the extreme makes the pregnant body especially vulnerable to stress. Sometimes, it goes over the edge naturally. But sometimes, stress during pregnancy is, for lack of a better phrase, the straw that breaks the camel's back.

Tell us more about how the stress of being pregnant can be another source of worry for the birthing person and their family.

So, the “stress of pregnancy,” which I discussed with Dr. Karen Sheffield-Abdullah for The Maternal Stress Project, is the stress related to the fear of negative birth outcomes, especially for Black mothers. In our discussion, she explained: "We also know that one of the things that is a stressor for Black women is the fear of dying. That is also exacerbating the stress. Fear is a stressor."

Then there is additional stress during pregnancy, which is the external stress related to being pregnant—pregnancy discrimination or lack of accommodations at work, navigating the healthcare system, especially with access issues, to get basic perinatal care, birth trauma, and health conditions related to pregnancy.

We know that chronic stress from experiencing racism—meaning food insecurity, housing issues, exposure to toxins, etc.—further exacerbates stress for Black birthing persons, which worsens their health outcomes. One thing that deeply frustrates me in my research and reporting is the lack of focus on solutions. We know the data. It's dismal. I'm not saying we shouldn't talk about it, but what can policymakers do to lighten this disproportionate burden on Black folks?

I am 100 percent with you on that frustration. The focus has definitely been on reporting the dismal data without spending much time running through potential solutions, big and small, that will make impacts. I wonder how much of that relates to the lack of research and historical underfunding on the solutions side of the equation.

With that said, on the solutions side, there is lots of important information in the interview with Dr. Sheffield-Abdullah, and from other work in this space—especially when it comes to what needs to change in healthcare and with healthcare providers. [This includes more] diversity in the medical profession and listening to Black women.

On the policy side, connecting evidence to demonstrate why these solutions work, psychologically and physiologically, is part of the goal of The Maternal Stress Project. If we accept that chronic stress negatively impacts health. If we accept that a lifetime of chronic stress leads to weathering, especially for Black people as it relates to all the things you list. If we accept that weathering results in a body that is even more vulnerable to negative pregnancy outcomes and stress-related health issues—then we need to accept that, from a societal, community-based, and policy-driven perspective, the imperative must be to limit as much stress exposure as possible during the perinatal period.

As it relates to the stressors on the map, child care, paid leave, job security, housing security, food security, and more can be decreased or mitigated through policy and a more robust social safety net. These stressors disproportionately impact Black communities, which means that any policy to address the burden of these stressors—federal funding for accessible, quality child care and addressing causes of eviction/housing instability—lightens the load in a way that could significantly impact health across the board.

Let’s take a step back. Explain your stress map. It's very confusing.

Molly Dickens: The way the maternal stressor map is constructed is incomplete; it's narrow in terms of the timeline, which is right on top of the map and spans through pregnancy, postpartum, and early parenting. It should absolutely extend across the reproductive lifespan because even at the other end, with perimenopause and menopause, there are stressors related to caregiving, ageism, and other aspects that coincide with physiological flux. But for simplicity, I kept it in this range.

I consider the psychological stressors in the bubbles. Some of these stressors have physical components. An obvious one is food security, which has clear physical components, but for the purpose of the map, it's on the psychological level. The fear of food insecurity and the perception of food insecurity are stressors. That's what I'm trying to capture. We are processing these external stressors in a way that causes a physical response that affects our health.

Then you have connection points, which help us understand that if an individual identifies with certain stressors on the map, it's also important to know how those stressors are connected. Links between stressors help us understand how deeply they impact people. They also help us identify opportunities for things like paid leave or child care stability, which also affect the stress of housing security, income security, or financial stability. You can envision big solutions that address how each of these stressors are connected.

What made you realize this research should be investigated and shared with people?

I have my doctorate in physiology, specifically in stress. Having come from the research space, I understand stress as it relates to natural processes in the body and health effects when those natural processes are pushed too far. Then, I made my way through the world of maternal, pregnancy, and postpartum health and then back into the space of gender equity and working motherhood. I started to see how all of these dots are connected through this lens of stress. Yet, when we talk about stress as it relates to health, we have this inclination to make it a personal problem. We pin stress management to personal responsibility via classic advice: if you're under stress, maybe you should be sleeping, exercising, or meditating more.

But those are not solutions that are actually going to impact health. If we want to talk about stress, what is causing stress, and ways to impact stress, we have to think about stressors in a different way. How do we mitigate or remove these stressors rather than tell people who are under stress to sleep, exercise, and meditate?

It’s humorous, in a macabre way, that if you're stressed out and overwhelmed, instead of more systemic support, you’re told, “Well, girl, download this meditation app.”

It's so backward in a world that's like, “We need big solutions for big population public health change.” Something on such an individual level is not going to have that much of an impact on health broadly. Why are we stuck stuck in that space? And your work, too, is a great example of this issue for housing. If you look at housing and housing instability through the lens of stress, you see all the connection points to financial stress, which we know is a potent stressor. It is tied to child care stress, and we know child care precarity is a potent stressor. It ties to workplace stress, and we know that workplace discrimination and microaggression are stressors.

There’s mental load, or navigating how to balance [affording and accessing] child care and housing. When you see these things through the lens of stress, you can see how all of this adds up to affect health.

Those little individual things aren't particularly helpful at rectifying systemic issues, but they can help you breathe through them. I'm really interested in how you distinguish between loving meditation, for instance, and understanding that this practice is just helping someone cope with a messed-up situation. It's not actually fixing it.

There are big, broad solutions that can impact a lot of people at once, and there are day-to-day solutions that can help you as an individual. Meditation, sleep, and exercise can be helpful for someone who is really swimming in these stressors. But I want to get away from individual responsibility as the default—even as we wait for big, sweeping policy change.

I would like this narrative to radiate out a bit more so that it is not just on the individual but also at family, partnership, and community levels. And part of that sleep, exercise, and meditation advice is finding the time for it. So, if that is something that is going to really buffer your stress load, how are those around you also able to ensure that you have the time to do that? What are they taking on to lighten your load and support that as a stress buffer for you?

Footnotes:

[1] While pregnancy is not a disease state, pregnant people may experience various health risks and symptoms similar to those seen in certain diseases. Medical treatment may also involve similar approaches used for managing certain conditions typically regarded as diseases.