Relational resilience as a potential mediator between adverse childhood experiences and prenatal depression

Abstract

This study examined the indirect effects of individual, relational, and contextual resilience in the relationship between adverse childhood experiences and prenatal depression. Participants included 101 pregnant women. Adverse childhood experiences had a direct effect on depression, B = 1.11, standard error = .44, p = .01, and relational resilience, B = −1.15, standard error = .19, p < .001, but not individual or contextual resilience. With resilience as a mediator, the effect of adverse childhood experiences on depression was no longer significant. Specifically, relational resilience had a significant indirect effect (IE) on the association between adverse childhood experiences and depression, IE = 1.04, boot standard error = .28 (95% confidence interval = .58, 1.68). Results emphasize the associated role of relational qualities, such as sense of security and belongingness, with childhood adversity and mental health.

Keywords

depression pregnancy trauma well-being women’s health

Prenatal psychosocial stress is common, with up to 78 percent of urban pregnant women endorsing low to moderate stress and 6 percent experiencing high stress levels (Schetter and Tanner, 2012). Psychosocial stress during pregnancy significantly jeopardizes women’s prenatal and mental health. For example, rates of generalized anxiety disorder range from 4.4 to 8.2 percent and rates of posttraumatic stress disorder (PTSD) range from 2 to 6 percent among pregnant and postpartum women (Ross and McLean, 2006). The form of psychopathology most closely linked to pregnancy and the postpartum period is depression (Ajinkya et al., 2013). During pregnancy, women are at increased risk for the development, recurrence, or exacerbation of major depressive episodes (Bennett et al., 2004; Rich-Edwards et al., 2010). Upward of 15 percent of women in the United States experience depressed mood during the prenatal period (Bansil et al., 2010; Bennett et al., 2004; Dietz et al., 2007; Gavin et al., 2005) and 5 percent develop clinical depression (Schetter and Tanner, 2012). Rates of the first incidence of depression in the prenatal period are also quite high—7.5 to 14.5 percent of pregnant women (Gavin et al., 2005). These rates rise even higher among pregnant women in disadvantaged neighborhoods or from lower socioeconomic status (SES) backgrounds (Rich-Edwards et al., 2010), making the examination of factors that may be associated with prenatal depression in this at-risk group a priority.

Decades of research have robustly demonstrated the deleterious effects of maternal psychopathology on maternal and infant health and functioning. For pregnant women, prenatal depression has been implicated in reduced quality of prenatal care, adverse health behaviors (i.e. substance use, inadequate nutrition, and unhealthy weight gain), as well as increased use of emergency room services, greater time spent at the hospital, and higher rates of maternal and fetal complications (Alder et al., 2007; Bansil et al., 2010; Marcus et al., 2003). Prenatal depression significantly increases the risk of postpartum and chronic depression and undermines early attachment processes, with depressed mothers showing less affection and more rigidity toward their infants (Wachs et al., 2009). Likewise, infants of depressed mothers demonstrate less secure attachment. Furthermore, prenatal depression is associated with preterm birth, low birthweight, elevated cortisol, and low levels of dopamine and serotonin in infants, which may jeopardize emotion regulation processes as the child develops (Field et al., 2006; Wachs et al., 2009). Infants of depressed mothers have been shown to display elevated heart rates, greater physiological reactivity, reduced positive affect, increased irritability, greater negative affect, and a higher frequency of temperament difficulties (Field et al., 2006; Huot et al., 2004). As they mature, children of mothers who experienced prenatal depression also show higher rates of internalizing and externalizing behavioral problems and increased social and emotional difficulties (Luoma et al., 2001; Maughan et al., 2007). Given the high rates of prenatal depression and the deleterious consequences for both the mother and her child, it is critical to understand factors that are correlated with more positive mental health outcomes for pregnant women.

One factor receiving increased attention as a candidate risk for the development of prenatal depression is adverse childhood experiences (ACEs), which include physical, sexual, and psychological abuse, household dysfunction, substance abuse or mental illness of a family member, violent treatment of mother, and incarceration of a household member (Centers for Disease Control and Prevention, 2015). The prevalence of ACEs among women is quite high, with one recent national study indicating that between 15.2 and 34.1 percent of women had a history of childhood adversity (Centers for Disease Control and Prevention, 2015). ACEs have far-reaching consequences for adult mental health, with the risk for adult affective and somatic disorders (such as depression) linearly increasing as ACEs accumulate (Anda et al., 2006). This finding holds for non-pregnant women, with research evidence of a well-documented link between a greater number of ACEs and increased rates of depression in this population (Goodman and Brand, 2002).

While there is an established association between ACEs and depression in women, minimal empirical work has been done on the role of ACEs in prenatal depression. The few studies on this topic have identified a relationship between experiencing early childhood trauma and a heightened risk for depression in the prenatal period (Chung et al., 2008; Robertson-Blackmore et al., 2013). However, a majority of the research examining childhood adversity and prenatal depression has focused solely on the influence of one form of adversity, childhood sexual abuse (Lang et al., 2006; Robertson-Blackmore et al., 2013). Other studies in this area slightly broadened their examination to include both physical and sexual childhood abuse (Barrios et al., 2015; Holzman et al., 2006; Rich-Edwards et al., 2010), with only one study also including emotional abuse in their measure of childhood adversity (Leigh and Milgrom, 2008). While these studies shed light on an important connection between child abuse and prenatal depression, they have neglected to examine a broader range of childhood adversities (e.g. parental psychopathology, substance use, family violence) that are more consistent with the types of experiences endured by millions of individuals, including pregnant women. Furthermore, they have not considered the indirect effects of factors related to positive functioning, such as resilience, which may account for some of the relationship between early life adversity and prenatal depression.

Resilience is generally understood as the capacity for dynamic systems to withstand or recover from challenges to their stability (Masten, 2011). While no research as of yet has examined the mediating role of resilience on the pathway of childhood adversity to prenatal depression, several studies have found positive effects of resilience on functioning in other populations. For example, in a longitudinal study, Bethell et al. (2014) found that resilience protected children in adverse circumstances from chronic disease. Logan-Greene et al. (2014), in a study spanning four birth cohorts, similarly found that the availability of resilience resources mitigated the effect of ACEs on physical health into old age. Resilience may also alleviate the effects of poor mental health on functioning. In a study of veterans diagnosed with PTSD, resilience, particularly social support, mediated the link between PTSD and social functioning (Tsai et al., 2015).

Most current conceptualizations of resilience are broadly based on Bronfenbrenner’s (1977) ecological model of human development, emphasizing interactions between individual and socio-environmental systems. Although many Western measures of resilience focus on individual factors, such as cognitive skill and self-agency, the social–ecological model of resilience not only recognizes individual factors as important but also places emphasis on the role of families and social institutions to make resources available to enhance positive functioning (Ungar, 2012). Social–ecological resilience theorists posit resilience as a heterogeneous construct, comprising individual, relational, and contextual components (Ungar et al., 2007). Under this model, resilience is conceptualized as resources at different social–ecological levels that can be cultivated to impact functioning. Thus, from this theoretical framework, resilience is viewed as a set of factors that might be related to both adversities and mental health, making it an appropriate variable to consider as a mediator between ACEs and prenatal depression.

In their research on war-affected children, Betancourt and Khan (2008) describe each of the three aspects of resilience—individual, relational, and contextual—as interacting, yet distinct in their effect on various socio-emotional factors. Indeed, in their study with veterans, Tsai et al. (2015) found that individual factors (e.g. acceptance of change), relational factors (e.g. family cohesion and social support), and community factors (e.g. cultural identity) each mediated the effects of PTSD on social functioning, which suggests that different aspects of resilience may play different direct and indirect roles. Previous research has more consistently emphasized the central role of relational resilience. For example, Coker et al. (2002) found that emotional support from family and/or friends (i.e. relational resilience) reduced the likelihood of mental and physical health problems among violence-exposed women. Similarly, an older study of low-income pregnant women found that aspects of relational resilience during the perinatal period mitigated postpartum depression and low birthweight (Collins et al., 1993). There may therefore be considerable benefit to assessing the mediating role of individual, relational, and contextual aspects of resilience separately rather than analyzing resilience as a unitary construct. This is particularly true when examining ACEs given the family-based nature of these adversities.

Most ACEs are interpersonal in nature in that they involve negative experiences caused by dysfunction and mistreatment within the family system (i.e. physical, sexual, and/or psychological abuse by a household member; divorce; family incarceration; and parental substance abuse) (Centers for Disease Control and Prevention, 2015). Thus, when utilizing a social–ecological framework that assesses different domains of resilience, it is likely that these family-based adversities would most influence relational aspects of resilience, such as family support or sensitive caregiving practices (i.e. responsive and supportive parenting) (Herrman et al., 2011; Turner et al., 2012). Previous research has indicated that childhood victimization is associated with family dysfunction, instability, and poor parenting practices, and in turn, these maladaptive qualities are associated with increased psychopathology (e.g. depression, suicidal ideation, and PTSD) among individuals exposed to childhood victimization (Turner et al., 2012). While past research has assessed how problematic relational and support factors may mitigate the association between childhood adversity and psychopathology, to date, studies have not considered how domains of resilience may serve as a mediator between ACEs and prenatal depression. Due to the interpersonal nature of ACEs, as well as the direct link between ACEs and reduced quality of relationships, relational resilience may be particularly diminished in comparison with other components of resilience in Ungar’s model (i.e. individual or contextual). However, the distinction between different forms of childhood victimization affecting different components of resilience has yet to be thoroughly evaluated in the literature, as resilience is typically examined as one broad construct rather than as separate and unique components.

Current study

Consistent evidence points to the damaging effects of prenatal depression on women and children. Furthermore, research is beginning to highlight the link between childhood adversity and increased rates of depression. To date, minimal work has been conducted on the relationship between ACEs and prenatal depression. Furthermore, there is a lack of information on the role of resilience in mediating this relationship despite the importance of positive functioning not only for the woman but also for her future child. To contribute to the current body of knowledge on the relationships between exposure to childhood adversity, resilience, and prenatal depression in at-risk pregnant women, this study examined both the direct effects of childhood adversity and resilience on prenatal depression and the indirect effects of ACEs on depression via resilience (see Figure 1).

Figure 1.

Hypothesized mediation model.

According to social–ecological theory, resilience is conceptualized across the individual, relational, and contextual levels. Developing a clear understanding of which particular components of resilience are most influential to the relationship between childhood adversity and prenatal depression may offer insight into mutable targets for intervention with at-risk women. As such, the goal of this study is to examine the direct and indirect effects of ACEs and different domains of resilience on prenatal depression. The four study hypotheses are as follows:

Given that the types of adversities encapsulated by ACEs are family-based experiences, such as abuse by a family member and parental substance use or psychopathology, we hypothesize that number of ACEs will be negatively related to relational resilience, but not individual or contextual resilience (Path a).

We hypothesize that higher number of ACEs will be associated with higher levels of prenatal depressed mood (Path c).

We hypothesize that more resilience (of all types) will be associated with lower levels of prenatal depressed mood (Path b).

Given the expected association between ACEs and relational resilience, we hypothesize that this type of resilience will mediate the relationship between ACEs and depressed mood. Specifically, it is hypothesized that more ACEs will be associated with decreased relational resilience, which will in turn be associated with increased prenatal depression (indirect effect: Path a*Path b).

Methods

Participants

This study examined a sample of low-income pregnant women (n = 101) recruited from a Women, Infants, and Children (WIC), Food and Nutrition Service program in the Midwest. On average, women were 17 weeks pregnant (range: 3–39 weeks; standard deviation (SD) = 10.16) and were a mean age of 26 (range: 18–40; SD = 5.67) years. The sample was racially/ethnically diverse (37.6% Black, 36.6% White, 17.8% Hispanic/Latina, and 7.9% biracial or multiracial). Average monthly household income was low (US$1002.07; SD = US$879.03). The sample displayed substantial variability in women’s educational attainment; 21 percent of participants had not completed high school, 37 percent had completed either high school or a GED (General Educational Development), 32 percent had attended some college, and 10 percent had a college or graduate degree.

Procedures

Data were collected as part of a university–community partnership aimed at fostering collaborative community-based research. The institutional review boards at both the participating university and the hospital overseeing the WIC office approved the study protocol. Following approval, trained project personnel at the WIC office provided a brief description of the study and a flyer during WIC prenatal care appointments with women aged 18 years or older. If interested, women could participate in the study immediately following their appointment. Those participating were directed to a private room where they completed the informed consent process. All questionnaires were administered aloud by a trained interviewer, and women could elect to participate in either Spanish or English. On average, the interview took 30–40 minutes. Women were compensated US$10 in the form of a gift certificate to a local grocery store.

Measures

Demographics

Participants began the interview by responding to a series of brief questions assessing basic background information, including age, racial/ethnic background, educational attainment, and monthly household income.

Childhood adversity

Childhood adversity was evaluated with the ACE Questionnaire. This 10-item survey assesses exposure to a range of adverse and traumatic events taking place in the household prior to the age of 18 years, including physical abuse, emotional abuse, and sexual abuse, neglect, and household dysfunction. For each item, women were asked to indicate whether or not the event had ever happened during their childhood (1 = Yes; 0 = No). Consistent with recommendations from the measure developer, endorsed items were tallied for a total possible ACE score ranging from 0 to 10. The ACE Questionnaire was developed as part of a large epidemiological study that examined the longitudinal health consequences of child maltreatment and has since been widely used in psychological and epidemiological research (Dube et al., 2001; Felitti et al., 1998).

Resilience

Consistent with the social–ecological model of resilience, this study assessed women’s individual, relational, and contextual levels of resilience using the Resilience Research Centre Adult Resilience Measure (RRC-ARM; resilienceresearch.org; Ungar and Liebenberg, 2011). Items represented in the questionnaire were generated and validated based on numerous samples collected in a variety of international contexts (Ungar and Liebenberg, 2011). Women in this study responded to each of the 28 items using a scale of 1 to 5, indicating how much each item described them (1 = Not at all; 5 = A lot). Items are organized into three subscales: individual resilience, relational resilience, and contextual resilience. The individual resilience subscale assesses individuals’ intrinsic skills that contribute to resilient functioning (e.g. perseverance, prosocial skills, peer support, and problem solving). Sample items include “Getting and improving qualifications or skills is important to me” and “I try to finish what I start.” The relational resilience subscale aims to evaluate individuals’ sense of security and belonging in close relationships, including family instrumental support (e.g. physical caregiving) and emotional support (e.g. psychological caregiving). Sample items on this subscale include, “My family stands by me during difficult times” and “I feel secure when I am with my family.” Finally, the contextual resilience subscale assesses the extent to which individuals feel a strong sense of belonging and support in their community, including items related to spiritual, educational, and cultural pride and participation. Sample items include, “I feel I belong in my community” and “I am proud of my ethnic background.” The RRC-ARM has been shown to have good reliability and convergent validity with other assessments of well-being (Liebenberg and Moore, 2016). Internal reliabilities for this study were good: individual resilience (α = .90), relational resilience (α = .89), and contextual resilience (α = .80).

Depressed mood

Women’s depressed mood was evaluated with the Center for Epidemiologic Studies Depression Scale (CESD; Radloff, 1977). This 20-item scale evaluates symptoms of depression such as loneliness, low self-esteem, and depressed mood. For each item, women reported how frequently they experienced it in the past week using a scale ranging from 0 to 3 (0 = Rarely or None of the time; 3 = Most or all the time). Scores across items are totaled, with a possible score range from 0 to 60. The CESD has high internal consistency, retest reliability, and validity (Radloff, 1977). Internal reliability for this study was α = .89.

Analytic plan

To identify potential covariates, preliminary analyses assessed for relationships between key study variables (ACEs, resilience, prenatal depression) and relevant demographic/pregnancy variables (number of weeks pregnant, maternal age, maternal education, and monthly household income). To examine hypotheses 1–3, regression models were run in SPSS version 23 between the ACE total score; individual, relational, and contextual resilience; and total score on the CESD, respectively. For hypothesis 4, a mediation model was run using the PROCESS macro (Hayes, 2013) in SPSS to examine in parallel the indirect effects of individual, relational, and contextual resilience on the relationship between ACEs and prenatal depressive symptoms (see Figure 1). A nonparametric bootstrapping method was used as it makes no assumptions about the sampling distribution. To test the indirect association of ACEs on depression through the paths of individual, relational, and contextual resilience, a nonparametric bootstrapping method of 5000 samples using a confidence interval of 95 percent was used. An indirect association is considered to be significant if the confidence interval does not include 0 (zero). Model effect sizes were calculated using Cohen’s f² (.02 = small effect; .15 = medium effect; .35 = large effect). Multicollinearity diagnostics were examined using the variance inflation factor (VIF) and all values fell within an acceptable range (VIF < 3).

Results

Over 70 percent of pregnant women in this sample reported at least one ACE (range: 0–10), with an average of nearly three adverse childhood events experienced prior to the age of 18 years (mean (M) = 2.71, SD = 2.82). Levels of prenatal depression were quite variable across participants (M = 14.98, SD = 10.32), with 37 percent of pregnant women having clinically significant levels of depressed mood. Complete scale descriptive statistics and correlations can be found in Table 1. Preliminary analyses of the relationships between key study variables and candidate covariates yielded non-significant findings; therefore, number of weeks pregnant, maternal age, maternal education, and monthly household income were not included in remaining analyses.

Table 1.

Descriptive statistics and correlations.

Variable	M (SD)	Range	1	2	3	4	5
1. Depressed Mood	14.98 (10.31)	0–46	1
2. ACEs	2.71 (2.82)	0–10	.30**	1
3. Resilience Ind.	47.93 (7.20)	23–55	−.50***	−.13	1
4. Resilience Rel.	29.98 (5.74)	15–35	−.52***	−.56***	.63***	1
5. Resilience Con.	40.42 (6.56)	19–50	−.36***	−.17	.61**	.59***	1

ACEs: adverse childhood experiences; Resilience Ind.: individual resilience; Resilience Rel.: relational resilience; Resilience Con.: contextual resilience; M: mean; SD: standard deviation.

p < .01; ***p < .001.

We first hypothesized that total number of ACEs would be inversely associated with relational resilience, but not individual or contextual (Path a). A significant linear regression model F(1, 97) = 43.38, p < .001, adj. R² = .30 was generated with total childhood adverse events being negatively related to relational resilience. Specifically, having more ACEs was associated with lower levels of relational resilience (β = −.56, p < .001). No significant models emerged for individual or contextual resilience. Thus, hypothesis 1 was supported.

The second hypothesis postulated that total ACEs would be associated with higher levels of depressed mood (Path c). This hypothesis was supported as evident in a significant linear regression model F(1, 94) = 9.08, p < .01, adj. R² = .08. Here, ACEs were positively associated with symptoms of depression (β = .30, p < .01).

Third, we hypothesized that resilience (of all types) would be significantly related to depressed mood (Path b), controlling for total ACEs. This hypothesis was partially supported via linear regression analyses. The overall model was significant F(4, 87) = 11.94, p < .001, adj. R² = .32, but only relational resilience (β = −.47, p < .01) was associated with prenatal depression.

Finally, we hypothesized that relational resilience, but not individual or contextual resilience, would significantly mediate the relationship between ACEs and depressed mood (indirect effect: Path a*Path b). To account for moderate inter-correlations between types of resilience, a single model was run including all three mediators in parallel. The model was significant, R² = .35, F(4, 87) = 11.94, p < .001. ACEs had a direct effect on relational resilience, B = −1.15, standard error (SE) = .19, p < .001, and relational resilience had a direct effect on depression, B = −.69, SE = .20, p < .001. There was a significant indirect effect of ACEs on depression through relational resilience, IE = 1.04, boot SE = .28 (95% confidence interval (CI) = .58, 1.68). Individual and contextual resilience were not significant mediators, thus hypothesis 4 was supported. Direct, indirect, and total effect sizes can be found in Table 2. The overall effect size (.09) is considered small.

Table 2.

Summary of mediation analysis.

IV	M	DV	IV to M coefficient	M to DV coefficient	Indirect effect coefficient	Boot SE	95 percent confidence interval
ACEs	Resilience Ind.	Depressed Mood	−.37	−.40	.26	.19	−.036, 1.331
ACEs	Resilience Rel.	Depressed Mood	−1.15***	−.69***	1.04	.28	.575, 1.676^a
ACEs	Resilience Con.	Depressed Mood	−.44	.20	−.09	.12	−.455, .042

ACEs: adverse childhood experiences; Resilience Ind.: individual resilience; Resilience Rel.: relational resilience; Resilience Con.: contextual resilience; SE: standard error; IV: independent variable; M: mediator; DV: dependent variable.

Significant indirect effect.

***

p < .001.

Discussion

The effects of prenatal depression on the health and well-being of pregnant women and their children have received substantial empirical attention, but there remain many gaps to address in the research on what is associated with higher levels of depression in this population. This study sought to assess both risk and resilience to offer a more comprehensive understanding of what might be related to depression during pregnancy among a low-income, urban sample of women. By including a broad measure of family-based childhood adversity, as well as assessing unique domains of resilience resources, this line of research provides much-needed information on prenatal depression. Such knowledge makes a novel contribution to the body of research on risk and resilience factors related to maternal mental health during the prenatal period.

Results of this study suggest that relational resilience may be a potential mediator of the relationship between ACEs and prenatal depression. Although the cross-sectional nature of the research design precludes causal inferences regarding the role of relational resilience, this study provides important information for future longitudinal work. That is, among the various types of resilience examined here, relational resilience appears to be the most promising factor to evaluate as a process related to positive functioning. This not only provides critical information for future longitudinal work but also has useful implications for the most promising domains for clinical intervention as well. For this study, resilience was defined using the social–ecological model (Ungar, 2007), which examines the multiple contexts within which adaptive functioning may be displayed (i.e. individual, relational, and contextual). Individual resilience resources reflect functioning specific to the person including personal skills and acceptance of change. Relational resilience resources are displayed in a person’s physical and psychological support via familial and partner relationships. Contextual resilience resources capture a person’s feeling of belonging and support in their community through spiritual, educational, and cultural components.

The results of our analyses indicated that individual and contextual resilience did not mediate the relationship between ACEs and prenatal depression, which is due to the non-significant relationship between ACEs and both individual and contextual resilience. An explanation for this lack of an association may be that the types of adversity assessed via the ACEs measure are related to family-based and relational experiences, such as parental psychopathology and substance use, parental incarceration, and family member perpetrated abuse (Felitti et al., 1998). Thus, it is likely that these types of adversities are most impactful on interpersonal and family-oriented resources, which are reflected in relational resilience. The ACEs measure does not capture community-oriented exposure to violence, non-interpersonal trauma, or exposure to natural disasters, which may more directly influence contextual resources and individual capacities. Perhaps, if a broader measure of poly-victimization is used in future studies, contextual and individual resilience may emerge as related to ACEs and potentially as a mediator of ACEs and prenatal depression.

Consistent with what was hypothesized, relational resilience mediated the relationship between ACEs and prenatal depression. This finding corroborates literature on the central role of social support for pregnant women in reducing the likelihood of low birthweight and postpartum depression (Collins et al., 1993; Gjerdingen et al., 1991). It also aligns with Coker et al.’s (2002) finding that social and emotional support mitigates the effects of violence exposure on women’s mental health. Along with supporting previous studies, the current finding extends past research in several ways. First, to our knowledge, it is the first study to assess relational resilience as a central variable to better understand the relationship between childhood adversity and prenatal mental health. Second, it highlights relational resilience as a distinct construct of relevance to women’s health during the prenatal period. Here, relational resilience includes not only perceived emotional support but also feelings of security, closeness, and belonging in family and partner relationships (Liebenberg et al., 2012). As such, the current finding not only demonstrates the far-reaching consequences of childhood adversity on prenatal depression but also underscores that various aspects of resilience are differentially related to those consequences. Importantly, if such findings are replicated in future research, the availability of relational resilience resources may be key to reducing the risk of prenatal depression for expectant mothers exposed to childhood adversity.

While these findings make a new and valuable contribution to the literature, it is critical to consider them as exploratory and in need of replication with larger samples using longitudinal methodology that would allow causal inferences to be tested. One key issue requiring attention is the competing models that are also viable given the cross-sectional approach to assessing relationships in this study. For example, it may be that psychopathology mediates the relationship between ACEs and resilience, such that experiencing more childhood adversities leads to higher rates of depression, which in turn leads to lower levels of resilience. There is also likely a bidirectional relationship between resilience and depression that cannot be accounted for in this analysis. Furthermore, other variables missing from this study model likely impact prenatal depression, including women’s exposure to trauma and adversities during adulthood. For this and other models, it would be important to use a longitudinal design with at least three time points for analysis, such that predictor variables are based on childhood adversities, mediating variables are based on prenatal mental health, and outcome variables are based on postnatal experiences. Such research is critical to advance the field of maternal mental health and to promote positive functioning following adversity across the life span.

Limitations

Although this study has many strengths, several limitations must be noted. Most importantly, the current data were cross-sectional in nature. As such, the mediation analyses presented here, although guided by relevant theoretical frameworks and supported by time constraints on some of the measures of interest, should be considered as exploratory. Future longitudinal research should examine whether or not women’s relational resilience has true promotive effects over time. It is also possible that the promotive effects of individual and contextual resilience may be more evident over time and may be affected by other relevant system features (e.g. neighborhood quality). Future research should therefore broaden the conceptualization of resilience within each of these systems, more deeply examining specific components of women’s micro- and exosystems that might be potentially relevant, as well as examining cross-level interactions. Additionally, the data represent information collected from low-income women who have experienced multiple adversities and traumas. As such, it is not clear whether the pattern of effects reported in this study would generalize to samples at lower environmental risk. Furthermore, although the study was able to obtain a diverse sample of women in terms of racial/ethnic background, it was only collected from one geographic region in the Midwest United States.

Clinical health implications

A variety of clinical implications related to the health and well-being of women can be generated from these findings. With regard to assessment, screening for depression primarily takes place in the postpartum period, but this research shows that it is important to screen for known risk factors (i.e. ACEs, trauma history) during pregnancy. Early detection of depression through prenatal screening incorporated into routine medical visits has the potential to preclude the adverse postpartum outcomes associated with psychopathology. In addition to early screening for depression, these findings support the need for early intervention to treat depression before the mothers deliver. Clinical interventions bolstering resilience may be particularly effective for pregnant mothers exposed to high levels of stress or past adversity. Indeed, promoting resilience is likely to be beneficial for all women regardless of historical adversity. Given that relational resilience emphasizes perceptions of security, closeness, and belonging in families, service programs focusing on family interactions may be of particular relevance. Group-based counseling programs for mothers aimed at psychoeducation about pregnancy and mental health, stress-mitigation techniques, and parenting skills may also benefit this population. A small number of existing empirically supported group programs for mothers have noted the social benefits of the group format and importance of including family interactions in the program, whether through education on parenting skills or parallel programming for participants’ children (see Graham-Bermann and Miller, 2013; Muzik et al., 2015). For example, Muzik et al. (2015) found a significant reduction in depressive symptoms among mothers enrolled in a group program aimed at mental health and parenting competence. Even individual counseling with pregnant women may be strengthened by attending to clients’ key relationships or inviting the participation of a partner or other close family member.

Future research directions

Given the exploratory nature of these findings, a number of directions emerge for future research. First, future studies should utilize a variety of informants to gather a more comprehensive understanding of mental health and resilience. Such informants might include members of the woman’s support system (i.e. partner, parent, and close friend) given the importance of relational resilience identified in this study. To gain a more reliable assessment of exposure to childhood trauma, future studies could seek access to the Department of Children’s Services records of substantiated abuse allegations. Such future work should also aim to collect data at multiple time points, including pre- and post-pregnancy, as well as repeated assessments during pregnancy, to evaluate change in functioning longitudinally. Furthermore, while this study was an initial assessment of ACEs and depression, future work might consider a more detailed evaluation of past trauma, including the exact timing and frequency of exposure to adversity. This future work would also benefit from the inclusion of a well-validated measure of social support given the central role of relationships and support identified in this study.

Conclusion

Results of this study add to a growing body of research focused on the relationship between ACEs and prenatal depression. The key finding that relational resilience mediates the association between ACEs and prenatal depression provides fruitful avenues for screening and intervention that have not been identified in previous studies. Given the implications that prenatal depression has for pregnancy complications, child socio-emotional development, child health, and postpartum depression, the documentation of this relationship is one of utmost clinical and empirical value.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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