In this section of the chapter we will be focusing on factors that influence health and wellness during conception, pregnancy, and fetal development. Genetics and heredity play an important role in conception, pregnancy, and fetal health, but they do not address issues of equity and equality. There are environmental and social factors that impact a pregnant person’s experience and their developing child. It is important to look deeper into social issues like health care, environment, and mental health to understand how they result in diverse pregnancy experiences and how they impact life outcomes.

Social Determinants of Health

Social determinants of health (SDOH) are the “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes” (CDC, 2022). You may be wondering how these social determinants are related to pregnancy outcomes. Economic stability, an important determinant of health, involves financial resources such as income, cost of living, and socioeconomic status. Therefore, poverty, unemployment, food insecurity, and housing instability can influence pregnancy outcomes and complications. Research shows that higher socioeconomic status (SES) is associated with better pregnancy outcomes.

Economic Stability

Financial hardship is highly prevalent among pregnant women. A weighted study representing more than 1 million women found that financial hardship was common in 2013–2018. Twenty-four percent of pregnant women reported unmet health-care needs, 60 percent reported health-care unaffordability, and 54 percent reported general financial stress (Taylor et al., 2021). Pregnancy outcomes associated with poverty include increased risk for preterm birth (babies that are born before 37 weeks of pregnancy), intrauterine growth restriction (when the baby in the uterus does not grow as expected), and neonatal and infant death. Additionally, experiencing poverty during and after pregnancy is linked to delayed cognitive development and poor school performance in children (Larson, 2007). Therefore, having access to good quality prenatal care, financial stability, and food security, among many other SDOH, is crucial for optimal health and thriving development.

There is a significant disparity in pregnancy outcomes in the United States based on race and ethnicity (Akinyemi et al., 2022). Indigenous, Black/African American, Latin, and Asian women have higher rates of unemployment and poverty (Chinn et al., 2021; Srinivasan & Guillermo, 2000; Vega et al., 2009). The stresses associated with these two factors have a significant impact on the developing child and maternal health. A healthy pregnancy requires access to quality prenatal care. Consistent prenatal care throughout pregnancy helps identify potential problems and concerns early on that can be prevented or treated and reduces the risk of pregnancy and birth complications.

Health-Care Access and Quality

The World Health Organization (WHO) is striving for a world in which “every pregnant woman, and newborn receives quality care throughout pregnancy, childbirth, and the postnatal period.” A key word in this statement is quality. First, not everybody has access to prenatal care. However, having access to prenatal care is only half of the equation because not all prenatal care is created equal. Quality of the prenatal care can facilitate a healthy pregnancy, childbirth, and health of a newborn and mother postnatally. Yet, barriers to this care continue to affect many. In this section, first we will discuss access to healthcare and then quality of care.

Although the United States is one of the wealthiest countries in the world, it has the highest maternal mortality rate of 26.4 deaths per 100,000 live births versus 8.4 deaths per 100,000 live births for 10 other high-income nations (Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom). Additionally, the United States has the highest newborn mortality, infant mortality, and cesarean rates and the second highest low birth weight rate compared to these 10 nations (Papanicolas et al., 2018). Finally, the United States ranks 33rd among world nations on a composite index (Save the Children’s Mothers Index) that includes maternal health, child well-being, education, economic security, and political participation (Save the Children, 2016).

Unsurprisingly, these unfavorable maternal and infant indicators are driven by inequitable outcomes of maternity care. Racial and ethnic disparities especially impact Black and Native women and their newborns. Black women are more than three times as likely and Native women more than two times as likely as White women to experience a pregnancy related death (Peterson et al., 2019). It is important to note that even when race and access to healthcare are put aside, research has determined that 60 percent of pregnancy-related deaths are considered preventable (Daw et al., 2017). This highlights the importance of women’s health and maternal care overall.

Unfortunately, disparities that drive unequitable maternal and infant indicators also include geographic location. Rural women are 9 percent more likely than urban women to experience a composite measure of severe maternal morbidity and mortality (Kozhimannil et al., 2019) and 59 percent more likely to have a substance use disorder diagnosis at birth (Soni et al., 2019). In rural counties, infant, newborn, and post-birth mortality rates are higher than in urban counties (Ely et al., 2018). Finally, the rates of teen births vary across states, from 7.2 per 1,000 births in the state of Massachusetts to 30.4 per 1,000 in the state of Arkansas (Daw et al., 2017).

As discussed previously, financial stability is an important factor in both access to and quality of prenatal care. Low-income women experience lack of health insurance and/or gaps in health insurance coverage (Admon et al., 2021). Therefore, low-income pregnant women are less likely to receive prenatal care in their first trimester or postpartum visits than women with steady health insurance coverage. While prenatal care can help identify potential pregnancy related complications, postpartum care is also essential for identifying potentially serious and life-threatening complications post birth and weeks after.

Admon and colleagues (2021) found that in a nationally representative sample of 39,378 women with an average age of 27, about 44 percent were continuously insured, 21 percent experienced changes between private and Medicaid coverage, 32 percent had shifted between insurance coverage and no coverage, and more than 2 percent were continuously without insurance coverage. Additionally, Spanish speaking Hispanic women composed two-thirds of the women who experienced no health insurance coverage continuously.

Given the variability in access to care, how can we ensure access to quality care? The WHO defines quality of care as “the extent to which health care services provided to individuals and patient populations improve desired health outcomes.“ To achieve this, health care should be “safe, effective, timely, efficient, equitable, and people-centered.” We can extend the last factor from people-centered to women-centered. Figure 3.5 breaks down each of these factors one by one.

Environmental Risk Factors and Pregnancy Outcomes

Because the developing baby is particularly vulnerable to environmental pollutants, limiting environmental exposures plays a crucial role in a healthy pregnancy. Many epidemiological studies suggest that there is an association between environmental exposures (teratogens) and pregnancy outcomes. Some examples of environmental exposures include air pollution, environmental tobacco smoke, pesticides, solvents, metals, radiation, water contaminants, and chemicals. Potential pregnancy outcomes include pregnancy loss, stillbirth, and congenital abnormalities (Nieuwenhuijsen et al., 2013). However, chemical and non-chemical exposures that have a detrimental effect on maternal health are not equitably distributed across the population (Boyles et al., 2021).

This inequitable distribution contributes to the many disparities observed in health conditions. Racial and ethnic minorities often live in largely different physical and social environments than the majority of the White population (Daw et al., 2017). Furthermore, the exposure to stressors can come from institutional and individual behaviors, as well as internalized discriminatory policies and practices. This can lead individuals to experiencing either a higher or lower risk across the lifespan, including during the essential reproductive period.

These conditions can contribute to the disparity in increased risk of adverse maternal health behaviors (increased stress exposure) and outcomes (preeclampsia) (Feinstein et al., 2020; James-Todd et al., 2016). More importantly, environmental risk factors have a greater impact on the health of racial and ethnic minorities than on White populations. The affected cardio and metabolic health conditions include obesity, hypertension, type II diabetes mellitus, chronic kidney disease, and cardiovascular disease (James-Todd et al., 2016; Liu et al., 2019; Noor et al., 2019; Varshavsky et al., 2019).

A recent review found an association between the effects of synthetic chemicals such as some POPs (e.g., perfluoroalkyl/polyfluoroalkyl substances) and non POPs (i.e., phenols, phthalates, and parabens) and gestational diabetes and non-regulated glucose metabolism in pregnant women and other vulnerable populations (Gaston et al., 2020). Moreover, racial and ethnic minority women commonly have a higher body burden of exposures that include consumer products, occupations, and residential environments (James-Todd et al., 2011; McDonald et al., 2019). For example, people living in low-income neighborhoods often have little access to fresh and healthy food. As a result, they consume higher quantities of EDCs (endocrine-disrupting chemicals) in the processed food available at fast-food restaurants, convenience stores, and discount stores. These environments are known as “food deserts” (i.e., lacking access to healthy food) or “food swamps,” (i.e., “swamped” with unhealthy food options). When grocery shopping, people without a lot of money are more likely to purchase cheaper, more chemically loaded consumer products (Ruiz et al., 2018).

A main focus of minority health research is to investigate and identify health burdens of racial and ethnic minority populations that stem from environmental exposure and social disadvantages resulting from discriminatory policies and to identify how these practices contribute to maternal health disparities (Duran & Perez-Stable, 2019). For example, pregnant mothers who belong to racial and ethnic minorities will often have to navigate food deserts and food swamps as they seek nutritious food for their developing fetuses. When they go to the doctor, they will also experience structural discrimination in the form of discriminatory policies and practices. Often, Black women express that they are not listened to and that their concerns, signs, and symptoms are ignored.

Serena Williams, the professional tennis player, has spoken up about her experience as a Black woman with the healthcare system in the United States. As she wrote, “No one was really listening to what I was saying.” The tennis player felt something was wrong after she gave birth to her child. However, although she insisted that something was wrong, the nurses continued to dismiss her worries. Finally, her obstetrician listened to her and ordered some tests. Later, they found out that she had developed blood clots in her lungs, which may have resulted in a tragedy if not treated. Despite her wealth and status, Serena experienced injustice during her pregnancy. Unfortunately, Serena’s experience is all too familiar to many Black women in the United States.

Common Health Conditions During Pregnancy

Although every pregnancy is different, there are common health conditions pregnant women may experience. As discussed previously, regular, quality prenatal visits can help identify potential health problems early so that steps can be taken to treat them and protect the health of the mother and developing fetus. Figure 3.6 includes common health conditions that can be experienced in pregnancy.

Mental Health During Pregnancy

In addition to the medical conditions listed above, women can experience changes in mental health, resulting in positive and negative feelings related to pregnancy. To a degree, experiencing mood swings and being worried, anxious, depressed, and stressed during pregnancy can be normal. However, women can also develop depression and anxiety during pregnancy and postpartum depression after birth.

Depression is defined as feeling sad, down, or irritable for weeks or months at a time. Some women may have depression before getting pregnant, and it may worsen during pregnancy. However, depression can also start during pregnancy for many reasons. For example, a woman may develop depression if she isn’t happy about being pregnant due to the pregnancy being unplanned.

Anxiety is a feeling of worry, fear, dread, and uneasiness over things that may happen. Although many of these feelings are common during pregnancy, if these feelings become excessive, all-consuming, and interfere with daily activities, it might be an indicator of an underlying condition, such as anxiety.

Postpartum depression (PPD) is the most common mental health illness observed after birth. Commonly, it is difficult to distinguish PPD from depression occurring at any other time in a woman’s life. However, negative thoughts are mainly related to the newborn with PPD. This condition is seen in 10–15 percent of women after birth (Rai et al., 2015).

Furthermore, it is common for new mothers to experience feelings of guilt or inadequacy about their ability to care for the infant and all-consuming worry about the infant’s well-being or safety severe enough to be considered obsessive (Kendall et al., 1981). The onset of PPD ranges from a few days to a few weeks after delivery, but it occurs most commonly in the first 2–3 months post childbirth. Women who have a history of major depression have a 25 percent increased risk for PPD. Additionally, past history of PPD increases the risk of recurrence to 50 percent (Henshaw, 2003).

Licenses and Attributions for Health and Wellness

“Health and Wellness” by Esmeralda Janeth Julyan is licensed under CC BY 4.0.

Figure 3.5. Variables for Quality Health Care adapted from Tuncalp et al., 2015 under fair use.

Figure 3.6. Health Conditions During Pregnancy adapted from (CDC, 2015).