Association of COVID-19 and Endemic Systemic Racism With Postpartum Anxiety and Depression Among Black Birthing Individuals

IMPORTANCE The intersection of endemic structural racism and the global health crisis secondary to the COVID-19 pandemic represents a syndemic, defined as the aggregation of 2 or more endemic and epidemic conditions leading to adverse repercussions for health. Long-standing inequities have placed Black individuals at disproportionate risk for negative postpartum mental health outcomes. Studies are urgently needed to understand how the COVID-19 pandemic has added to this risk (eg, syndemic associations)

T he COVID-19 pandemic has exposed our limited knowledge of how current experiences of acute adversity act in concert with long-standing disparities to affect mental health.In the US, the COVID-19 pandemic has disproportionately impacted Black communities, 1 who have experienced higher rates of infection, morbidity and mortality, 2,3 unemployment, 4 housing and food insecurity, 2 and adverse mental health outcomes. 5,6][9] Specifically, researchers have leveraged the original syndemic framework by Singer 10 to understand the health consequences arising from the COVID-19 pandemic exacerbating preexisting inequitable endemic factors. 8,9,11In leveraging this framework, we aimed to examine how the joint associations of structural and interpersonal racism (2 endemic conditions) and the COVID-19 pandemic (epidemic condition) contributed to postpartum anxiety and depression in Black individuals.
Before the COVID-19 pandemic, Black birthing individuals had documented disparate reproductive health experiences compared with non-Latinx White peers that are linked to racism, 12 including obstetric racism (eg, beliefs and practices that harm the reproducing Black body), 13 higher rates of untreated mental health disorders, including postpartum depression, 14 and 3 times greater likelihood of perinatal complications 15 and pregnancy-related mortality. 16,17During the COVID-19 pandemic, Black individuals have also faced particular difficulties, including more worry about COVID-19, 18 food and job insecurity, 4 challenges during pregnancy and postdelivery, 19 and mental health adversity. 20Our data, collected early in the COVID-19 pandemic, showed that compared with non-Latinx White participants, pregnant Black participants reported higher rates of depression and anxiety.Black participants also endorsed more COVID-19-specific worries, including worries about giving birth and childcare. 18While studies have begun to explore the factors affecting birthing individuals during the COVID-19 pandemic, 18,21 a paucity of evidence exists from studies that have used a syndemic framework 7 to explore the intersection of race, 21 racism, and COVID-19 22 on the postpartum mental health of Black individuals. 18,23,24istorically, race has been confounded with racism, resulting in the use of phenotypic appearance as a major variable in illness and health. 8The context in which individuals live, work, and play has largely been ignored, resulting in failures to acknowledge that health disparities are secondary to endemic racist systems and barriers. 25Structural racism, defined as "practices that maintain or exacerbate unfair inequalities in power, resources or underlying systemic racist conditions," 26 is embedded within experiences of health care, housing, employment, and education. 27These experiences confer negative health consequences for Black individuals, which the COVID-19 pandemic has exacerbated.For example, in the 1930s, the Home Owners' Loan Corporation (HOLC) created a systematic appraisal that graded neighborhoods based on quality of housing, proximity to industry, and characteristics of residents in the neighborhood. 28These grades commonly redlined Black communities, deeming them high-risk to mortgage lenders. 29Redlining created restrictive covenants where Black families could live, which undermined their ability to build wealth [29][30][31][32] and left a persistent and quantifiable legacy of negative health effects. 28,33Additionally, interpersonal or personally mediated racism represents prejudiced assumptions assigned to an individual's abilities, motives, aptitude, and intentions based solely on race. 34Interpersonal racism confers heightened states of psychological and physiological stress, which has been linked to poor health outcomes. 35he clinical care that Black individuals receive during pregnancy represents a vital determinant of long-term health and is susceptible to both structural and interpersonal racism. 26,36,37ore broadly, pregnancy can be a vulnerable period for psychological well-being, 38 and studies have established negative trajectories of mental health among parents during the COVID-19 pandemic. 39Thus, when considering the COVID-19 pandemic in the context of postpartum mental health in Black birthing individuals, 40 it is imperative to understand how multiple types of racism are associated with negative experiences.We assessed Black participants from a prospective longitudinal study to explore how the syndemic was associated with postpartum mental health.Specifically, we developed multidimensional measures of racism and negative COVID-19 pandemic experiences during the peripartum period (eg, syndemic) and explored associations with risk for postpartum depression and anxiety.

Participants
This observational study followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline 41 and included Black participants from a longitudinal cohort study examining the perinatal period during the COVID-19 pandemic. 18,23Participants from all gestational ages who received prenatal care at 1 of 2 urban hospitals in the University of Pennsylvania Health System in Philadelphia were recruited by email, without exclusionary criteria.The study was approved by the university institutional review board.After obtaining written informed consent, participants completed an online REDCap survey about their experiences of the COVID-19 pandemic.Data were also collected on childbirth through electronic medical records and a follow-up online REDCap survey completed during the postpartum period.Participant race (African American/Black, Asian, Latina [not otherwise specified], Native Hawaiian/Pacific Islander, White, declined, other, and unknown) and ethnicity (Hispanic/Latina, non-Hispanic/non-Latina, declined, unknown) data were collected from the electronic medical records.
The pregnancy survey (mean [SD] gestational age, 25.3 [7.8] weeks) was completed during a statewide stay-at-home order, a period of high community spread of COVID-19 (April 17 to July 8, 2020).The postpartum survey (mean [SD] gestational age, 12.7 [5.5] weeks) was completed between August 11, 2020, and March 2, 2021.Participants completed each survey in about 20 minutes, although not all survey sections were completed by all participants.Figure 1 presents recruitment flowchart and attrition, and eTable 1 in the Supplement provides comparison of Black and non-Latinx White individuals, which were the 2 groups powered for further analysis owing to sample size.Participants received $25 gift cards for completing the postpartum survey.

Measures COVID-19 Pandemic Variables
At both assessments, participants were asked about 3 COVID-19-related stressors: how the COVID-19 pandemic had affected their lives (eg, job loss, knew someone who had passed away from COVID-19 complications).Participants also completed 4 items assessing how the COVID-19 pandemic had impacted their birthing and postpartum experience (postpartum survey) and if they were worse off financially because of the pandemic (postpartum survey).Participants rated their worries about 6 general COVID-19 stressors 42 (pregnancy and postpartum surveys) and 4 COVID-19 stressors specific to pregnancy (pregnancy survey) (eTable 2 in the Supplement).

Racism Variables
Structural Racism Information from electronic medical records and participant report was used to assess income inequality (below vs above $20 000 annually), education (no college vs partial college graduate degree), insurance type (private vs public/ Medicaid), relationship status (married/living with partner vs other), 43 parity, and house ownership (own vs other).Additionally, a HOLC-informed Philadelphia measure of structural racism-based redlining was used based on prior digitized HOLC boundaries. 44Each participant received a risk grade from A (minimal) to D (hazardous) based on their street address. 44A census-based neighborhood socioeconomic status composite variable 45 was also created using census-based geocoding of neighborhood-based variables (eg, percentage of residence in poverty, percentage married, percentage with <high school education, median family income) based on participant zip codes.Neighborhoods were blocked into census groups, generally containing 600 to 3000 persons.

Interpersonal Racism
Participants completed 2 scales: the 10-item Everyday Discrimination Scale 46,47 and 6-item Major Experiences of Discrimination Scale. 46,48enatal and Postpartum Mental Health Measures Prenatal anxiety was assessed using the Generalized Anxiety Disorder 7-item scale, 49 and prenatal depression was assessed using the Patient Health Questionnaire 2. 50 Postpartum anxiety was assessed using the Generalized Anxiety Disorder 7-item scale, and postpartum depression was assessed using a 9-item Edinburgh Postnatal Depression Scale.51,52 We removed item 10, which assesses self-harm, given the difficulty of monitoring self-harm endorsements in online surveys.Consistent with prior studies, we used clinical cutoffs of 10 or higher for postpartum depression 52,53 and 11 or higher for postpartum anxiety. 54

Analytic Strategy
Data reduction techniques were used to create composites to capture experiences of the COVID-19 pandemic and racism.First, to create a summary score reflecting negative pandemic experiences, all COVID-19-related items (detailed above) were summed together.Variables were recoded such that 1 indicated negative experiences and 0 indicated absence/neutral COVID-19 experiences.For items rated on a Likert scale (eg, COVID-19 pandemic worries), endorsement of higher values (eg, moderate, a lot, a great deal) were recoded as 1, with other response options (eg, a little, not at all) coded as 0 (eTable 2 in the Supplement provides frequencies for each response option prior to creating binary scores).For other items (eg, positive COVID-19 test), a yes response was coded as 1 and no as 0. A composite factor was created by summing all items, with higher scores reflecting more negative COVID-19 pandemic experiences.Second, to capture the multidimensional experience of racism, all racism variables were subjected to Exploratory Factor Analysis 55 in Mplus 56 using the mean-and variance-adjusted weighted least squares (wlsmv) estimator 57 and oblimin rotation.Items with fewer than 4 response categories (including binary items) were treated as ordinal in the analysis; all others were treated as continuous.Additionally, the number of factors (3) was determined by parallel analysis with Glorfeld correction 58 at a 0.95 threshold using the 'psych' package in R version 2.1.3(R Foundation). 59ext, a series of logistic regression analyses examined the associations of negative COVID-19 pandemic experiences and racism with postpartum depression and anxiety.In each regression model, data were entered in 3 blocks.Block 1 included maternal age, parity, gestational weeks at prenatal assessment, and weeks post partum at the postpartum survey.In block 2, we entered the negative COVID-19 pandemic experience and racism factors to examine their unique associations with postpartum outcomes.To reduce multicollinearity across the racism and COVID-19 pandemic factors, all factors were regressed out of each other.In block 3, we entered 2-way associations between the pandemic factor with each racism factor, which together represented syndemic measures.To probe significant interactions, logistic regressions were re-run at high and low levels of the racism factor scores (median split).Supplemental analyses examined (1) models only using the redlining measure (HOLC grades) and perceived discrimination as measures of racism, controlling for socioeconomic status and (2) models using only COVID-19 worries and the 3 racism variables.Cronbach α were acceptable for all scales (eTable 3 in the Supplement).Two-sided P values were significant at .05 or less.

The Syndemic and Postpartum Anxiety
A total of 20 participants (13%) met screening criteria for postpartum anxiety.There were no main associations of COVID-19 pandemic experiences or racism with risk for postpartum anxiety.However, as with postpartum depression, there was a significant association between negative COVID-19 pandemic experiences and interpersonal racism.Negative pandemic experiences were associated with postpartum anxiety for those reporting high interpersonal racism (OR, 1.85; 95% CI, 0.86-4.01)but not low levels (OR, 0.94; 95% CI, 0.43-2.02; Figure 3C).The associations remained significant after controlling for prenatal anxiety (eTable 5 in the Supplement).

Discussion
No epidemic has impacted the global community for such a protracted period of time as the COVID-19 pandemic. 60Because the COVID-19 pandemic is ongoing, understanding its disproportional association with vulnerability of Black birthing individuals is critical. 61Historically, Black individuals have been more vulnerable to develop postpartum depression compared with non-Latinx White counterparts 62 but are less likely than other racial and ethnic groups to receive treatment. 14,63tudies conducted during the COVID-19 pandemic have similarly reported that more than one-third of Black pregnant individuals report levels of anxiety and depression that are clinically significant. 64Our focus on Black birthing individuals, drawn from a longitudinal study examining the association of the COVID-19 pandemic with peripartum experiences, engenders a deeper understanding of structural racism that is persistently negatively associated with mental health in Black communities in the US. 65Consistent with other recent reports, 29% of our sample met screening criteria for postpartum depressive symptoms. 66,67hese estimates highlight the possibility that the COVID-19 pandemic, when combined with structural endemic racism, has created syndemic forces that have worsened conditions for Black communities. 8,9,11In addressing this question among peripartum Black individuals, we hypothesized that the syndemic would have created extra burden and increased risk of postpartum depression and anxiety. 40In line with our hypotheses, worse experiences during the COVID-19 pandemic, interpersonal racism, and living in an area of greater historical redlining, were all uniquely associated with postpartum depression (eTable 7 in the Supplement).Moreover, significant associations between racism and adverse postpartum mental health outcomes were magnified with more negative COVID-19 pandemic experiences.Specifically, individuals with more b n = 148.
negative COVID-19 experiences combined with higher interpersonal and systemic general racism scores were at highest risk of meeting screening criteria for postpartum depression and anxiety.These findings are commensurate with the growing literature linking racism with maternal health and well-being, 68 which COVID-19 has worsened.The findings extend data on health inequities and deepen understanding of Black birthing individuals' disparate experiences during the syndemic.Our understanding and prevention of future syndemics can be viewed through a public health framework with need for wide-reaching changes that target larger structural factors that contribute to adverse mental health outcomes, including postpartum depression and anxiety, in Black individuals.Importantly, Black individuals face significant challenges and disadvantages during pregnancy and after delivery, with adverse associations with maternal mental health, which have only worsened during the COVID-19 pandemic.
We have articulated the specific challenges faced by Black individuals and, in the face of the ongoing COVID-19 pandemic, are hopeful that the field can meet this moment by collaborating across disciplines to ensure that those most at risk have equitable access to immediate assessment throughout the peripartum period; ensuring rapid and equitable treatment; and maintaining continued vigilance postdelivery.Furthermore, we urgently need to engage larger numbers of Black participants in research efforts and investigate how different forms of racism might be differentially associated with behavioral and mental health.If we are able to collectively work toward these goals, we can effectively support Black birthing individuals' mental health in 2022 and beyond.

Limitations
The study has several limitations.First, the sample is relatively small and there was attrition of Black participants from pregnancy to postpartum assessments.Although participants lost to follow-up did not report higher depression or anxiety in pregnancy, our findings may underestimate associations between negative COVID-19 experiences, racism, and risk for depression and anxiety.Second, because of our sample size, we assessed separate outcome measures of postpartum depression and anxiety, which represents only a snapshot of how the syndemic could be associated with mental health of Black birthing individuals (eg, larger samples could more fully ex- plore depression and anxiety associations).We also did not screen for other mental health disorders.Third, we found no main associations of the COVID-19 experience or racism variables with the clinical screening measure for anxiety.However, the pattern of findings was similar to that for depression risk and both COVID-19 experiences and interpersonal racism were significantly associated with anxiety in models using a continuous symptom measure (eTable 6 in the Supplement).Overall, given the lower rate of participants meeting criteria for postpartum anxiety (20 [13%]) relative to depression, we may have been underpowered to detect associations using a binary screening measure.Alternatively, COVID-19 pandemic experiences and different dimensions of racism (eg, structural vs interpersonal) could differentially influence postpartum anxiety vs depression.Fourth, we used selfreport surveys for our clinical measures, necessitating replication with comprehensive diagnostic assessments.Fifth, race and ethnicity assessments were based on electronic medical records, which is less accurate than patients self-identifying. 69inally, we did not compare syndemic experiences among a non-Black comparison group.However, by limiting the sample, we were fully able to explore the depth and diversity of the mental health and reproductive experiences of Black individuals in the midst of a global pandemic.

Conclusions
In this longitudinal cohort study of Black birthing individuals, experience of the syndemic was associated with negative postpartum mental health.Long-standing structural inequities have been negatively associated with every aspect of Black individuals' lives from neighborhood quality to nutrition, medical care, and related services.These findings underscore the importance of early detection of prenatal mood disorders and point to an urgent need for policy developments to mitigate downstream mental health effects of COVID-19, which may be disproportionately associated with Black birthing individuals.The results suggest that the key to better serving Black in-dividuals includes an improved understanding of the intertwining issues that many of the participants faced, namely, that structural racism produces a cascade of linked inequities surrounding wealth, wages, housing, educational attainment, and mental health.

Figure
Figure 1.Recruitment and Attrition Flow Diagram From Larger Cohort

Figure 2 .
Figure 2. Plot of Sample's Locations on the Home Owners' Loan Cooperation (HOLC) Redlining Map of Philadelphia, Pennsylvania

Figure 3 .
Figure 3. Joint Associations of the COVID-19 Pandemic and Racism (ie, the Syndemic) With Postpartum Depression and Anxiety 1. Recruitment and Attrition Flow Diagram From Larger Cohort 254 = 2.84; P < .001).The 2 groups did not differ on their prenatal depression status or prenatal anxiety status.For the pregnancy survey, we recruited from 3966 individuals, and 1173 (30%) completed the survey.For the postpartum survey, we recruited 1089 individuals of which 833 (78%) completed.

Table 2 .
Logistic Regression Examining the Associations of COVID-19 and Racism With Postpartum Depression and Anxiety in Black Birthing Individuals a bThe df for all was 1.