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Graduate Student Journal of Psychology
2023, Vol. 21

Copyright 2023 by the Department of Counseling and Clinical Psychology
Teachers College, Columbia University

The Role of Social Support in Determining Perinatal 
Anxiety and Depression Outcomes for

 Black and Latina Women

 Black and Hispanic mothers in the United States 
face higher maternal morbidity and mortality rates 
and more elevated risks for postpartum depression 
than their white counterparts (Gennaro et al., 2020; 
Howell, 2018). Black mothers are three times more 
likely to die from birth to their child’s first year of 
life, and Latina mothers are 2.5 times as likely to 
experience the same outcome (Hoyert, 2023). So-
cial support (SS) protects against perinatal mental 
health issues among these groups (Pao et al., 2019).
Maternal Health Disparities for Black and Latina 
Women
 Severe maternal morbidity (SMM) has increased 
by 200% in the United States from 1993 to 2014 
(Liese et al., 2019). SMM, or unintended consequenc-
es of pregnancy that could pose short- or long-term 
health issues, are 50 to 100 times more common than 
maternal death (Liese et al., 2019). SMM rates dis-
proportionately affect racial and ethnic minoritized 
groups in the US, and this disparity has continued 
to widen over the last century (Howell, 2018). Risk 
of pregnancy-related deaths in some regions of the 
U.S. for Black women in particular is similar to risk 
for women in low- and middle-income countries 
(Howell, 2018). Ethnically/racially minoritized wom-
en are disproportionately affected by multiple preg-
nancy complications. Black and Hispanic women 

have a 50% greater risk of having a baby at low birth 
weight and a 20% greater risk of having a preterm 
baby (Borrell et al., 2016; Gennaro et al., 2020).
 Black women have a significantly higher maternal 
mortality rate than their White counterparts. Approx-
imately 42.4 deaths occur out of every 100,000 live 
births for Black women as compared to 13.0 deaths 
per 100,000 live births for White women (Center for 
Disease Control, 2008). Similarly, Latina women are 
20% more likely to experience severe maternal mor-
bidity than non-Hispanic White women. The risks 
that Black and Latina women experience in the peri-
natal period are driven by the numerous manifesta-
tions of structural racism. Ethnic/racial minoritized 
groups have unequal access to healthcare, education, 
housing, stress, and implicit bias (Liese et al., 2019). 
Racism harms health through physical, social, and 
economic pathways along with maladaptive coping 
strategies and stereotype threats (Bailey et al., 2017). 
Racism is considered a social stressor, which leads to 
neurobiological and behavioral responses that impact 
mental and physical health, while chronic exposure to 
racism elevates the changes occurring in the brain and 
metabolism in response to prolonged stress (Bailey et 
al., 2017). Poor birth outcomes have been linked to 
racial discrimination and psychosocial stress through 
early health deterioration or weathering (Bediako 

Racial and ethnic minoritized groups in the United States face higher maternal morbidity and mortality rates and ele-
vated risks for postpartum depression and other perinatal mood disorders. Social support (SS) protects against perina-
tal mood disorders, particularly for Black and Latina women. This study aimed to determine if having two or more SS 
people was related to perinatal anxiety and depression outcomes in a convenience sample of Black and Latina women. 
Mothers (n = 51) with children between ages zero and three completed a socio-demographic and mental health status 
(PHQ4) survey. A two-way ANOVA was performed to analyze the effect of high SS and race on mental health scores. 
There was no significant difference in mental health scores for those with two or more social supports versus those 
with one or fewer social supports (p = 0.4865). Two-group comparison generally showed that mothers with high SS 
had a lower mental health score (M = 0.39) and mothers with low SS had a higher score (M = 0.60). There was a sig-
nificant relationship between SS and both race and age (p = 0.0498, race, p = 0.0010, age). Therefore, this study found 
no relationship between having two or more SS people and perinatal anxiety and depression outcomes. Future studies 
should examine how other contextual factors impact SS and mental health outcomes for Black and Latina mothers.
 Keywords: maternal morbidity, perinatal depression and anxiety, Black and Latina women

Clara L. B. Parsons1, May-Lorie Saint Laurent2, Yu Bi3, Valeriy Korostyshevskiy3, & Keri F. Kirk4 
1Department of Global Health, Milken Institute School of Public Health, George Washington University, 

2Division of General Pediatrics, Norwell Health, 
3Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University Medical Center,

4Department of Family Medicine, Georgetown University School of Medicine/Medstar Georgetown University Hospital



121

et al., 2015). Weathering is defined as the cumula-
tive impact that repeated exposure to social or eco-
nomic adversity and marginalization have on health 
(Geronimus et al., 2006). When underserved groups 
perpetually practice high-effort coping strategies in 
response to acute and chronic stressors, physiological 
deterioration results (Geronimus et al., 2006). There-
fore, maternal and child health are intertwined with 
the mother’s experiences of racial discrimination and 
chronic stress that are unique to women of color. 
Perinatal Mental Health Outcomes in Black and 
Latina Women
 Pregnancy can encompass a period of elevated 
stress, anxiety related to the pregnancy or fetus, and 
pain during labor and birth, posing significant stress 
on the body that increases vulnerability to mood dis-
orders (Alfayumi-Zeadna et al., 2021). The general 
population has a postpartum depression prevalence 
of 10-15%, which is disproportionately lower than 
rates for minoritized communities (Pao et al., 2019). 
For Latina women, the prevalence of perinatal depres-
sion is estimated to be between 54.2-60% (Center for 
Disease Control, 2008; Lucero et al., 2012; Shellman 
et al., 2014). Similarly, over 40% of Black women ex-
perience postpartum depression, over double the rate 
of the general population (Hernandez et al., 2022; 
Wisner et al., 2013). Furthermore, women of color 
experience more serious and chronic symptoms of 
depression than White women, despite meeting com-
parable criteria for mental illness (Guintivano et al., 
2018; Mukherjee et al., 2018; Parker, 2021). Black and 
Latina women are more likely to experience complica-
tions throughout their pregnancies, making the pro-
vision of perinatal mental health screenings and inter-
vention services especially important for these groups. 
Social Support Determines Perinatal Anxiety and 
Depression Outcomes
 Although all pregnant women, especially ethnic 
or racial minorities, are at risk of perinatal mental 
health disorders, risk is substantially reduced when 
protective factors such as social support are present. 
Social support, or psychological and material resources 
provided by friends, family, and romantic partners, has 
been found to protect against perinatal mental health 
disorders (Cohen & Wills, 1985). For the purposes of 
this study, social support is defined as the number of 
support people a person reports having in their life 
(Shiba et al., 2016). A mother’s satisfaction with her 

social support is dependent on maternal needs and ex-
pectations that vary across the perinatal period; thus, 
the quality of and satisfaction with social support is 
crucial (Li et al., 2017). Perceived social support is as-
sociated with stress, coping, and distress/depression. 
Both lack of positive support and presence of negative 
interpersonal relationships have been linked to depres-
sion (Coyne & Downey, 1991; Mendelson et al., 2013).
 Numerous studies have focused on the protec-
tive nature of social support, finding that increased 
social support and greater satisfaction with the sup-
port protects against symptoms of anxiety and de-
pression (Alfayumi-Zeadna et al., 2021; Coburn et al., 
2016; Lefkovics et al., 2018; Li et al., 2017; Pao et al., 
2019; Razurel et al., 2017). Similarly, lowered social 
support or dissatisfaction with support significant-
ly increases risk of perinatal depression and raises the 
levels of depressive/anxious symptoms experienced 
(Nisar et al., 2020; Ohara et al., 2017; Shakeel et al., 
2018; Sheng et al., 2010; Terada et al., 2021; Umuziga 
et al., 2020; Verreault et al., 2014; Zhou et al., 2021). 
For example, having a lower number of support peo-
ple during the perinatal period significantly predicted 
scores on measures of depression and mother-infant 
bonding in a prospective study of 494 women (Oha-
ra et al., 2017). Social support has been found to have 
a direct relationship to perinatal depressive/anxious 
symptoms, postpartum depression, and other mood 
outcomes (Ngai & Chan, 2012; Racine et al., 2018). 
 Based on research findings that suggest social sup-
port directly predicts symptoms of anxiety and depres-
sion during the perinatal period, social support must 
be discussed during perinatal visits to better screen 
for mental health risk. Assessing support in primary 
care visits during the perinatal period may allow pro-
viders to link mothers of highest need with relevant 
community resources (Barr & Caruso-Mcevoy, 2018).
Importance of Social Support Among Black/Lati-
na Women     
 Many studies show that the majority of research 
conducted on social support and mental health has 
been performed in predominantly White samples 
(Garthus-Niegel et al., 2022; Wenzel et al., 2021); 
however, social support is extremely relevant to the 
well-being of Black and Latina women. In collectiv-
istic cultures, significant cultural values include social 
connection, intergroup harmony, connectedness, and 
interdependence (Boroş et al., 2019). Collectivistic 

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PARSONS ET AL.

cultures also place more weight on close relationships 
among family, friends, and community members than 
Western cultures, which are typically individualis-
tic (Her & Joo, 2018). Research on racial/ethnic mi-
norities in the U.S. indicates that social support may 
be used in order to reduce the psychological distress 
that discrimination causes, especially for those from 
collectivist cultures (Steers et al., 2019). Both Black 
and Latinx communities rely on close social ties for 
support and have reported stronger and more sup-
portive relationships with family, friends, and others 
than White individuals do (Ai et al., 2014; Erving, 
2018). When family stress is present, Latinas may be 
particularly vulnerable during pregnancy based on 
the violation of cultural expectations about relation-
ships and the role of the family (Coburn et al., 2016).
Significance, Hypothesis, and Study Questions
 In Washington, D.C., women die from pregnan-
cy-related causes at a higher rate than anywhere else 
in the country, at 36 deaths per 100,000 live births 
(MedStar Health, 2021). African American women 
are three times more likely to die of pregnancy-related 
causes than White women. Washington, D.C.’s Afri-
can American infant mortality rate is the highest in the 
nation, at 59.7 deaths per 100,000 live births (Rob-
erts et al., 2020). However, White women in D.C. 
have the lowest maternal mortality ratio in the US; 
thus, adequate maternal care, which includes mental 
health support, is not equally available to all residents 
in the District (Roberts et al., 2020; Zubatsky et al., 
2018). Despite the existence of high-quality maternal 
healthcare in D.C., racial disparities in access to care 
put Black and Latina women at risk of severe mater-
nal mortality. In response to the severe maternal mor-
tality crisis in D.C., the D.C. Safe Babies, Safe Moms 
(SBSM) initiative delivers pre-conception, pregnancy, 
delivery, postpartum, and family care up to a child’s 
third year of life. This study aimed to assess maternal 
mental health and social support in the context of pri-
mary care visits for two critically underserved groups 
of women. For the purposes of this study, symptoms 
of anxiety and depression as reported on a self-re-
port measure constituted measurements of maternal 
mental health. Exploring the role of social support 
in perinatal anxiety and depression outcomes can fa-
cilitate better understanding of the relationship be-
tween social support and mental health during and 
after pregnancy. Our objective was to determine if a 

significant relationship between social support and 
perinatal anxiety and depression outcomes exists. We 
hypothesized that women who had two or more social 
support people in their lives would report fewer symp-
toms of anxiety and depression after giving birth. This 
is one of the first studies examining D.C. SBSM out-
comes and the first of this regional sample to evaluate 
social support and anxiety and depression outcomes.

Method
Sample and Procedures
 This study was part of standard clinic care en-
compassed within a larger program supported by the 
SBSM/HealthySteps program at a large health system 
on the East Coast. Institutional Review Board Ap-
proval was obtained through the Georgetown Univer-
sity IRB on December 23, 2021. This study includes 
participants who attended well-child checks for their 
children during the first 6 months of enrollment into 
the SBSM/HealthySteps program. The convenience 
sample initially consisted of 58 Black and Latina 
mothers with infants or toddlers ranging from age zero 
to three who received their care at a primary care clin-
ic within the hospital system. Mothers were invited to 
participate in this study during their child’s well-child 
checks and primary care visits as part of standard of 
care procedures. Overall primary care screening and 
assessment for children occurred by physicians, and 
mothers were screened for various social determinants 
of health issues, mental health concerns, and social 
support status by mental health faculty and staff. 
 Families were screened using the Family Health 
Survey (FHS), a demographic survey assessing the 
social determinants of health. The FHS was admin-
istered depending on the child’s age, at one month, 
16 months, 24 months, and 36 months. This survey 
also assessed social support and mental health status. 
The survey took approximately 15 minutes to com-
plete. The practitioner explained what the survey 
included and why it was being given so that the care 
team could better meet the patient’s needs. When this 
study launched, the FHS was not yet available online. 
The final 18 participants in this study completed the 
survey online once it was made available. For partic-
ipants completing the electronic survey, a link to the 
survey was generated and sent to the participant au-
tomatically when their child was scheduled for a vis-
it; they would then click on the link to complete the 



123

survey. Online surveys could be completed outside of 
well-child checks, allowing participants to complete 
the survey at home. For surveys completed by hand 
for parents who spoke Spanish, an interpreter assist-
ed with administering the survey in Spanish over the 
phone. Surveys administered on paper were filled 
out during the well-child checks within the clinic.
 We report how we determined all data exclusions, 
sample size, and measures in this study in compliance 
with reporting standards for non-experimental quan-
titative research (American Psychological Associa-
tion, 2020). This study is consistent with the Trans-
parency and Openness Promotion (TOP) Guidelines 
at level one for all eight aspects (Nosek et al., 2023). 
All data, analysis code, and research materials are 
available by emailing the corresponding author. This 
study’s design and its analysis were not pre-registered.
Measures
Demographics
 Socio-Demographic Characteristics. Socio-de-
mographic information was assessed through the 
Perinatal and Family Health Survey, which included 
information such as age, race, gender, educational 
attainment, employment status, and living arrange-
ments. Race was assessed by asking participants to 
select one of the following racial groups that they 
identified with, which included the following op-
tions: Black/African American, White, Asian/Asian 
American, American Indian/Alaskan Native, Native 
Hawaiian/Pacific Islander, multiracial, or other race. 
Ethnicity was assessed by asking participants to select 
either Not Hispanic/Latino/a or Hispanic/Latino/a. 
Perinatal and Family Needs
 Perinatal and Family Needs. In order to deter-
mine family needs, the FHS was administered. The 
full survey assessed social determinants of health, ex-
periences with racism, and other aspects of the family’s 
current social and health needs. For the purpose of this 
study, only the measures of social support and men-
tal health were utilized in analyses. The independent/
predictor variable was social support, measured by a 
mother’s open-ended answer to the question “Who 
are your most important support people?” When two 
or more people were listed, this was counted as “yes,” 
or having two or more social support people. Having 
fewer than two support people listed was counted as 
“no.” The dependent variable was experiences with 
anxiety and depression symptoms after giving birth. 

For the purposes of this study, anxiety and depression 
outcomes were measured by a combination of 5 items 
from the Personal Health Questionnaire-Two (PHQ-
2), PHQ4, and GAD7 (Kroenke et al., 2009), and the 
ninth question about self- harm on the PHQ-9. Partic-
ipants rated four statements on a 4-point Likert scale 
ranging from 0 (not at all) to 3 (nearly every day); the 
first two statements comprise the anxiety score (PHQ1 
and PHQ2), and the remaining statements comprise 
the depression score (PHQ3 and PHQ4). Statements 
measuring anxiety included “feeling nervous, anxious, 
or on edge” and “not being able to control or stop 
worrying.” Statements measuring depression includ-
ed “feeling down, depressed, or hopeless” and “lit-
tle interest or pleasure in doing things.” Scores were 
summed to yield a total mental health outcome vari-
able, which comprised the fourth variable of the men-
tal health score. The fifth question asked participants 
if the thought of hurting themselves has occurred to 
them in the last seven days; the yes/no answer choic-
es were coded as yes = 1, and no = 0. Internal consis-
tency of the PHQ4 is 0.82 (Mendoza et al., 2022).
Analytical Strategy
 All analyses were conducted using R 4.1.3. Sta-
tistical significance was set as p<0.05. Seven mothers 
with missing values for either social support or mental 
health outcomes were removed from the dataset: two 
participants lacked social support information, three 
participants lacked data for all PHQ questions, one 
participant lacked data for PHQ3, and one participant 
did not have data for PHQ4. After removing seven par-
ticipants from the analysis due to missing data, we had a 
final sample of n = 51 used in analyses. The mean men-
tal health scores, anxiety scores, and depression scores 
were computed and compared between mothers with 
and without social support using the two-sample t-test.
 Fisher’s exact test was used to compare the propor-
tion of race between groups, the proportion of educa-
tional levels between groups, the proportion of mothers 
who have completed a physical exam or well-woman's 
exam in the last year between groups, and the propor-
tion of relationship status between groups. Pearson’s 
chi-squared test was used to compare the proportions 
of mothers who worked outside the home between 
groups. The two-sample t-test was used to compare age 
between groups. A two-way ANOVA was performed 
to analyze the effect of having high social support and 
race on the mental health score. Two-way ANOVA is 

SOCIAL SUPPORT AND PERINATAL ANXIETY AND DEPRESSION OUTCOMES  



124

PARSONS ET AL.

suitable for assessing the impact of categorical indepen-
dent variables (social support and race) on a continu-
ous dependent variable (mental health scores). Two-
way ANOVA was chosen for its ability to highlight 
main effects, vital for understanding individual contri-
butions to observed variations in mental health scores.

Results
Demographic Characteristics of Participants
 The demographic characteristics of the study co-
hort are reported in Table 1. Thirty-one mothers had 
two or more social support people, and 20 mothers had 
one or fewer social support people. Thirty-seven per-
cent of the sample were Black women, 43% were Lati-
na, and 18% were categorized as “Other” races. There 
are two mothers whose race was both Black and Lati-
na. One mother in the low social support group was 
missing a race value; one mother in both social support 
groups were missing values for physical exam status. 
Additionally, 24 caregivers were missing values for age.
 On average, mothers with high social support 
were 28.47 years old (SD = 4.45), and those with low 
social support were 35.5 years old (5.02); there was 
a statistically significant difference between age (p = 
0.0010). There was a slightly statistically significant 
difference between races (p = 0.0498). The three racial 
groups were not uniform in social support reported. 
There was a similar distribution of Black and Latina 
mothers across the two social support groups; for the 
other race group, there were more people with no so-
cial support than with two or more social supports. 
 The results of the two-way ANOVA are present-
ed in Table 2. Simple main effects analysis showed 
that the levels of race did not have a statistically signif-
icant effect on the mental health score (p = 0.4942). 
Simple main effects analysis showed that the levels of 
high social support did not have a statistically signif-
icant effect on the mental health score (p = 0.2439). 
We also verified that there was no statistically signifi-
cant interaction between the effects of high social sup-
port and race (p = 0.5802, not included in Table 2).
Relationship Between Social Support and Perina-
tal Mental Health Outcomes
 The two-sample t-test was run to compare men-
tal health scores between the two groups; the means, 
standard deviations, and p-values for the overall men-
tal health score and stratified by each question are 
reported in Table 3. Cronbach's Alpha for the study 

was α = 0.378. In this study, the maximum score on 
the PHQ-4 for our sample was four. Mothers in our 
sample did not endorse thoughts of self-harm; thus, 
the p-value for the self-harm question measure is not 
applicable as the mean score is zero. The two-sample 
t-test for the mean mental health score across the two 
groups yielded a p-value of 0.4865. Thus, there is no 
statistically significant difference between the mean 
mental health scores of mothers with and without 
social support. The results of the two-sample t-test 
for anxiety and depression similarly did not demon-
strate statistical significance. There was no difference 
between anxiety scores for those with and without 
social support (p = 0.4872), and no difference be-
tween depression scores for those with and without 
social support (p = 0.7137). The distribution of re-
sponses to each mental health question measure for 
both social support groups is illustrated in Figure 1. 

Discussion
 This study aimed to determine if having two or 
more social support people was related to anxiety and 
depression outcomes after giving birth in a sample of 
predominantly Black and Latina women within the 
context of primary care visits. This study is one of the 
first to examine      outcomes from the D.C. SBSM ini-
tiative, which delivers perinatal and family care up to 
a child’s third year of life, and the first of this regional 
sample to evaluate social support and anxiety and de-
pression outcomes. We found no significant difference 
in mental health scores for those with two or more 
social supports versus those with one or fewer social 
supports. Our hypothesis was that women who had 
two or more social support people in their lives would 
report fewer symptoms of anxiety and depression after 
giving birth. We expected to find a significant relation-
ship between social support and perinatal anxiety and 
depression based on prior literature in largely White 
populations, but did not find a statistically significant 
difference between anxiety and depression symptoms 
of mothers with high versus low social support. De-
spite lacking statistical significance, two-group com-
parisons generally showed that mothers with two or 
more support people had a lower mental health score, 
and mothers with one or fewer support people had 
a higher mental health score (Figure 1). This general 
trend must be interpreted with caution due to high 
variability (high standard deviation) in both groups.



125

 It is important to continue discussing mental 
health and social support in primary care visits with 
Black and Latina mothers. Practitioners must recog-
nize that minoritized communities often under-re-
port mental health struggles for a variety of reasons. 
A study found that African Americans’ recent expe-
riences of discrimination predicted unique variance 
in beliefs about mental health problems and higher 
concerns about stigma (Williston et al., 2019). Since 
mental health concerns may be viewed as a point of 
stigmatization, study participants may have hesitated 
to disclose mental health symptoms in fear of being 
further discriminated against (Williston et al., 2019). 
For many Latina individuals, psychological distress 
often manifests physically (e.g. shortness of breath, 
elevated heart rate); thus, Latina participants may not 
report symptoms on the PHQ-4 due to the lack of so-
matic symptom assessment (Abarca et al., 2022). Ad-
ditionally, Latinx cultural constructs such as “susto” 
or “nervios'' refer to somatic symptoms experienced 
due to significant life stressors; thus, participants 
may not report symptoms as these words are not di-
rectly translated on the Spanish version of the PHQ-
4 (Abarca et al., 2022; Matías-Carrelo et al., 2003). 
 Of further note is the significance of family ties 
and collectivism when discussing social support and 
mental health in Black communities in particular. 
Seminal work posits that Black families’ strong ties 
provide a buffer against the mental health implications 
of structural and systemic disadvantages (Stack, 1975). 
Current research has continued to demonstrate that 
Black Americans’ mental health is associated with per-
ceived closeness to family and friends such that family 
closeness is associated with lowered odds of 12-month 
major depressive disorder among African Americans 
(Taylor et al., 2015). Outside of family dynamics, Black 
Americans rely on support from church members and 
fictive kin networks. Black Americans attend church 
more frequently than White Americans and rely more 
on loosely defined networks of family that go beyond 
biological relatives. The utility of fictive kin networks 
for Black individuals provides an important source of 
resilience and, historically, an adaptive response to eco-
nomic difficulties (Chatters et al., 1994; Chatters et al., 
2009; Roxburgh & MacArthur, 2020; Stack, 1975).
 Our study found a difference between the two 
social support groups in terms of race, where those in 
the Other race/ethnicity category experienced less so-

cial support than Black and Latina participants. Black 
and Latina mothers were distributed similarly across 
the two groups, whereas the Other race/ethnicity cate-
gory had a larger ratio of participants in the one/no so-
cial support group. However, we did not find a statis-
tically significant interaction between race and social 
support that impacted mental health scores. Limited 
prior research generally shows that racial and ethnic 
minority groups tend to report lower levels of social 
support, but our study had more Black and Latina 
participants with high social support than the Other 
category, which included White participants (Rox-
burgh & MacArthur, 2020). Thus, likely due to our 
racially diverse sample, we found that our Other group 
participants had lower social support. Prior literature 
has shown that, despite Black individuals reporting 
less closeness in friendships, this type of social support 
is more salient for Black than for White participants 
(Roxburgh & MacArthur, 2020). Minoritized groups 
often place high value on things like family, collec-
tivism, and interdependence; thus, because Black in-
dividuals in particular have highly interconnected 
cultural beliefs, they may be more susceptible to the 
effects of social support (Assari & Lankarani, 2018). 
 In a prior study, the associations between famil-
ialism with social support and stress were larger for 
Latina women than for White women (Campos et al., 
2008). Latinos also report greater reliance on and dis-
closure to family than to friends compared to Whites 
and Asian Americans; similarly, their friend support 
significantly predicted mental health service utili-
zation (Chang et al., 2014). Since Black and Latina 
women may value interpersonal relationships more 
than White participants, placing unique emphasis on 
their friendships and family ties compared to Whites, 
they may be more likely to have more social support.
 There were significant age differences between the 
two social support groups. On average, mothers with 
high social support were younger than those with low 
social support. This may be partially due to how dif-
ferent age groups seek out social support. For example, 
prior research has found that older adults sought less 
explicit social support, particularly instrumental social 
support, despite using a similar amount of implicit so-
cial support during stressful experiences (Jiang et al., 
2018). Older adults were more worried about social 
costs than younger adults, and thus sought less explicit 
social support. Additionally, research has shown that 

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PARSONS ET AL.

126

perceived social support is most strongly negatively 
associated with depression and loneliness at young-
er ages (Anderson, 2019). Thus, older adults may 
have underreported social support as they perhaps 
relied more on implicit support than younger adults, 
viewed social support as potentially costly, and were 
concerned about social implications of seeking help. 
 As individuals become more involved in their so-
cial networks or communities, there may be hesitancy 
to disclose symptoms of mood disorders. Black indi-
viduals in particular report learning early in life that 
mental illness is a topic to be avoided, and to keep 
mental health issues within the family (Alvidrez et al., 
2008). Thus, there may be hesitancy to disclose symp-
toms to loved ones. Social responses to illness must be 
considered when examining the role of social support 
on mental health: based on one’s perception of the 
impact of stigma, one may view their social support 
differently (Kondrat et al., 2018). Individuals experi-
encing symptoms of depression or anxiety, in this case, 
may expect rejection, devaluation, or discrimination 
upon disclosing mental health concerns (Kondrat 
et al., 2018). Racial and ethnic differences in the role 
of social support, as noted previously, are evidenced 
through differences in social embeddedness of Black 
and White Americans. As stigma varies across cultures, 
racial and ethnic minoritized individuals may vary in 
disclosing mood problems to their communities based 
on their involvement in these groups. Our insignifi-
cant results may be further explained by the nature of 
conducting research studies within the context of pri-
mary care visits. Participants may have felt rushed, not 
have read through the study information thoroughly, 
or experienced response bias. The survey consisted of 
a large number of questions that may have been tax-
ing for participants to undertake, and their responses 
may not be as accurate as if they were to take the sur-
vey outside of their care visits (Booker et al., 2021).
Limitations
 There are several limitations to consider in this 
study. First, the small sample size (n = 51) limited the 
statistical power of analyses. Due to the study’s tim-
ing, which fell during the first six months of enroll-
ment into the SBSM/HealthySteps program, there 
were only 58 participants enrolled before analysis and 
seven needed to be removed due to missing data. This 
yielded a low-power sample after removing missing 
data from participants, limiting the ability of the anal-

yses to find true effects (Button et al., 2013). Smaller 
sample sizes confer larger variability, as seen in our 
wide standard deviations. Secondly, the non-random 
nature of the sample limited the reliability of the study. 
Convenience sampling was used because mothers were 
screened as part of standard of care during their pri-
mary care visits, and thus the variability and bias can-
not be measured or controlled (Acharya et al., 2013). 
The generalizability of the results is limited beyond the 
sample (Acharya et al., 2013). Thirdly, our assessments 
were made across electronic and paper surveys. Not all 
participants were offered the electronic mode of survey 
completion, as it became available after many partic-
ipants had already completed pen-and-paper versions 
(Booker et al., 2021). Web-based surveys allow partici-
pants to complete studies in a more comfortable envi-
ronment, without time constraints, and are more con-
venient (Booker et al., 2021). Many questions asked 
were of high sensitivity (e.g., mental health symptoms), 
which is linked to lower response rates in patient sur-
veys, which might have been improved if the partici-
pant could have taken the survey electronically in a 
private space (Booker et al., 2021). Lastly, despite the 
advantages of the two-way ANOVA, it is important to 
acknowledge that this method may not be capable of 
including more confounders in the analysis. Our study 
emphasized group differences rather than predictive 
potential, thus factoring additional confounders into 
the model was beyond the scope of our current inves-
tigation. Additionally, our low Cronbach's Alpha (α = 
0.378) may be attributed to our survey's small question 
set (total of five questions for mental health scores). 
Future Directions
 Despite limitations, this study highlights import-
ant areas for next steps in perinatal mental health re-
search for Black and Latina women. Future studies 
must examine how racism and discrimination, on the 
interpersonal and systemic level, impact birth out-
comes and complications in women of color, partic-
ularly Black and Latina women. Understanding the 
pathways by which discrimination impacts infant 
health, in addition to maternal outcomes, will be in-
strumental in reducing maternal and infant mortality. 
In terms of statistical analysis approaches, future re-
search topics may consider the application of regression 
analysis to delve deeper into the relationships between 
social support, mental scores, and other confounders, 
particularly for predictive modeling. Such an approach 



127

could provide a more comprehensive understanding 
of the factors influencing mental well-being within 
our target demographic. Future research should con-
sider a more comprehensive approach to understand-
ing mood outcomes by taking into account additional 
variables within a broader scope. Additionally, future 
studies might incorporate covariates in predictive 
modeling for a more comprehensive understanding of 
these relationships. Although we did not find a signifi-
cant relationship between social support and perinatal 
anxiety and depression outcomes, this is still an im-
portant relationship to explore in perinatal research. 
Conclusion
 This study found a significant relationship be-
tween social support and both race and age, which 
may suggest that there are other points of intervention 
for similar communities. Given how contextual fac-
tors such as race, socioeconomic status, and the like 
intersect within health care systems, placing Black and 
Latina moms at a disadvantage in receiving equitable 
perinatal support, future studies should examine how 
everyday racism impacts social support and mental 
health outcomes. In places such as Washington, D.C., 
where access to adequate perinatal care is disparate, 
initiatives such as SBSM may improve mental health 
care accessibility. More research is needed on how 
to best examine patients’ social support and men-
tal health symptoms during primary care visits, the 
mechanisms by which racism and discrimination im-
pact health outcomes, and the influence of resilience 
on perinatal outcomes for Black and Latina women.

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Table 1

Sociodemographic Characteristics of Participants



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Table 2

Means, Standard Deviations, and Two-Way Analyses of Variance in Race and Social Support



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Table 3

Relationship Between Social Support and Anxiety or Depression Scores



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Figure 1

Relationship Between Social Support and Mental Health Score 




