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Maternal and Infant Health Assessment (MIHA)

Publish Date

January​ 2024

Preview of data brief

This data brief series describes the well-being of Californians who gave birth early in the pandemic using data from the Maternal and Infant Health Assessment (MIHA) survey. The MIHA 2020 sample was drawn from births occurring from March 16, 2020 to June 15, 2020. For more information about MIHA visit MIHA webpage​.​​

Mental Health During and After Pregnancy Early in the COVID‑19 Pandemic

COVID-19 Impacts on Pregnant People  and Families in California, 2020

Anxiety and depression are serious mental health conditions commonly experienced during and after pregnancy. These conditions can negatively affect maternal well-being, contribute to poor health outcomes, including preeclampsia and preterm delivery, and have negative impacts on breastfeeding and infant development.1-4

Early in the COVID-19 pandemic, many birthing people in California experienced clinically significant symptoms of mental health conditions during or shortly after pregnancy:

1 in 5
experienced symptoms
of
DEPRESSION

1 in 4
experienced symptoms
of
ANXIETY

1 in 3
experienced symptoms of ANXIETY and/or DEPRESSION​

Financial Hardships and Mental Health

Financial difficulties, housing instability, trouble paying bills, food insecurity, and job loss, increased substantially during the COVID-19 pandemic. These hardships contribute to poor mental health through chronic stress, stigma, and trauma.5 Overall, 32.7% of birthing people experienced symptoms of anxiety and/ or depression during or after pregnancy. Symptoms of anxiety and/or depression were more common among those with financial hardships.

Symptoms of anxiety and/or depression were more common among those who experienced financial hardships than among those who did not

Unstable housing: with hardship 55.9%, without hardship 31%Trouble paying bills: with hardship 55.5%, without hardship 28.7%Food insecurity: with hardship 47.1%, without hardship 29.7%Job loss or pay cut: with hardship 40.2%, without hardship 28.3%


Health Insurance, Race, and Ethnicity and Mental Health

Both private health insurance and Medi-Cal cover mental health screening and treatment. Birthing people who had Medi-Cal for prenatal insurance reported depression symptoms more frequently than did those with private insurance. Anxiety symptoms were similarly high in each group. The high prevalence of these symptoms demonstrates a great need for pregnancy-related mental health services.

Symptoms of anxiety and depression by prenatal health insurance type

Medi-Cal: Anxiety 25.4%, Depression 22.8%Private: Anxiety 26.8%, Depression 18.2% 


The chronic stress of racism is also associated with depression and other mental health concerns.6 Black birthing people have the highest prevalence of both anxiety and depression symptoms among all racial and ethnic groups.

Symptoms of anxiety and depression by race and ethnicity

Symptoms of anxiety and depression by race/ethnicityBlack: Anxiety 34.4%, Depression 27.5%White: Anxiety 30.7%, Depression 18.7%Hispanic: Anxiety 24.2%, Depression 20.2%Asian/Pacific Islander: Anxiety 21.4%, Depression 23.6% 


“Having to shelter in place after the delivery of my third baby, unable to receive tangible help from friends or family while home schooling my older two children, increased my anxiety and decreased coping skills. Out of my 3 deliveries, this year was the first time I was diagnosed with postpartum depressive disorder.”

– MIHA 2020 respondent

Addressing Maternal Mental Health

The COVID-19 pandemic has increased stress, financial hardships, social isolation, and disruptions to health care services. These conditions have had negative impacts on mental health and emotional well-being.7-9

Early in the pandemic, one-third of California’s birthing population reported anxiety and/or depression symptoms during or after pregnancy. Awareness of the pandemic’s impact on emotional well-being has highlighted long-standing challenges in accessing maternal mental health care. Recent improvements in California’s maternal mental health care system include required universal depression screening10 and the expansion of Medi-Cal coverage periods and benefits.11

Maternal mental health conditions may be prevented by reducing stressors across the life course, particularly by addressing racism and reducing financial, housing, and food insecurity.12, 13 Going forward, achievement of mental health and emotional well-being among birthing people in California will require an ongoing effort to ensure health-promoting social and environmental conditions, easy and affordable access to mental health care, and high-quality data to track progress.​​

​​​​​​Resources for California Families

​Help With Emotional Well-Being or Mental Health
​Information About Maternal Mental Health
​National Maternal Mental Health Hotline
Call or text 1-833-TLC-MAMA (1-833-852-6262)
in English and Spanish. Interpreter services in 60
languages. TTY users can use a preferred relay
service or dial 711 and then 1-833-852-6262.
Maternal, Child and Adolescent Health Division​
Links to maternal mental health partners, print
materials, videos and a social media library.
Postpartum Support International
Call or text “Help” to 1-800-944-4773
Text en Español: 971-203-7773
​​Policy Center for Maternal Mental Health
A national maternal mental health non-profit
organization focused ​on improving maternal mental health care.
County Mental Health Programs
National Alliance on Mental Health (NAMI)
​​​​Maternal Mental Health Leadership Alliance
A non-profit organization dedicated to promoting
the mental health o​f women and childbearing
people in the United States.
Crisis Text Line
Provides support and information for any type of
crisis. Text “HOME” to 741741.
National Suicide Prevention Lifeline 24/7
Call 988 or (800) 273-8255 (English and Spanish)​

About the Data

Methods

This data brief uses 2020 data from the Maternal and Infant Health Assessment (MIHA) survey, a statewide representative survey of individuals with a recent live birth in California, conducted annually since 1999, linked to birth certificates. The survey collects self-reported information about maternal and infant experiences before, during, and shortly after pregnancy. 

MIHA is a stratified random sample of English- or Spanish-speaking individuals. MIHA data used in this brief are weighted to be representative of California residents with a live birth from May 16, 2020 to June 15, 2020, excluding those who were younger than 15 years old at delivery, had a multiple birth greater than triplets, or had a missing address on the birth certificate. The MIHA 2020 sample size was 6,363. For more information on weighting and technical definitions, see the MIHA Technical Notes at go.cdph.ca.gov/MIHA-methods

MIHA is led by the Maternal, Child and Adolescent Health Division in the California Department of Public
Health (CDPH) in collaboration with the CDPH Women, Infants and Children (WIC) Division and the Center for Health Equity at the University of California, San Francisco.

Definitions

Self-reported symptoms of anxiety and depression were ascertained using an adapted four-item Patient Health Questionnaire (PHQ-4), which includes the two- item Generalized Anxiety Disorder (GAD-2) scale and the twoitem PHQ-2, which assesses symptoms of depression.14 Adaptations to the PHQ-4 for use in MIHA included (1) changing the time period from “Over the last 2 weeks” to the prenatal period ("During your pregnancy") and postpartum period ("Since your most recent birth") and (2) changing the response categories from the frequency of days in the past two weeks to a general frequency scale ("always," "often," "sometimes," "rarely," and "never").15 Measures were defined as follows: 

Anxiety symptoms – During pregnancy or since most recent birth, always or often felt nervous, anxious or on edge, or was unable to stop or control worrying.

Depression symptoms – During pregnancy or since most recent birth, always or often felt down, depressed or hopeless, or had little interest or pleasure in doing things usually enjoyed. 

Anxiety and/or depression symptoms – During pregnancy or since most recent birth, experienced either anxiety symptoms, depression symptoms, or both.

References

  1. Sayres van Neil M, Payne JL. Perinatal depression: A review. Cleveland Clinic J Med 2020; 87(5): 273-277.

  2. Stuart-Parrigon K, Stuart S. Perinatal depression: An update and overview. Curr Psychiatry Rep 2014;16:468.

  3. Paul IM, Downs DS, Schaefer EW et al. Postpartum anxiety and maternal-infant health outcomes. Pediatrics 2013; 131(4): e1218-e1224.

  4. Hu R, Li Y, Zhang Z, Yan W. Antenatal depressive symptoms and the risk of preeclampsia or operative deliveries: a meta-analysis. PLOS One 2015; 10(3): e0119018.

  5. Tracking the COVID-19 Economy’s Effects on Food, Housing, and Employment Hardships. Center on Budget and Policy Priorities, 2021.

  6. Knifton L, Inglis G. Poverty and mental health: policy, practice and research implications. BJ Psych Bull 2020; 44(5): 193-196.

  7. Paradies Y, Ben J, Denson N et al. Racism as a determinant of health: a systematic review and meta-analysis. PLOS One 2015; 10(9):e0138511.

  8. Panchal N, Kamal R, Cox C, Garfield R. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation Fact Sheet, 2021.

  9. Aknin LB, De Neve JE, Dunn EW et al. Mental health during the first year of the COVID-19 pandemic: a review and recommendations for moving forward. Perspectives on Psycholog Sci 2022.

  10. Liu J, Hung P, Alberg AJ et al. Mental health among pregnant women with COVID-19-related stressors and worries in the United States. Birth 2021; 48:470-479.

  11. Cal. Assemb. B. 2193, Chapter 755 (Cal. Stat. 2018).

  12. Parma A. New Medi-Cal Policy Expands Access to Family Therapy for Young Children. https://first5center.org/blog/newmedi- cal-policy-expands-access-to-family-therapy-for-youngchildren. Accessed May 11, 2022.

  13. Misra DP, Guyer B, Allston A. Integrated perinatal health framework: A multiple determinants model with a life span approach. Am J Prev Med 2003;25(1):65-75.

  14. Shim RS, Compton, MT. Addressing the social determinants of mental health: if not now, when? If not us, who? Psychiatr Serv 2018; 69:844-846.

  15. Kroenke K, Spitzer RL, Williams JB, et al. An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics. 2009;50(6):613-21.​​​

Data Tables

Anxiety and/or depression symptoms during or after pregnancy among individuals who gave birth in spring 2020, Maternal and Infant Health Assessment

Categories Depression symptoms
Anxiety
symptoms
Depression and/or anxiety symptoms
%
95% Confidence Interval %
95%​ Confidence Interval % 9​5% Confidence Interval
California total 20.8 19.4 - 22.2 26.3 24.9 - 27.8 32.7 31.2 - 34.3
Age: 15-19 years 26.3 19.4 - 33.3 25.4 18.6 - 32.2 34.7 26.8 - 42.5
Age: 20-24 years 27.5 23.5 - 31.6 32.7 28.3 - 37.1 41.6 37.0 - 46.1
Age: 25-29 years 21.0 18.4 - 23.6 26.5 23.7 - 29.2 33.2 30.1 - 36.2
Age: 30-34 years 20.2 17.7 - 22.6 25.1 22.5 - 27.8 31.1 28.3 - 33.9
Age: 35 years or older 16.8 14.3 - 19.4 24.2 21.3 - 27.0 29.1 26.0 - 32.1
Education
Education: <High school
20.0 16.4 - 23.7 21.1 17.3 - 25.0 30.4 26.1 - 34.7
Education: High school or GED
20.7 17.5 - 23.9 22.9 19.6 - 26.2 30.8 27.1 - 34.4
Education: Some college 23.8 21.2 - 26.4 30.0 27.2 - 32.8 36.4 33.5 - 39.4
Education: College graduate 18.5 16.4 - 20.6 26.7 24.3 - 29.1 31.4 28.8 - 33.9
Income as percentage of Federal Poverty Guidelines (FPG)
Income as percentage of Federal Poverty Guidelines (FPG): 0-200% FPG 23.6 21.6 - 25.6 27.1 25.0 - 29.2 34.7 32.4 - 37.0
201-400% FPG 20.8 17.4 - 24.1 26.5 22.9 - 30.1 33.2 29.3 - 37.1
>400% FPG 16.4 14.0 - 18.9 26.4 23.5 - 29.2 29.8 26.8 - 32.8
Prenatal health insurance
Prenatal health insurance: Medi-Cal
22.8 20.8 - 24.8 25.4 23.3 - 27.5 33.2 30.9 - 35.5
Prenatal health insurance: Private 18.2 16.3 - 20.1 26.8 24.6 - 28.9 31.6 29.4 - 33.9
Prenatal health insurance: Uninsured 25.5 14.6 - 36.4 20.8 10.9 - 30.7 28.1 17.0 - 39.1
Race/ethnicity
Race/ethnicity: Asian/Pacific Islander 23.6 19.6 - 27.5 21.4 17.6 - 25.2 32.2 27.8 - 36.5
Race/ethnicity: Black 27.5 23.8 - 31.3 34.4 30.4 - 38.4 41.3 37.1 - 45.5
Race/ethnicity: Hispanic 20.2 18.2 - 22.1 24.2 22.0 - 26.3 30.8 28.5 - 33.1
Race/ethnicity: White 18.7 16.3 - 21.1 30.7 27.8 - 33.5 34.1 31.1 - 37.0
Total live births
Total live births: First live birth 23.0 20.8 - 25.2 30.2 27.8 - 32.6 37.2 34.7 - 39.7
Total live births: Second live birth or more 19.3 17.6 - 21.1 23.7 21.9 - 25.6 29.8 27.8 - 31.8
Hardships during pregnancy
Hardships during pregnancy: Unstable housing 39.9 33.9 - 45.8 46.0 39.9 - 52.2 55.9 49.8 - 62.0
Hardships during pregnancy: Trouble paying bills 40.4 36.2 - 44.5 48.2 43.9 - 52.4 55.5 51.3 - 59.7
Hardships during pregnancy: Food insecurity 33.8 30.3 - 37.3 38.4 34.7 - 42.1 47.1 43.3 - 50.9
Hardships during pregnancy: Job loss or pay cut 25.5 23.1 - 27.8 32.7 30.1 - 35.2 40.2 37.5 - 43.0
MIHA region
MIHA region: Los Angeles County 19.4 16.2 - 22.6 23.4 20.1 - 26.8 29.5 25.8 - 33.2
MIHA region: San Francisco Bay Area 19.7 17.1 - 22.2 26.2 23.3 - 29.1 32.3 29.2 - 35.3
MIHA region: San Diego County 23.4 17.6 - 29.3 28.1 22.1 - 34.2 34.5 28.1 - 40.9
MIHA region: Orange County 15.6 10.3 - 21.0 27.8 21.1 - 34.5 32.0 25.0 - 39.0
MIHA region: San Joaquin Valley 24.0 20.9 - 27.2 29.0 25.5 - 32.5 36.6 33.0 - 40.2
MIHA region: Greater Sacramento Area 23.5 18.7 - 28.3 28.1 23.3 - 33.0 36.5 31.1 - 41.8
MIHA region: Southeastern California 18.8 15.0 - 22.6 24.1 19.8 - 28.4 29.7 25.0 - 34.3
MIHA region: Central Coast Area 23.0 19.5 - 26.6 27.1 23.6 - 30.7 35.5 31.6 - 39.4
MIHA region: North/Mountain Region 28.5 21.2 - 35.7 33.6 26.1 - 41.1 40.6 33.0 - 48.2
County
County: Alameda 17.9 12.4 - 23.4 26.6 20.1 - 33.2 34.4 27.3 - 41.4
Butte
31.2 19.2 - 43.2 28.9 18.0 - 39.7 43.2 30.2 - 56.3
Contra Costa 23.0 16.7 - 29.4 29.6 22.8 - 36.4 34.1 27.0 - 41.3
El Dorado 19.6 10.6 - 28.7 29.3 19.1 - 39.6 33.5 22.7 - 44.2
Fresno 25.2 17.2 - 33.1 35.0 25.7 - 44.3 40.6 31.3 - 50.0
Humboldt 26.9 16.7 - 37.0 38.8 28.2 - 49.3 45.9 35.6 - 56.2
Imperial 22.3 13.9 - 30.6 33.3 23.4 - 43.3 35.8 25.8 - 45.9
Kern 26.6 19.2 - 33.9 26.7 19.1 - 34.2 38.3 30.1 - 46.5
Kings 32.9 19.1 - 46.8 38.8 24.4 - 53.2 45.6 30.7 - 60.4
Los Angeles 19.4 16.2 - 22.6 23.4 20.1 - 26.8 29.5 25.8 - 33.2
Madera 23.0 11.5 - 34.4 22.9 9.7 - 36.1 32.3 17.9 - 46.8
Marin 9.2* 3.0 - 15.4 17.1 9.9 - 24.3 21.8 13.4 - 30.1
Merced 16.0 7.8 - 24.3 17.9 9.5 - 26.3 22.4 13.0 - 31.8
Monterey 20.8 13.0 - 28.5 26.5 18.6 - 34.3 34.2 25.5 - 42.9
Napa 13.4 6.4 - 20.4 20.5 12.7 - 28.4 25.9 16.9 - 34.8
Orange 15.6 10.3 - 21.0 27.8 21.1 - 34.5 32.0 25.0 - 39.0
Placer 23.6 13.3 - 33.9 35.8 24.5 - 47.1 42.1 30.3 - 53.9
Riverside 17.9 12.8 - 23.0 25.8 19.4 - 32.2 30.8 24.1 - 37.5
Sacramento 24.3 17.7 - 30.9 28.4 21.7 - 35.1 37.5 30.2 - 44.8
San Bernardino 19.5 13.3 - 25.6 21.7 15.5 - 27.8 28.0 21.1 - 34.9
San Diego 23.4 17.6 - 29.3 28.1 22.1 - 34.2 34.5 28.1 - 40.9
San Francisco 16.4 10.9 - 21.9 20.8 15.0 - 26.6 26.4 19.9 - 33.0
San Joaquin 18.0 11.8 - 24.1 24.5 17.8 - 31.2 32.2 24.7 - 39.7
San Luis Obispo 16.2 8.8 - 23.6 31.1 21.1 - 41.0 36.0 25.5 - 46.5
San Mateo 18.0 11.9 - 24.1 25.9 19.0 - 32.8 32.9 25.6 - 40.2
Santa Barbara 24.4 16.8 - 32.1 22.1 15.3 - 29.0 33.3 25.2 - 41.4
Santa Clara 17.9 11.3 - 24.5 21.4 14.1 - 28.8 27.7 19.9 - 35.6
Santa Cruz 16.4 9.6 - 23.2 16.0 9.4 - 22.6 21.9 14.2 - 29.5
Shasta 19.8 10.7 - 29.0 26.6 16.5 - 36.6 34.0 23.1 - 45.0
Solano 25.4 17.4 - 33.4 40.3 31.2 - 49.3 42.6 33.6 - 51.7
Sonoma 34.6 24.9 - 44.2 37.6 28.0 - 47.3 44.3 34.6 - 54.1
Stanislaus 26.3 17.4 - 35.1 29.8 20.7 - 38.9 37.0 27.3 - 46.6
Tulare 25.7 18.0 - 33.3 31.6 23.5 - 39.7 37.7 29.3 - 46.1
Ventura 27.2 20.5 - 33.9 32.2 25.3 - 39.0 40.7 33.3 - 48.2
Yolo 32.1 18.2 - 46.0 30.8 17.6 - 44.0 43.1 28.9 - 57.3


* Estimate should be interpreted with caution due to low statistical reliability (Relative Standard Error between 30% and 50%)

MIHA 2020 sample size was 6,363. Percent (%) and 95% confidence interval (95% CI) are weighted to represent all California residents with a live birth from May 16, 2020 to June 15, 2020. See the MIHA Technical Notes for information on weighting and technical definitions. 

Table Citation: COVID-19 Impacts on Pregnant People and Families in California: Mental health during and after pregnancy early in the COVID-19 pandemic, Maternal and Infant Health Assessment, 2020. California Department of Public Health, 2022.​​​​

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