A randomized trial of prenatal cognitive behavioral stress management effects on obstetric health outcomes and infant cortisol levels.

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Published in final edited form as: Psychoneuroendocrinology. 2026 Feb 21;187:107807. doi: 10.1016/j.psyneuen.2026.107807 A randomized trial of prenatal cognitive behavioral stress management effects on obstetric health outcomes and infant cortisol levels Guido G Urizar Jr a, * , Ilona S Yim b , Ruby Barragan a , Jacob Nguyen a , Gwendolyn Manning c , Angela Dixon-Hamlett c Author information Article notes Copyright and License information a Department of Psychology, California State University, Long Beach, 1250 Bellflower Blvd, Long Beach, CA 90840-0901, USA b Department of Psychological Science, University of California, Irvine, 4562 Social and Behavioral Sciences Gateway, Irvine, CA 92697-7085, USA c Long Beach Department of Health & Human Services, Black Infant Health Program, 3820 Cherry Ave, Long Beach, CA 90807, USA * Corresponding author. guido.urizar@csulb.edu (G.G. Urizar). Issue date 2026 May. This is an open access article under the CC BY-NC license ( http://creativecommons.org/licenses/by-nc/4.0/ ). PMC Copyright notice PMCID: PMC13235819  NIHMSID: NIHMS2178798  PMID: 41747450 The publisher's version of this article is available at Psychoneuroendocrinology Abstract Background: Altered cortisol patterns during pregnancy have been linked to heightened risk for obstetric health complications (e.g., low infant birthweight) and dysregulated infant cortisol levels after birth, particularly in chronically stressed, low-income and ethnic minority families. Considering the detrimental effects that dysregulated cortisol may have on maternal and infant health, prenatal interventions aimed at cortisol regulation in at-risk families are needed. In a previous study, we reported that low-income, ethnic minority pregnant women randomized to a prenatal cognitive behavioral stress management (CBSM) intervention showed improved pre- and postnatal stress and salivary cortisol patterns relative to a control group. The current study extends this work by investigating whether families who received this prenatal CBSM intervention, relative to a control group, experienced fewer obstetric health complications and more regulated infant post partum cortisol patterns, and if maternal cortisol patterns and psychosocial factors (stressful life events, resilience) influenced CBSM intervention effects. Methods: One hundred pregnant women (76 % annual income < $20 K, <17 weeks of gestation) were randomized to an eight-week CBSM group intervention ( n = 55) or a control group ( n = 45). Salivary cortisol was collected at baseline (1st trimester), after the intervention (3rd trimester), and at three months post partum (mothers and infants). Obstetric health complications were assessed via a medical record review. Results: Prenatal CBSM (compared to the control group) showed fewer obstetric health complications for mothers with elevated prenatal cortisol levels. Further, CBSM (compared to the control group) showed more regulated cortisol patterns (i.e., reducing total cortisol, steeper decline in diurnal cortisol) for infants of mothers who had high cortisol and stress levels, and for infants of African American mothers. Conclusions: These results lend support to the effectiveness of prenatal CBSM in enhancing the health of low-income, ethnic minority mothers and their infants, and emphasize the need to investigate the prolonged impact of CBSM in community-based settings. Keywords: Cortisol, Pregnancy, Infants, Stress management, Prenatal health, Birth outcomes 1. Introduction 1.1. Prenatal stress and its impact on maternal and infant health Chronic stressors experienced during pivotal moments in a person’s life, such as the transition to motherhood, may adversely affect the well-being of pregnant mothers and their babies. Low-income and ethnic minority mothers are especially at risk, given their greater likelihood of experiencing chronic stressors during pregnancy (e.g., financial strain, discrimination) and subsequent obstetric health complications, including preeclampsia, gestational diabetes, anemia, preterm labor, and unplanned C-sections ( Blumenshine et al., 2010 ). Their infants also show higher rates of having a low birthweight, low APGAR scores, being born premature, and being more likely to be hospitalized in the NICU after birth ( Adegoke et al., 2022 ; Larrabee Sonderlund et al., 2021 ). African American mothers, in particular, face significantly poorer obstetric health outcomes regardless of socioeconomic status, including higher rates of preeclampsia, unplanned C-sections, maternal mortality, preterm births, low infant birthweight, and infant mortality compared to non-Hispanic white mothers ( Adegoke et al., 2022 ; Burris and Hacker, 2017 ). 1.2. Psychosocial factors and obstetric health outcomes To address these pre- and post-natal health disparities, studies have examined psychosocial and biological factors potentially related to these adverse health outcomes, including exposure to major stressful life events. Studies show that approximately 63% of pregnant women experience at least one stressful life event (e.g., financial strain, death of family/friend, separation/divorce, major illness), with higher rates among ethnic minority mothers (76%; Burns et al., 2015 ). Exposure to multiple stressful life experiences during pregnancy has been linked with a greater risk for obstetric health complications, such as premature labor ( Mukherjee et al., 2017 ). Similarly, stressful life events related to discrimination and U.S. acculturation have been tied to higher rates of preterm births and low infant birthweights among African American and Latina mothers ( D'Anna-Hernandez et al., 2012 ; Rankin et al., 2011 ). The psychosocial factor of resilience, the capacity to adapt to or recover from life adversities, has been examined as a potential protective factor in reducing obstetric health complications ( Young and Ayers, 2021 ). Specifically, recent studies show higher resilience during pregnancy to be associated with lower rates of gestational diabetes, preeclampsia, preterm births, low birthweight babies, and infant neurodevelopmental impairment, especially among women experiencing high risk pregnancies and those with elevated symptoms of prenatal depression and anxiety ( Deutsch et al., 2022 ; Khalil et al., 2024 ; Maxson et al., 2016 ). Despite these results, research in resilience and obstetric health outcomes remains scarce and merits further investigation. 1.3. Prenatal maternal cortisol and obstetric health outcomes In addition to psychosocial factors, studies have also examined potential biological mechanisms, such as prenatal maternal cortisol, that may be related to a greater risk for developing obstetric health complications. Cortisol is regulated by the hypothalamic-pituitary-adrenal (HPA) axis and is one of the main hormones released in response to environmental stressors ( Fries et al., 2009 ). During pregnancy, maternal cortisol levels naturally increase, reaching their peak during the third trimester. Fetal exposure to these rising maternal cortisol levels is regulated by a placental enzyme (11β-HSD2) that helps convert excessive maternal cortisol to its inactive form (cortisone), with levels of this enzyme decreasing later in pregnancy ( Zhu et al., 2019 ). During the third trimester, this combination of rising maternal cortisol levels and a decrease in the placental enzyme 11β-HSD2 help ensure that the fetus receives sufficient levels of cortisol, playing a critical and necessary role in fetal lung maturation, organ and brain development, metabolic regulation, and preparing the fetus for delivery ( Krontira et al., 2020 ; Mastorakos and Ilias, 2003 ). While it is normal for maternal cortisol levels to rise during pregnancy, research indicates that when prenatal cortisol levels increase beyond their optimal range, this can lead to several adverse birth outcomes, such as a higher likelihood of mothers experiencing preterm births and infants having a low birthweight and/or needing resuscitation assistance at birth ( Castro-Quintas et al., 2024 ; Zijlmans et al., 2015 ). Along with total cortisol levels, researchers have also begun to examine diurnal cortisol patterns, or variations in cortisol throughout the day, in connection with obstetric health outcomes. Throughout pregnancy, diurnal cortisol patterns frequently show a rise in cortisol in the morning followed by a gradual drop throughout the day ( Mastorakos and Ilias, 2003 ). Alternate diurnal cortisol patterns, on the other hand, might not exhibit this drop in cortisol and instead appear flatter (i.e., less cortisol change during the day). These atypical cortisol patterns are especially noted in pregnant women who have experienced multiple significant stressful life events ( Obel et al., 2005 ) and have been linked to low infant birthweight ( D'Anna-Hernandez et al., 2012 ; Kivlighan et al., 2008 ). 1.4. Maternal and infant cortisol Altered maternal cortisol patterns during pregnancy may not only increase women’s risk for obstetric health complications but also affect infants’ cortisol levels after birth. Because the fetus undergoes sub-stantial physiological and developmental changes during pregnancy, significant disruptions in the fetal environment (e.g., altered maternal cortisol patterns) may have long-lasting effects, possibly making the fetus more susceptible to environmental stressors after birth ( Duthie and Reynolds, 2013 ). Typically, only 3%−10% of prenatal maternal cortisol reaches the fetus during pregnancy due to the placental enzyme 11β-HSD2 breaking down excessive cortisol and helping the fetus receive the optimal level of maternal cortisol needed for growth and development ( Krontira et al., 2020 ). However, studies have shown that highly stressed mothers during pregnancy show lower 11β-HSD2 activity compared to less stressed mothers, potentially increasing fetal exposure to maternal cortisol levels ( O'Donnell et al., 2012 ; Glover et al., 2009 ). Indeed, infants born to mothers with higher than optimal prenatal cortisol levels have been shown to exhibit higher cortisol levels shortly after birth ( Van den Bergh et al., 2020 ), especially among infants of low-income and ethnic minority mothers ( Clearfield et al., 2014 ; Dismukes et al., 2018 ; Luecken et al., 2013 ). These elevated infant cortisol levels can have long-lasting effects on their development as they enter school ( Hodyl et al., 2017 ; Zijlmans et al., 2015 ). Together, these findings show that altered pre- and postnatal cortisol patterns can negatively affect maternal and infant health, underlining the need for prenatal interventions that target cortisol regulation in at-risk families. 1.5. Cognitive behavioral stress management One such prenatal intervention that international OBGYN organizations have endorsed to help prevent stress-related health outcomes is group cognitive behavioral stress management (CBSM; ACOG, 2006 ). CBSM interventions consist of teaching several active coping skills (e.g., changing maladaptive thoughts, diaphragmatic breathing) to promote health ( Antoni, 2013 ; Beck and Dozois, 2011 ). In terms of obstetric health complications, randomized control studies have specified mothers’ participation in group-based prenatal CBSM (delivered face-to-face) to be especially beneficial in reducing rates of C-section births, low infant birthweight, small for gestational age infants, and low infant APGAR scores ( Bastani et al., 2006 ; Ghalehkhani Safat et al., 2018 ; Karamoozian and Askarizadeh, 2015 ; Siebach et al., 2024 ). Although studies have begun to document that prenatal CBSM can be effective in affecting maternal cortisol ( Pida et al., 2021 ; Hasriyanti Romadhoni et al., 2021 ; Urizar, 2023 ), fewer studies have examined whether prenatal CBSM affects infant cortisol levels. Two such randomized control studies showed that infants whose mothers participated in a group-based prenatal CBSM intervention had lower cortisol at birth and at six months post partum, compared to infants of mothers in a control group ( Puertas-Gonzalez et al., 2023 ; Urizar and Muñoz, 2011 ). Despite these encouraging findings, few studies have investigated whether group-based prenatal CBSM is effective in decreasing obstetric health complications and regulating infant cortisol levels among low-income and ethnic minority families that are in most need of these programs. Furthermore, not much is known about whether maternal factors (e.g., stressful life events, resilience, cortisol) may influence CBSM intervention effects. 1.6. Current study In a previous study, we reported that low-income, ethnic minority pregnant women randomized to a prenatal CBSM intervention (SMART Moms Program) showed lower perceived stress levels during pregnancy (second and third trimesters) and at three months post partum, relative to women in a control group ( Urizar et al., 2019a ). At three months post partum, women randomized to CBSM also showed a steeper decline in their diurnal cortisol levels throughout the day compared to women in the control group, whose diurnal cortisol levels were flatter (i.e., less cortisol change throughout the day). The current study extends this work by investigating whether mothers who received this prenatal CBSM intervention, relative to the control group, experienced fewer obstetric health complications and more regulated infant post partum cortisol patterns (i.e., lower total cortisol, steeper drop in diurnal cortisol). This study also explored whether maternal psychosocial factors (i.e., stressful life events, resilience) and maternal cortisol patterns (pre- and post partum) moderated CBSM intervention effects on obstetric health outcomes and infant cortisol regulation. 2. Method 2.1. Participant recruitment & eligibility criteria As part of the SMART Moms (Stress Management and Relaxation Training for Moms) randomized control trial, women were recruited early in their pregnancy from prenatal clinics and organizations in southern California (2011–2013) that primarily served a low-income population (38% living below the poverty level; U.S. Census Bureau, 2014; for full information on study enrollment and the CONSORT statement, see Urizar et al., 2019a ; NIH Clinical Trial NCT03627247 ; https://clinicaltrials.gov/study/NCT03627247 ). To be eligible, participants had to be 18 years of age or older, less than 17 weeks pregnant, and fluent in either Spanish or English. The study excluded women who had any significant health issues at baseline (e.g., high-risk pregnancy, major depressive disorder), were taking any medications that could affect cortisol levels (e.g., antidepressants, asthma inhaler), or who smoked or used illicit drugs. 2.2. Procedures and study design All study procedures were approved by the Institutional Review Board at California State University, Long Beach. After obtaining written informed consent, research staff administered a health survey in either Spanish or English to eligible women (less than 17 weeks pregnant) to assess their sociodemographic background and baseline levels of exposure to stressful life events and resilience. They were then instructed on how to collect their saliva at home (by passive drool using cryovials and saliva collection aids) at four times on one day (upon waking in the morning, 12 pm, 4 pm, and 8 pm; collected on a weekday to represent a typical day and sleep schedule), making sure not to drink liquids other than water, eat, or brush their teeth for at least half an hour before collecting each saliva sample (substances known to disrupt cortisol assays). They used a personal digital assistant (PDA) device and a self-report survey provided to them to record the times of their saliva collections. Mothers were asked to place their saliva samples in their freezer upon completing their saliva collection (98% adherence; for full information on cortisol collection adherence, see Urizar et al., 2019a ). After completing their baseline health survey and salivary cortisol collection, women were randomized to participate in either a prenatal CBSM or control group (prospective, pre-test post-test, experimental control group design). Computer-generated randomization was used (parallel assignment design), and to avoid selection bias, group assignment was hidden inside plain, consecutively numbered sealed envelopes (research staff were blinded to the assigned groups). To account for anticipated variations in CBSM class attendance, the CBSM group was slightly oversampled using a 1.2 to 1 (CBSM to Control group) randomization ratio. The CBSM group instructors recorded class attendance. Women in both the CBSM and control groups completed follow-up assessments when they reached 30–32 weeks of pregnancy (i.e., maternal salivary cortisol) and three months after giving birth to their baby (i.e., medical record review for obstetric complications, maternal and infant salivary cortisol). At three months post partum, mothers collected two samples of their infant’s saliva at home on one collection day (at 8 am and at 8 pm; collected on the same day as the mother’s saliva collection) using a plastic pipette device, which suctions saliva from inside the infant’s cheek into a cryovial (Salimetrics, LLC). Similar to the mother’s saliva collection, they were asked not to feed their infants for at least 30 minutes before collecting each sample (to avoid contaminants that could interfere with cortisol sampling), to record the collection time (using the PDA and collection log), to place the infant saliva samples in their freezer, and to call the research staff once they completed their infant’s saliva collection so that the samples could be picked up from their home (99% adherence; these saliva collection procedures have shown to provide reliable cortisol data for infants at three months of age; Tryphonopoulos et al., 2014 ). Participants were provided with gift cards after finishing each assessment ($50 at baseline, $50 at third trimester, $75 at three months post partum). 2.3. Randomization groups CBSM Intervention. Mothers in CBSM took part in an eight-week, group-based, prenatal intervention (SMART Moms Program) where they learned coping and relaxation skills to help them manage challenges that often arise during pregnancy and after birth (e.g., worries about the baby’s health, financial hardship; see Urizar et al., 2019b for treatment fidelity of the CBSM intervention). Twelve different groups, each consisting of three to eight pregnant women, were taught the classes in either Spanish or English by group instructors at a nearby clinic where most women received their prenatal care. The course content was derived from CBSM interventions demonstrated to be successful in managing stress and cortisol levels among pregnant mothers, as well as cancer and HIV+ patients ( Antoni, 2013 ; Antoni et al., 2005 ; Urizar and Muñoz, 2011 ). Each class was led by one to two clinically-trained group facilitators (holding master’s or PhD degrees), utilizing content from an instructor manual (refer to Urizar et al., 2019b for a description of the intervention content and training). Participants received weekly CBSM coping and relaxation skills, such as cognitive reappraisal and diaphragmatic breathing, to practice outside of the class setting. They documented their use of these skills on a handout, which they turned in and shared with the class the subsequent week. Control Group. Over the course of eight weeks, women in the control group were sent weekly materials (available in Spanish and English) via mail on different prenatal health topics (e.g., labor and delivery, pregnancy discomfort) that were selected from the March of Dimes Foundation's “Becoming a Mom” handouts ( March of Dimes, 2011 ). Once a week, participants were contacted by research staff to check if they had received and reviewed their weekly topic and to inquire about any questions they might have regarding the material. 2.4. Measures Sociodemographics. Maternal variables, including age, ethnicity, number of weeks pregnant, parity, marital status, education, income, and how many days mothers breastfed their infant (if applicable) after birth, were evaluated using a sociodemographic questionnaire. Stressful Life Events. The 17-item Life Event Scale (LES; Sarason, Johnson and Siegel, 1978 ) was used to measure the number of significant stressful life events that occurred during pregnancy. The LES evaluates how many stressful life events (e.g., financial strain, partner strain, close family member hospitalized) occurred during the previous six months. Each item is rated as ‘no’ (score of 0) or ‘yes’ (score of 1) and all items are then summed (range = 0–17), with higher scores denoting experiencing more stressful life events. The LES has been well-validated for use among low-income ethnic minority women ( Norhayati et al., 2015 ; Tatevosyan et al., 2024 ; current study α = 0.71, English-speakers α = 0.66, Spanish-speakers α = 0.67). Resilience. The Brief Resilience Scale (BRS), which consists of six items, was used to measure resilience ( Smith et al., 2008 ). The BRS evaluates a person's capacity to recover or bounce back from stressful situations. Each item is scored on a 5-point scale, and all items are then summed and averaged (range = 1–5), with higher scores representing greater resilience. The BRS has shown good internal consistency and discriminant validity among ethnic minority populations and parents ( Karaman et al., 2019 ; Shah et al., 2018 ); current study α = 0.65, English-speakers α = 0.79, Spanish-speakers α = 0.61). Salivary Cortisol. Saliva samples were sent to an off-site laboratory for analysis (samples stored at −80 ° C after collection). After saliva samples were thawed and centrifuged, a time-resolved immunoassay with fluo-rescence detection was used to measure salivary cortisol levels in mothers and their infants. Each sample was analyzed twice and averaged. Variability within and between assays was less than 10 %. Once assayed, raw cortisol values (nmol/L) were used to calculate total cortisol (area under the curve; AUC) and diurnal cortisol slope. The values for both AUC and diurnal cortisol slope were then log transformed (log base 10) for statistical modeling. AUC (with respect to ground) was determined by applying the trapezoidal rule ( Pruessner et al., 2003 ), accounting for individual differences in participant collection times ( Scheyer and Urizar, 2016 ). Participant collection times were obtained from the personal digital PDA device and self-report survey that mothers used to record the times of their and their infant’s saliva collections. The PDA device’s time stamp was significantly correlated with the self-reported collection times across all study time points ( r = 0.61, p = .04). For mothers’ AUC, the following formula was used: AUC = [(Waking cort + 12 pm cort )/2 × Time elapsed between Waking and 12 pm] + [(12 pm cort + 4 pm cort )/2 × Time between 12 pm and 4 pm] + [(4 pm cort + 8 pm cort )/2 × Time between 4 pm and 8 pm]. For infants’ AUC, the 8 am and 8 pm cortisol values were averaged, accounting for individual collection times: AUC = [(8 am cort + 8 pm cort )/2 × Time between 8 am and 8 pm]. Larger values for AUC represent greater cortisol production throughout the day. Mothers’ and infants’ diurnal cortisol slope were determined by computing cortisol changes from the morning (i.e., waking for mothers, 8 am for infants) to 8 pm, accounting for individual collection times: Diurnal cortisol slope = [(8 pm cort – Waking cort )/Time elapsed between Waking and 8 pm]. Larger values represent a flatter diurnal cortisol slope, or a smaller drop in cortisol levels throughout the day. Previous findings have emphasized the importance of examining both AUC and diurnal cortisol slope as altered cortisol patterns (i.e., higher cortisol concentrations, flatter diurnal cortisol slope) have been associated with distinct adverse postnatal health outcomes for both mothers and their infants ( Castro-Quintas et al., 2024 ; D'Anna-Hernandez et al., 2012 ; Van den Bergh et al., 2020 ; Zijlmans et al., 2015 ). Obstetric Health Complications. An 11-item Medical Complication Index ( Urizar and Muñoz, 2011 ) was used to calculate the number of obstetric health complications experienced. This index included three prenatal health outcomes (i.e., preeclampsia, gestational diabetes, and/or anemia) and eight birth outcomes [i.e., preterm labor (<37 weeks), C-section delivery, very low or very high infant birth weight (less than 2499 g or more than 4000 g), low APGAR scores at 1 min (<7), breech birth, the need for infant oxygen resuscitation, an inpatient stay longer than 3 days, and/or other medical complications during pregnancy/childbirth (e.g., miscarriage, umbilical cord around the infant’s neck during birth)]. Each obstetric health outcome was assigned a score of 0 (not present) or 1 (present), determined by a review of maternal and infant medical records, for a total possible score between 0 and 11. Higher scores indicate more obstetric health complications experienced during pregnancy and childbirth. 2.5. Statistical analyses The few studies that have examined the effectiveness of prenatal CBSM interventions on reducing obstetric health complications and regulating infant cortisol have reported medium to large effect sizes ( d range = 0.53–1.80) with samples of 30–104 participants ( Bastani et al., 2006 ; Ghalehkhani Safat et al., 2018 ; Karamoozian and Askarizadeh, 2015 ; Puertas-Gonzalez et al., 2023 ; Urizar and Muñoz, 2011 ). Therefore, to make sure a sufficient sample size was acquired, an a priori power analysis was carried out using G*Power ( Erdfelder et al., 1996 ) to test our primary study aim (main effect analyses) of examining prenatal CBSM intervention effects on obstetric health complications and infant cortisol. It was conservatively estimated that a total sample size of 67 participants (for a medium effect size of 0.25) was needed in the current study to obtain statistical power to detect meaningful associations among study variables at the recommended.80 level. Of 100 participants, 96% had complete medical record data and 73% had infants with complete saliva samples at three months post partum (two participants had miscarriages, five were lost to contact, five no longer wanted to participate, and 15 mothers either had difficulty collecting sufficient saliva from their infants or had undetectable infant cortisol levels; see Fig. 1 for CONSORT statement). No randomization group differences for missing infant cortisol data were observed ( χ 2 = 0.95, p = .33), however, younger mothers in the study were more likely to have missing infant cortisol data compared to older mothers ( t = −2.37, p = .02). Participants with incomplete infant cortisol data did not differ from those with complete data on any other study characteristics or outcomes ( p > .05). No outliers for obstetric health complications or maternal or infant cortisol were identified, therefore, results represent 96 participants with obstetric health complications data and 73 participants with infant cortisol data. Fig. 1. Open in a new tab CONSORT Statement. Pearson’s chi-squared and independent samples t -tests were used to test for any differences between the CBSM and Control groups on baseline study characteristics ( Table 1 ). Pearson product-moment correlations and ANOVAs were used to detect potential covariates (i.e., ethnicity, maternal age, number of children, number of times pregnant, marital status, education, income, number of CBSM classes attended, infant gender, breastfeeding duration) on study outcomes. Ethnicity, maternal age, and number of children were significantly associated with obstetric health complications and/or infant cortisol outcomes (all p < .05) and were included as covariates in the main analyses. Table 1. Baseline sociodemographic, psychosocial, and salivary cortisol characteristics of low-income pregnant mothers in SMART Moms Program by group condition (CBSM versus Control Group). CBSM n = 55 Control Group n = 45 Sociodemographic Age [M (SE)] 26.3 (± 0.9) 26.8 (± 0.9) Number of weeks pregnant [M (SE)] 10.3 (± 0.6) 9.5 (± 0.6) Number of children [M (SE)] 1.2 (± 0.2) 1.4 (± 0.2) Number of previous pregnancies [M (SE)] 2.3 (± 0.2) 2.9 (± 0.3) High school education or less (%) 67.3 75.6 Annual family combined income < $20,000 (%) 79.6 71.1 Unemployed (%) 72.7 66.7 Single (%) 52.7 48.9 Latina (%) 69.1 72.7 Country of birth, Outside of US (%) 58.2 55.6 Female infant gender (%) 53.7 59.6 Number of days breastfed [M (SE)] 66.7 (± 5.5) 63.3 (± 6.6) Baseline psychosocial characteristics Number of stressful life events [M (SE)] 2.8 (± 0.3) 2.9 (± 0.4) Resilience [M (SE)] 3.2 (± 1.0) 3.4 (± 1.0) Baseline salivary cortisol levels Overall cortisol output (nmol/L) [M (SE)] 141.8 (± 7.0) 166.5 (± 16.8) Diurnal Cortisol Slope (nmol/L) [M (SE)] −1.9 (± 0.5) −1.2 (± 0.2) Baseline salivary cortisol collection times Waking [hour:minutes (minutes)] [M (SE)] * 8:10 (± 0:11) 7:36 (± 0:11) 12 pm [hour:minutes (minutes)] [M (SE)] 12:06 (± 0:02) 12:06 (± 0:03) 4 pm [hour:minutes (minutes)] [M (SE)] 4:07 (± 0:02) 4:10 (± 0:03) 8 pm [hour:minutes (minutes)] [M (SE)] 8:09 (± 0:03) 8:07 (± 0:02) Open in a new tab Note . Pearson’s χ 2 and Independent samples t tests were conducted to examine for between group differences among categorical and continuous variables, respectively. * p < .05 Mixed effect linear models were used to test CBSM vs. Control group differences in obstetric health complications and infant cortisol outcomes (AUC and diurnal cortisol slope), controlling for ethnicity, maternal age, and number of children. Mixed models were estimated by maximum likelihood using SAS PROC MIXED (SAS Institute, Cary, NC, USA). Cohen's d was used to report the effect sizes for these group effects. Additionally, exploratory mixed effect linear models were conducted to test for two-way interactions (i.e., randomization group by pre- and postnatal maternal cortisol, randomization group by stressful life events, randomization group by resilience) that could influence CBSM effects on obstetric health complications and infant cortisol, respectively (A Bonferroni correction was used to test for multiple comparisons; significant interaction terms were defined as p < .02). Group means for all significant effects were compared using the least-squares means method. 3. Results 3.1. Participant characteristics Mothers in the CBSM and control groups were similar on all baseline (sociodemographic, psychosocial, and salivary cortisol) characteristics (see Table 1 ; p > .05). At baseline, participants were approximately 10 weeks pregnant ( SD = 4.25; range = 2–17 weeks) and 27 years of age ( SD = 6.26; range = 18–40 years). In terms of ethnicity, 49% of mothers were foreign-born Latinas (77% from Mexico), 22% were U.S.-born Latinas, 18% were African American, 4% were Asian American, 4% were non-Hispanic white, and 3% were of mixed ethnicity. The majority of participants were single (51%), unemployed (70%), had a high school education or less (71%), and had a family income of less than $20,000 annually (76%). Further, they had been pregnant approximately three times (including the current pregnancy; M = 2.57, SD = 1.71), and most had at least one other child (63%, range = 0–5 children). Infants born during the study were mostly girls (57%) and were breastfed for approximately two months post partum ( M days = 65.22, SD = 37.43; range = 0–150 days). Approximately 76% of mothers experienced at least one major stressful life event (i.e., 39% financial strain, 27% housing instability, 24% conflicts with partner) and 71% had medium to high levels of resilience (BRS score ≥3; Smith et al., 2008 ) during pregnancy (<17 weeks pregnant). A majority of mothers in CBSM (76 % attended ≥ 4 classes; Mdn = 5 classes; range = 1–8 classes) and in the control group (82 % read ≥ 4 prenatal topics; Mdn = 8 topics; range = 0–8 topics) participated in over half of their respective programs. 3.2. Associations of sociodemographic, psychosocial, & cortisol factors on study outcomes Obstetric Health Complications. Approximately 67 % of mothers and their infants experienced at least one obstetric health complication ( M = 1.36, SD = 1.26, range = 0–4 health complications; e.g., 33% with a C-section delivery, 31% with an inpatient stay longer than three days, 18% with anemia, 13% with low infant birth weight). African American ( M = 2.06, SD = 1.30) and U.S.-born Latina mothers ( M = 1.77, SD = 1.34) experienced more obstetric health complications than foreign-born Latina ( M = 1.08, SD = 0.16), Asian American ( M = 0.75, SD = 1.50), and non-Hispanic white mothers ( M = 0.50, SD = 1.00), as shown in ANOVA analyses [ F (5, 91) = 2.97, p = .016, d = 0.81, CI .95 = 0.02, 0.24]. Further, older mothers experienced more obstetric health complications as indicated by Pearson correlations ( r = 0.20, p = .048). In terms of psychosocial factors, mothers experiencing more stressful life events during pregnancy had more obstetric health complications ( r = 0.21, p = .040). In contrast, mothers with higher levels of resilience during pregnancy had fewer health complications ( r = −0.21, p = .042). For maternal cortisol, neither AUC ( r = −0.09, p = .389) nor diurnal cortisol slope ( r = −0.01, p = .969) during the third trimester of pregnancy was associated with obstetric health complications. Infant Cortisol. On average, infants’ postpartum cortisol levels decreased from morning ( M = 32.62 nmol/L, SE = 8.37) to evening ( M = 12.83 nmol/L, SE = 1.67) and were mostly within the cortisol range reported in previous studies with infants (range = 5–28 nmol/L; Tollenaar et al., 2010 ). No significant group differences were found between mothers’ ethnicity and either infant AUC [ F (5, 68) = 0.76, p = .519] or infant diurnal cortisol slope [ F (5, 68) = 1.74, p = .167]. Similarly, maternal age was not significantly associated with infant cortisol ( r AUC = 0.22, p = .059; r DSlope = 0.08, p = .524). However, infants of mothers with a greater number of children had flatter diurnal cortisol patterns ( r DSlope = 0.25, p = .032; a similar association did not emerge with infant AUC, r AUC = 0.01, p = .908). For maternal psychosocial factors, neither stressful life events ( r AUC = 0.11, p = .364; r DSlope = 0.17, p = .163) nor resilience during pregnancy ( r AUC = 0.14, p = .256; rDSlope = 0.11, p = .373) were associated with infant cortisol. Similarly, maternal cortisol (AUC, diurnal slope) during the third trimester of pregnancy was not associated with infant cortisol ( r AUC = 0.13, p = .292; r DSlope = 0.12, p = .307). However, mothers with higher AUC at three months post partum had infants with higher AUC ( r AUC = 0.26, p = .025). Similarly, mothers with flatter diurnal cortisol patterns at three months post partum had infants with flatter diurnal cortisol patterns ( r DSlope = 0.28, p = .019). 3.3. CBSM intervention effects on obstetric health complications Mixed effect linear model analyses revealed that there was not a significant main effect of randomization group on obstetric health complications, controlling for ethnicity, maternal age, and number of children [ F (4, 92) = 1.46, p = .230, d = 0.26, CI .95 = −0.77, 0.19; see Fig. 2a ]. However, randomization group effects on obstetric health complications were shown to be influenced by maternal prenatal cortisol levels during the third trimester of pregnancy (significant two-way interaction). Specifically, CBSM was shown to be effective in reducing obstetric health complications among mothers with elevated prenatal cortisol levels, when compared to the control group [ F (7, 89) = 6.57, p = .012, d = 0.56, CI .95 = −0.39, 0.05; see Fig. 2b ]. No significant two-way interactions were found for randomization group on obstetric health complications by maternal diurnal slope during pregnancy [ t (7, 89) = −0.26, p = .797], ethnicity [ t (5, 91) = −1.14, p = .258], or psychosocial factors [ t Stressful Life Events (5, 91) = −0.49, p = .625; t Resilience (5, 91) = −1.37, p = .173]. Fig. 2. Open in a new tab Group Differences in Obstetric Health Complications for Low-Income Mothers Randomized to Prenatal Cognitive Behavioral Stress Management (CBSM) vs. Control Group. Note. Numbers represent means and standard errors for each randomization group (CBSM vs. control group), controlling for maternal ethnicity, age, & number of children. Cortisol values (Area Under the Curve; AUC) represent centered, continuous raw scores (nmol/L). 3.4. CBSM intervention effects on infant cortisol Infant AUC. Mixed effect linear model analyses revealed that there was not a significant main effect found for randomization group on infant AUC [ F (4, 69) = 0.17, p = .896, d = 0.13, CI .95 = −2.14, 1.87; see Fig. 3a ], controlling for ethnicity, maternal age, and number of children. However, randomization group effects on infant AUC were shown to be influenced by maternal cortisol levels at three months post partum (AUC; significant two-way interaction). Specifically, infants of mothers in CBSM demonstrated lower cortisol levels than infants of mothers in the control group if their mothers had elevated postpartum cortisol levels [ F (7, 66) = 4.68, p = .014, d = 0.52, CI .95 = −1.23, 0.05; see Fig. 3b ]. No significant two-way interactions were found for randomization group on infant AUC by maternal prenatal AUC [ t (7, 66) = −0.57, p = .570], ethnicity [ t (5, 68) = −1.24, p = .220], or psychosocial factors [ tStressful Life Events (6, 67) = −0.61, p = .546; tResilience (6, 67) = −0.67, p = .508]. Fig. 3. Open in a new tab Group Differences in Infant Cortisol Outcomes for Low-Income Mothers Randomized to Prenatal Cognitive Behavioral Stress Management (CBSM) vs. Control Group. Note. Numbers represent means and standard errors for each randomization group (CBSM vs. control group), controlling for maternal ethnicity, age, & number of children. Cortisol values (Area Under the Curve; AUC) represent raw scores (nmol/L). Infant Diurnal Cortisol Slope. Mixed effect linear model analyses revealed that there was not a significant main effect found for randomization group on infant diurnal cortisol slope [ F (4, 69) = 0.76, p = .387, d = 0.21, CI .95 = −0.21, 0.93; see Fig. 4a ], controlling for ethnicity, maternal age, and number of children. However, randomization group effects on infant diurnal cortisol slope were shown to differ by ethnicity (significant two-way interaction), with infants of African American mothers in CBSM showing a more normal (steeper) decline in their diurnal cortisol levels at three months post partum compared to infants of African American mothers in the control group [ F (6, 67) = 3.24, p = .011, d = 0.43, CI .95 = −2.85, −0.12; see Fig. 4b ]; these randomization group by ethnicity differences on infant diurnal cortisol slope were not observed among other ethnic groups (see Fig. 4c ). Fig. 4. Open in a new tab Diurnal Cortisol Slopes for Infants of Mothers Randomized to Cognitive Behavioral Stress Management (CBSM) vs. Control Group by Ethnicity, Maternal PostPartum Diurnal Cortisol, and Maternal Prenatal Stressful Life Events. Note. Numbers represent means and standard errors for each randomization group (CBSM vs. control group), controlling for maternal ethnicity, age, & number of children. Infant diurnal cortisol values represent raw scores (nmol/L). Higher prenatal stressful life events determined by median split. Randomization group effects on infant diurnal cortisol slope were also influenced by maternal diurnal cortisol slope, with infants of mothers in CBSM showing a steeper decline in their diurnal cortisol levels compared to infants of mothers in the control group if their mother also showed a steeper decline in her diurnal cortisol levels at three months post partum [ F (7, 66) = 6.08, p = .016, d = 0.61, CI .95 = 0.88, 1.18; see Fig. 4d ]; these effects were not significant for prenatal maternal diurnal cortisol [ t (7, 66) = −0.52, p = .605]. Finally, randomization group effects on infant diurnal cortisol slope were found to be influenced by maternal stressful life events experienced during pregnancy. Specifically, infants of mothers in CBSM showed a steeper decline in their diurnal cortisol levels compared to infants of mothers in the control group if their mother experienced more prenatal stressors [ F (6, 67) = 3.57, p = .007, d = 0.45, CI .95 = −0.89, −0.02; see Fig. 4e ]. No significant two-way interactions were found for randomization group on infant diurnal cortisol slope by resilience [ t (6, 67) = 0.23, p = .817]. 4. Discussion The primary aim of this randomized control study was to examine whether a prenatal CBSM intervention (SMART Moms Program), compared to a control group, was effective in reducing obstetric health complications and regulating infant postpartum cortisol patterns (i.e., lower total cortisol, steeper drop in diurnal cortisol) among low-income ethnic minority mothers and their infants. This study also explored whether maternal cortisol patterns and psychosocial factors moderated CBSM intervention effects on obstetric health outcomes and infant cortisol regulation. Although results showed no overall efficacy (main effects) for prenatal CBSM on reducing obstetric health complications and regulating infant cortisol, significant, hypothesis-generating, subgroup intervention effects were detected when taking into account maternal cortisol patterns, maternal stress levels, and ethnicity. 4.1. CBSM intervention effects on obstetric health complications Prenatal CBSM effects on reducing obstetric health complications were found for mothers who had elevated cortisol levels during their third trimester of pregnancy. These results are particularly noteworthy given that mothers’ cortisol levels during this crucial stage of pregnancy can significantly impact the fetus’s health. During the first two trimesters of pregnancy, the fetus is protected by an enzyme in the placenta (11β-HSD2) that converts excessive maternal cortisol to its inactive form (cortisone), thereby preventing the fetus from being exposed to high levels of cortisol ( Zhu et al., 2019 ). However, the activity of this enzyme decreases during the third trimester, resulting in the fetus being more susceptible to the effects of elevated maternal cortisol levels during this gestational period and increasing risk for preterm births and low infant birthweight ( Castro-Quintas et al., 2024 ; Zijlmans et al., 2015 ). Elevated maternal cortisol levels during the third trimester of pregnancy have especially been documented among low-income and ethnic minority families ( Thayer and Kuzawa, 2014 , 2015 ), those experiencing chronic stressors ( Rinne et al., 2023 ), and mothers with low resilience ( García-León et al., 2019 ) and may explain the higher rates of prenatal health and adverse birth outcomes found for these pregnancy subgroups (including African American and U.S.-born Latinas) in the current and previous studies ( Adegoke et al., 2022 ; Khalil et al., 2024 ; Larrabee Sonderlund et al., 2021 ; Mukherjee et al., 2017 ). Therefore, our CBSM findings have significant implications for improving health outcomes in these at-risk mothers and their infants and are consistent with past randomized control studies in Iran and Pakistan showing significantly reduced rates of C-section births, low infant birthweight, small for gestational age infants, and low infant APGAR scores for mothers receiving group-based (in-person) CBSM relative to mothers in a control group ( Bastani et al., 2006 ; Ghalehkhani Safat et al., 2018 ; Karamoozian and Askarizadeh, 2015 ; Siebach et al., 2024 ). However, more studies are required to identify the mechanisms (e.g., regulation of prenatal cortisol, increased resilience) by which specific CBSM coping and relaxation strategies may help to reduce obstetric birth complications in at-risk families. 4.2. CBSM intervention effects on infant cortisol This study is one of the few to examine prenatal CBSM intervention effects on postpartum infant cortisol. Interestingly, CBSM effects in regulating infant cortisol (i.e., lower total cortisol levels, steeper decline in diurnal cortisol) were found for infants of mothers who experienced more stress during pregnancy, infants of mothers with elevated cortisol at post partum, and infants of African American mothers, when compared to a control group. These findings are significant in that elevated maternal stress and cortisol levels during pregnancy and early post partum (sensitive developmental periods) could have health implications for infants. These include alterations in infants’ biological stress response and cortisol activity that can result in emotional and cognitive problems later in childhood ( Buhler-Wassmann and Hibel, 2021 ; Hodyl et al., 2017 ; Zijlmans et al., 2015 ) and future chronic disease risk (e.g., cardiovascular disease, major depression; Belsky et al., 2015 ; Gump et al., 2023 ). Ethnic minority mothers experiencing major stressors (e.g., housing instability, food insecurity, structural racism) have especially shown more elevated and dysregulated cortisol patterns at post partum, with their infants already showing similar cortisol patterns ( Blair et al., 2013 ; Dismukes et al., 2018 ; Saridjan et al., 2010 ; Tarullo et al., 2020 ). This cortisol pattern synchronicity between mothers and infants was observed in the current study, with both showing elevated and flatter postpartum cortisol patterns. The prenatal CBSM intervention seemed to counteract these effects, with mothers in CBSM showing more regulated postpartum diurnal cortisol patterns compared to mothers in the control group ( Urizar et al., 2019a ) and their infants also showing more regulated diurnal cortisol patterns (i.e., steeper decline in cortisol across the day), particularly among African American families (with medium effect sizes, d = 0.43–0.61). The finding that CBSM only benefitted infants of African American mothers should be interpreted with caution, given the small ethnicity subgroup sample sizes, highlighting the need for additional studies to examine CBSM effects on infant cortisol patterns by ethnicity. Nevertheless, these CBSM effects on infant cortisol are promising and are important for promoting developmental outcomes and reducing health inequities in at-risk families. This study is the first to our knowledge to demonstrate the long-term effects of prenatal CBSM on regulating infant postpartum diurnal cortisol levels. Previous research has indicated that prenatal interventions can reduce total infant cortisol output at birth or six months postpartum ( Puertas-Gonzalez et al., 2023 ; Urizar and Muñoz, 2011 ), but they have not shown effects on diurnal cortisol regulation. These prenatal intervention effects on infant cortisol may be attributed to mothers in CBSM shifting from higher to lower perceived stress over time compared to mothers in the control group ( Urizar et al., 2019a ), suggesting that CBSM mothers likely continued to utilize coping and relaxation skills to manage their stress and adapt to their parenting responsibilities. Further research is required to investigate potential pathways by which prenatal CBSM strategies might help regulate infant diurnal cortisol patterns post partum (e.g., specific CBSM skills, increased maternal sensitivity; Buhler-Wassmann and Hibel, 2021 ). 4.3. Study limitations & strengths The current study presents several notable limitations and strengths that warrant discussion. First, although our results showed that 67% of families in our sample experienced at least one obstetric health complication (e.g., 33% with a C-section delivery, 13% with low infant birth weight), women experiencing high-risk pregnancies (e.g., preexisting diabetes) were excluded from this study. As a result, our findings may not apply to pregnant mothers and their infants who might be most vulnerable to adverse prenatal health and birth outcomes. More research is required to determine whether CBSM has an impact on obstetric health outcomes in this population. Second, the obstetric health complications index used in this study consisted of a mix of prenatal health and birth outcomes, thus making it difficult to discern which specific health outcomes were impacted by CBSM. These outcomes have different etiologies and risk factors, so collapsing them into one score may obscure meaningful clinical distinctions and artificially increase statistical power, potentially explaining some of our interaction effects. Although prior randomized control studies have used similar health indices ( Bastani et al., 2006 ; Ghalehkhani Safat et al., 2018 , Urizar and Muñoz, 2011 ), larger sample sizes are required to examine CBSM effects on specific obstetric health outcomes. Third, although the measure used in this study to assess major stressful life events (Life Events Scale) has been well-validated for use in pregnant populations ( Norhayati et al., 2015 ; Tatevosyan et al., 2024 ), it did not include chronic stressors (e.g., racial discrimination, acculturation stress) that have been associated with obstetric health complications and cortisol dysregulation among ethnic minority families ( D'Anna-Hernandez et al., 2012 ; Dismukes et al., 2018 ). Therefore, additional studies are needed that examine how these unique chronic stressors may influence CBSM effects on reducing obstetric health complications and regulating infant cortisol patterns in this population. Finally, maternal and infant salivary cortisol were assessed on one collection day at each study timepoint and, thus, could have been affected by several factors (e.g., infant sleep and feeding schedule) as infant cortisol is particularly variable day-to-day, thereby reducing reliability. Although saliva samples should ideally be taken over several days to capture stable diurnal cortisol patterns ( Ryan et al., 2016 ), findings from randomized control studies with low-income ethnic minority mothers and infants have shown that high adherence rates to saliva collection instructions (98% adherence rates in current study; Urizar et al., 2019a ) and reliable diurnal cortisol patterns can be obtained with one collection day ( Urizar, 2023 ). This flexibility in saliva collection protocols has been shown to help mitigate barriers to participation in salivary bioscience studies by traditionally difficult-to-recruit, underrepresented populations ( Kuhlman et al., 2019 ). In particular, our results indicate that younger mothers, compared to older mothers, may struggle in collecting their infant’s salivary cortisol samples due to competing time demands or misunderstanding the saliva collection protocol, requiring additional efforts by research teams to modify protocols to increase representation of this subsample of mothers who may be experiencing unique stressors. To enhance the reliability of infant cortisol samples in these subgroups of underrepresented mothers, studies are needed that examine CBSM effects on infant cortisol patterns across multiple time points, which would help increase reliability by pooling infant cortisol samples across time. The study’s strengths include its representation of low-income and ethnic minority mothers and their infants (76% earning less than $20,000 per year; 71% Latina, 18% African American) who are most at risk for obstetric health implications and dysregulated cortisol patterns. Second, this study demonstrated strong retention and participation rates (88%−96%) despite the obstacles and conflicting time demands that low-income pregnant women may encounter (e.g., lack of transportation, child care). Finally, to the best of our knowledge, this is the first randomized control study to investigate whether maternal pre- and postnatal cortisol patterns and psychosocial factors (i.e., major stressful life events, resilience) influence prenatal CBSM intervention effects on obstetric health complications and infant cortisol patterns. 4.4. Conclusions and implications In sum, these results imply that learning CBSM skills during pregnancy can effectively lower one’s risk for obstetric health complications and lead to more regulated infant cortisol patterns after birth, particularly for mothers who experience elevated stress and cortisol levels and for African American families. These intervention effects may be due to regulation of pre- and postnatal maternal cortisol levels, as well as mothers’ continued use of CBSM skills they learned while pregnant, resulting in positive postpartum health outcomes. Still, more research is required to identify the processes (e.g., implementation fidelity, specific CBSM skills, social support, maternal sensitivity) by which these interventions work to effectively disseminate them across specific healthcare settings and populations. These findings have important implications for reducing stress-related health outcomes (e.g., preterm births) among low-income ethnic minority families, as fewer than 25% of mothers indicate that they participate in CBSM skills (e.g., diaphragmatic breathing) to manage their stress while pregnant ( Birdee et al., 2014 ; Urizar et al., 2023 ). Therefore, community-based prenatal CBSM interventions (that teach mothers coping and relaxation skills) are needed to help mitigate the detrimental health impact that chronic stress and dysregulated cortisol patterns can have for mothers and their infants. SMART Moms provides a manualized prenatal CBSM program for prenatal health care providers (e.g., community health workers, social workers) to implement with English- and Spanish-speaking mothers in settings where they are already receiving their prenatal care (e.g., community prenatal clinics, home visitation programs). These settings can help to provide safe spaces and support for low-income ethnic minority mothers to discuss their prenatal experiences (e.g., unconscious biases in healthcare, housing issues, financial strain, violence, family trauma, Black Superwoman Syndrome; Parks and Hayman, 2024 ). This community-centered approach was shown to be successful in the recruitment of mothers for the current study ( Urizar et al., 2019a ) and in a dissemination study of the SMART Moms Program (taught by social workers) that demonstrated improved mental health (i.e., stress, depression, anxiety) and developmental (i.e., prosocial behaviors) outcomes for African American mothers and their children, respectively ( Urizar et al., 2021 ). These community settings and partnerships are ideal as they help reduce barriers to participation in such programs (e.g., transportation, language barriers, childcare, experiences with racism) and are in line with the USPSTF’s guidelines to adopt a collaborative approach to healthcare that makes it easier for prenatal care providers to connect their patients to stress management programs ( Siu et al., 2016 ). This collaborative care approach also fosters trust for low-income ethnic minority women to engage in CBSM research that includes the collection of biological samples to test the intervention’s effectiveness in regulating biomarkers of health ( Kuhlman et al., 2019 ). Despite our findings, more research is needed to test how to make prenatal CBSM interventions accessible to mothers experiencing obstacles to receiving prenatal care (e.g., working mothers, those without transportation) and how to tailor CBSM content and instructional approaches to match the cultural experiences of mothers. In conclusion, our results indicate the need to implement empirically supported CBSM programs in prenatal settings to improve the health of low-income ethnic minority mothers and their infants. Acknowledgments This study was conducted as part of a collaboration between the Partners in Research and Outreach for Health (PRO-Health) Research Program (Guido G. Urizar Jr., Director), St. Mary Medical Center, and the Black Infant Health Program at the Long Beach Department of Health and Human Services (Gwen Manning, Director). Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number SC2HD068878 (Guido G. Urizar Jr., PI). Additional support was provided by grants from the National Institutes of Health and the National Science Foundation under Award Numbers: 1 R16 GM145482 and NSF 21-542 (Guido G. Urizar Jr., PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors gratefully acknowledge the contributions of the PRO-Health Research Program for their instrumental support in data collection. Footnotes CRediT authorship contribution statement Ruby Barragan: Writing – review & editing, Writing – original draft. Guido Urizar: Writing – review & editing, Writing – original draft, Supervision, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Ilona Yim: Writing – review & editing, Resources, Methodology, Investigation, Funding acquisition, Formal analysis, Conceptualization. Angela Dixon-Hamlett: Writing – review & editing, Resources. Jacob Nguyen: Writing – review & editing, Writing – original draft. Gwendolyn Manning: Writing – review & editing, Resources, Investigation. Declaration of Competing Interest The authors declare that there are no conflicts of interest. References ACOG) Committee on Health Care for Underserved Women (2006). Psychosocial risk factors: Perinatal screening and intervention. Obstetrics & Gynecology, 108(2), 469–477. 10.1097/00006250-200608000-00046. [ DOI ] [ PubMed ] [ Google Scholar ] Adegoke TM, Pinder LF, Ndiwane N, Parker SE, Vragovic O, Yarrington CD, 2022. 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