Resilience During Pregnancy: How Early Life Experiences are Associated with Pregnancy-Specific Stress

Abstract

High levels of maternal pregnancy–specific stress are associated with an increased risk for adverse birth outcomes as well as anxiety and depression symptoms during and following pregnancy. There is evidence that early childhood experiences play an important role in maternal psychological health and well-being and may be important for shaping maternal vulnerability to pregnancy-specific stress. The current study examined the link between both maternal adverse childhood experiences (ACEs) and protective and compensatory experiences (PACEs) and pregnancy-specific stress and considered the mediating and moderating roles of resilience on these associations. Data came from a high-risk clinic cohort of 138 racially diverse pregnant women (ages 16–38). We found that resilience mediated the associations between PACEs and pregnancy-specific stress and moderated the association between ACEs and pregnancy-specific stress. In particular, high levels of resilience were protective against pregnancy-specific stress at low and moderate levels of ACEs. The findings highlight the importance of early childhood experiences on women’s well-being during pregnancy and demonstrate how both ACEs and PACEs contribute to and are protected by resilience.

Full text

ORIGINAL ARTICLE
Resilience During Pregnancy: How Early Life Experiences
are Associated with Pregnancy-Specific Stress
Mira Armans
1
&Samantha Addante
1
&Lucia Ciciolla
1
&Machele Anderson
2
&Karina M. Shreffler
2
Accepted: 18 September 2020
#Springer Nature Switzerland AG 2020
Abstract
High levels of maternal pregnancy–specific stress are associated with an increased risk for adverse birth outcomes as well as
anxiety and depression symptoms during and following pregnancy. There is evidence that early childhood experiences play an
important role in maternal psychological health and well-being and may be important for shaping maternal vulnerability to
pregnancy-specific stress. The current study examined the link between both maternal adverse childhood experiences (ACEs)
and protective and compensatory experiences (PACEs) and pregnancy-specific stress and considered the mediating and moder-
ating roles of resilience on these associations. Data came from a high-risk clinic cohort of 138 racially diverse pregnant women
(ages 16–38). We found that resilience mediated the associations between PACEs and pregnancy-specific stress and moderated
the association between ACEs and pregnancy-specific stress. In particular, high levels of resilience were protective against
pregnancy-specific stress at low and moderate levels of ACEs. The findings highlight the importance of early childhood
experiences on women’s well-being during pregnancy and demonstrate how both ACEs and PACEs contribute to and are
protected by resilience.
Keywords Pregnancy stress .ACEs .PACEs .Adversity .Resilience .Childhood experiences
Pregnancy is a major life event associated with physiological
and psychological changes, including heightened levels of
stress for many women (Glynn et al., 2004). High levels of
stress during pregnancy have been associated with adverse
perinatal outcomes for mothers and infants (Copper et al.,
1996; Davis et al., 2005;Doleetal.,2003; Hedegaard et al.,
1996; Hoffman & Hatch, 1996). Therefore, it is imperative to
identify potential risks as well as protective factors that may
ameliorate stress levels and contribute to pregnant women’s
health and well-being (Dunkel Schetter & Tanner, 2012).
Recent research has demonstrated a positive link between ad-
verse childhood experiences (ACEs) and increased rates of
stress and stress-related difficulties (Manyema et al., 2018),
but less is known about the impact of ACEs on pregnancy-
specific stress. Moreover, to our knowledge, studies have not
yet examined whether protective and compensatory experi-
ences (PACEs) during childhood contribute to lower stress
in adulthood. Finally, we explore the role of individual resil-
ience to explain how childhood experiences are associated
with women’s pregnancy-specific stress. Understanding how
childhood experiences contribute to women’swell-beingdur-
ing pregnancy offers the potential for informing intervention
and prevention efforts designed to promote maternal and child
health and well-being. There is, therefore, a crucial need to
explore the relationships between exposure to both adverse
and protective early life experiences, resilience in adulthood,
and stress among pregnant women.
Pregnancy-Specific Stress
Women commonly experience a wide range of adaptations
during pregnancy, such as changes in psychosocial and bio-
logical processes, which may be stressful during the course of
pregnancy (Dunkel Schetter & Tanner, 2012). A number of
stressors may arise during pregnancy related to the
*Karina M. Shreffler
karina.shreffler@okstate.edu
1
Department of Psychology, Oklahoma State University,
Stillwater, OK, USA
2
Department of Human Development and Family Science, Oklahoma
State University, 700 N. Greenwood Ave., Tulsa, OK 74106, USA
https://doi.org/10.1007/s42844-020-00017-3
/ Published online: 8 October 2020
Adversity and Resilience Science (2020) 1:295–305

management or significance of physical symptoms, bodily
changes, parenting apprehensions, relationship tension, labor
and delivery procedures, and the baby’swell-being(Guardino
& Dunkel Schetter, 2014; Hamilton & Lobel, 2008; Misra
et al., 2010). Stressors that account for maternal perceptions
and appraisals of personal and environmental circumstances
in relation to pregnancy are conceptualized as pregnancy-
specific stress (also labeled pregnancy-specific distress or
pregnancy anxiety) (Lobel, 1994). Pregnancy-specific stress
is also thought of as an interaction between a woman’sgeneral
predisposition toward anxious affective states and the condi-
tions and complications of her pregnancy (Guardino &
Dunkel Schetter, 2014). Although it may be adaptive to expe-
rience some degree of stress during pregnancy, as it may en-
courage women to be cautious and take steps to protect their
pregnancies (Guardino & Dunkel Schetter, 2014), when ma-
ternal perception of stress becomes impairing and unmanage-
able, it can quickly turn into distress, which has been linked
with a number of negative outcomes (Wheaton & Montazer,
2010).
A number of previous studies have suggested deleterious
effects of stress during pregnancy on maternal and child
health, demonstrating that prenatal stress increases maternal
vulnerability to anxiety and depression symptoms during and
following pregnancy as well as infant susceptibility to fetal
distress and congenital malformations (Andersson et al.,
2006; Dunkel Schetter & Tanner, 2012). Stress during preg-
nancy produces these harmful effects through neuroendocrine,
immune, cardiovascular, metabolic, and behavioral mecha-
nisms (Dunkel Schetter, 2011; Lobel and Dunkel-Schetter,
2016). Further, stress during pregnancy is particularly impor-
tant because changes in perception of stress during pregnancy
may cue chronically elevated levels of stress in future years
through these pathways. Indeed, Monk and colleagues (2018)
found that perceived maternal stress during pregnancy was
independently associated with higher stress levels several
years later. Yet some previous studies found small or no neg-
ative effects of stress on perinatal outcomes, though this may
be a function of the magnitude or types of perceived stress
among sample participants or sample demographic character-
istics (i.e., there may be a stronger link between stress and
adverse perinatal outcomes among women who identify as
racial/ethnic minority group members) (Littleton et al.,
2010). Thus, collectively these findings suggest the impor-
tance of investigating which types of stressors during preg-
nancy are most impactful.
A wide range of stressors occur during pregnancy and have
implications for adverse perinatal outcomes; however, re-
searchers have concluded that pregnancy-specific stress is as-
sociated with distinct and independent outcomes compared
and global stress (Alderdice et al., 2012). Global stress, also
known as general stress or stress nonspecific to pregnancy,
such as daily hassles, is likely to cooccur with pregnancy-
specific stress; however, pregnancy-specific stress captures a
unique form of stress that women experience during pregnan-
cy (Lobel et al., 2008; Dunkel Schetter & Glynn, 2011).
Pregnancy-specific stress seems to be a particularly potent
form of stress for pregnant women, as it more reliably predicts
preterm birth compared with global stress (Dunkel Schetter &
Glynn, 2011). For example, Roesch et al. (2004)demonstrat-
ed that pregnancy anxiety was associated with earlier birth,
while general state anxiety, general perceived stress, and life
events was not. Further, Kramer et al. (2009) found that
pregnancy anxiety was the only significant predictor of
preterm birth among a large sample of Canadian pregnant
women. Pregnancy-specific stress is argued to be especially
potent because it elicits greater physiological arousal through
neuroendocrine, immune, cardiovascular, metabolic, and be-
havioral pathways, and women may lack coping strategies to
manage this new type of stressor (DiPietro et al., 2002,2004;
Dunkel Schetter, 2011; Huizink et al., 2004; Lobel and
Dunkel-Schetter, 2016).
Additionally, the stress of pregnancy may be exacerbated
by cooccurring stressors. For example, women who are youn-
ger, at high risk for obstetric complications, experiencing on-
going chronic stressors, of racial/ethnic minority group mem-
bership, of lower socioeconomic status, and those experienc-
ing their first time or unplanned pregnancy demonstrate higher
pregnancy-specific stress (e.g., Asghari et al., 2016; Auerbach
et al., 2014,2017). In addition to cooccurring stressors, early
life experiences are relevant for pregnancy-related outcomes
and perinatal well-being (see Olsen, 2018 for a review). It is
critical, therefore, to examine the development of pregnancy-
specific stress, including factors that contribute to, or protect
against, experiencing higher levels of pregnancy-specific
stress.
EarlyLifeExperiences
The life course perspective as well as the theory of allostatic
load provide a comprehensive theoretical framework for un-
derstanding how early life experiences may influence health
outcomes and general well-being. Chronic and repeated stress
at an early age, such that occurs with adverse childhood ex-
periences (ACEs) (Danese et al., 2009), disrupt healthy bio-
logical, neurological, and psychological development, includ-
ing dysregulation of the stress response system, thereby in-
creasing physiological “wear and tear”and hindering the ac-
quisition of healthy coping strategies in the face of adversity,
ultimately placing individuals at greater risk for psychological
and physical health problems (Danese et al., 2009;Jaffee&
Christian, 2014; Nemeroff, 2004; Nurius et al., 2015).
Alternatively, emerging research suggests there might be
equally significant protective childhood experiences that mit-
igate the effects of adversity. There is a lack of a unified
296 ADV RES SCI (2020) 1:295–305

assessment tool for examining positive childhood experi-
ences, unlike the ACEs survey which has been widely used
to assess for negative childhood experiences. The Protective
and Compensatory Experiences (PACEs) scale (Hays-Grudo
&Morris,2020) has been introduced to assess the strengths
and availability of positive childhood experiences. Consistent
with the developmental literature, experiences such as having
access to a safe and loving caregiver, close friends, a stable
home environment, and community opportunities (e.g., social
clubs and educational resources) have been found to be pro-
motive of favorable health outcomes that extend into adult-
hood (Masten, 2001;Morrisetal.,2014;Wrightetal.,2013).
Specifically, early social interactions such as secure attach-
ment with caregivers, relationships with peers, teachers, and
supportive adults have been shown to promote feelings of
safety and security and lay the foundation for later positive
relational experiences (Hays-Grudo & Morris, 2020;Sroufe,
2000;Sroufe,2005).
Childhood Experiences and Pregnancy
Early life experiences, both negative and positive, have sig-
nificant implications for health and well-being during preg-
nancy. Women with a history of childhood adversity are at
greater risk for complications during and following pregnan-
cy, including low birth weight and preterm birth, alcohol use
and smoking during pregnancy, and psychological risk (e.g.,
depression, anxiety, stress) (Chung et al., 2010;Hillisetal.,
2004;Hudziak,2018; Racine et al., 2018). Thomas et al.
(2018) found women with a history of four or more ACEs to
have altered HPA (hypothalamic-pituitary-adrenal) axis func-
tioning (e.g., 2.5 times higher awakening cortisol levels) dur-
ing pregnancy than those who reported none. To date, much of
the psychological literature has focused on the dose-response
association between ACEs and depressive symptoms during
and following pregnancy (Ångerud et al., 2018; Chung et al.,
2008), whereas no studies have examined the associations
between ACEs and pregnancy-specific stress. However, the
“wear and tear”process of ACEs (e.g., altered HPA function-
ing) and the hindering of the acquisition of healthy coping
strategies in the face of adversity, may exacerbate
pregnancy-specific stress, especially among women with lack
of adequate resources. Thus, it is critical to expand the litera-
ture on ACEs to include impact on pregnancy-specific stress
due to the risks for adverse maternal and child health out-
comes that are due to exposure to increased physiological
arousal during childhood (Alderdice et al., 2012;Lieberman
et al., 2009; Narayan et al., 2016; Narayan et al., 2017).
Similarly, PACEs might also be critically important during
pregnancy, as pregnant women begin to shape and organize
their expectations for parenthood based on recollection of ear-
ly life experiences (Lieberman et al., 2009; Narayan et al.,
2016; Narayan et al., 2017). Protective childhood experiences
may be particularly important to buffer the impacts of child-
hood adversity. For example, Carroll and colleagues (2013)
found parental warmth to buffer the negative impact of child-
hood abuse on allostatic load during young and middle
adulthood. Chung et al. (2008) found positive influences in
childhood to buffer the risk for depressive symptoms during
pregnancy among a sample of African American, low-income
women with a history of ACEs. Similarly, Narayan et al.
(2017) found that higher benevolent childhood experiences
predicted lower levels of psychopathology and stress above
and beyond the effects of ACEs in a sample of ethnically
diverse, low-income pregnancy women. These studies high-
light how protective early life experiences might mitigate the
negative consequences of ACEs for women during
pregnancy.
Resilience
In addition to directly buffering the impact of ACEs on
pregnancy-related outcomes, PACEs may protect against the
negative effects of ACEs through the promotion of resilience
and resilient functioning (Masten, 2001; Wright et al., 2013).
Resilience, at its most basic meaning, refers to the ability to
bounce back or recover from threats and return to a previous
level of functioning in spite of adversity (Masten, 2001;
Wright et al., 2013). Having positive relationships with family
and peers and strong connections to adults are among the top
factors that promote resilient functioning among the general
population (Burt and Paysnick, 2012). Though research on the
direct link between PACEs and adulthood resilience is scant,
Bradley et al. (2013) found that a positive childhood family
environment (e.g., warmth) predicted resilience within a large
African-American adult sample (Bradley et al., 2013).
The concept of resilience has been defined in numerous
ways, including utilizing effective coping, adjusting to chang-
es in the environment, and not developing illness in the face of
adversity (Dunkle Schetter and Dolbier, 2011; Tusaie and
Dyer, 2004). A growing body of literature suggests that de-
spite lacking a uniform conceptualization and measurement,
resilience is associated with favorable maternal and infant
health outcomes (Chung et al., 2008;Lietal.,2016;
Narayan et al., 2017). Of particular relevance for the current
study, resilience may buffer the negative impacts of childhood
adversity among pregnant women; Young-Wolf and col-
leagues (2019) found that among pregnant women, higher
ACE scores were associated with poorer mental health out-
comes (e.g., anxiety, depression) only among those with low
levels of resilience. Further, a study that examined the associ-
ations between pregnancy-specific stress, resilience, and sleep
quality demonstrated that resilience was a protective factor for
sleep quality (Li et al., 2016). These findings suggest that
297ADV RES SCI (2020) 1:295–305

resilience may attenuate the negative impacts of childhood
adversity for pregnant women.
Although no studies to our knowledge have examined re-
silience as it directly relates to the relationship between early
life experiences and pregnancy-specific stress, resilience may
explain or moderate this association, because higher levels of
resilience are associated with healthier functioning (or less
disruptions in functioning) strategies in the face of stress
(Chung et al., 2008;Lietal.,2016; Narayan et al., 2017). In
sum, resilience may be especially salient for pregnant women
experiencing pregnancy-specific stress. An examination of the
mediating and moderating roles of resilience is needed given
the limited attention this research has received to-date in the
literature.
Current Study
The current study examined the direct effects of ACEs and
PACEs on pregnancy-specific stress as well as the mecha-
nisms through which resilience may be a protective factor in
a clinic-based cohort sample of pregnant women. We hypoth-
esized that exposure to more ACEs is associated with higher
levels of pregnancy-specific stress, whereas exposure to more
PACEs is associated with lower levels of pregnancy-specific
stress. To better understand the role of resilience, tests of
moderation and mediation were examined. We hypothesized
that resilience moderates the association between ACEs and
pregnancy-specific stress such that the relationship between
ACEs and pregnancy-specific stress is weaker at higher levels
of resilience. Additionally, resilience was examined as a pos-
sible mediator between PACEs and pregnancy-specific stress.
We hypothesized that resilience mediates or explains the as-
sociation between PACEs and pregnancy-specific stress;
more protective early life experiences are expected to be as-
sociated with higher resilience in adulthood, which in turn is
expected to be associated with lower levels of pregnancy-
specific stress.
Methods
Study Sample
Data for the current study are from an ongoing clinic-based
cohort study involving 177 pregnant women (ages 16–38)
recruited from two university-affiliated perinatal clinics in a
metropolitan area in a South-Central US state. The focus of
the larger study is maternal early life experiences and adverse
birth outcomes, and the first wave of data collection occurred
in 2017–2018. The clinics serve a racially diverse, socioeco-
nomically disadvantaged, and medically underserved patient
population. The sample for the current study was restricted to
the 138 participants who responded to the first and third sur-
vey waves, conducted in the first and third trimesters of preg-
nancy. All variables for the current study were assessed in the
first wave. The study received approval from the authors’
university Institutional Review Board. All participants provid-
ed written informed consent, and participants younger than 18
provided written assent and their parents provided consent.
Measures
The Prenatal Distress Questionnaire (PDQ) (Yali and Lobel,
1999) was used to measure the dependent variable,
pregnancy-specific stress, and is the only variable in the study
drawn from the third survey wave. The PDQ is a 12-item self-
reported assessment of concerns and worries associated with
pregnancy including medical problems, physical symptoms,
parenting, relationships, bodily changes, labor and delivery,
and the health of the baby, and has good internal reliability
and validity (Alderdice and Lynn, 2011). Items were rated on
a 5-point scale ranging from 0 (not at all) to 4 (extremely), and
were summed. Items include “I worry about having an un-
healthy baby”and “physical symptoms of pregnancy such as
nausea, vomiting, swollen feet, or backaches irritate me.”
Although the PDQ average score in the current sample (M=
18.79) is higher than other studies that used the PDQ (M=
15.1; Lynn et al., 2011;M= 14.8; Pluess et al., 2010), these
studies examined pregnancy-specific stress among low-risk
mothers, while this sample is characterized as high-risk. In
the current sample, Cronbach’s alpha is 0.84.
Early life experiences are the primary independent vari-
ables in the study. Adverse childhood experiences (ACEs)
were coded as a sum of 10 items of childhood adversity that
include questions about physical and emotional abuse and
neglect as well as household dysfunction, with scores ranging
from 0 (no adverse childhood experiences) to 10 (Felitti et al.,
1998). Although the ACE scores in the current sample (aver-
age = 3) are nearly twice as high as the national average (1.57)
(Merrick et al., 2018), this is reflective of the sample popula-
tion, which is predominately nonWhite and low income.
Similar ACE scores have been noted in other samples of dis-
advantaged pregnant women (e.g., Howell et al., 2020).
Protective and compensatory experiences (PACEs) were also
coded as a sum of 10 items reflecting protective experiences
including being loved unconditionally, having a safe and
clean home, having enough food to eat, and having prosocial
relationships with peers and adults (Hays-Grudo and Morris,
2020).
Resilience was measured using the Brief Resilience Scale
(BRS) (Smith et al., 2008). The BRS is a six-item scale mea-
suring the ability to bounce back or recover from stress (e.g.,
“I tend to bounce back quickly after hard times,”“It does not
take me long to recover from a stressful event,”“It is hard for
me to snap back when something bad happens”), and scores
298 ADV RES SCI (2020) 1:295–305

are coded or reverse coded on a 5-point Likert scale from 1
(strongly disagree) to 5 (strongly agree) with higher scores
indicating higher resilience. The Cronbach’s alpha in our
study was 0.71.
Several control variables were also examined in relation to
pregnancy-specific stress, early life experiences, and resil-
ience that have known associations to the variables of interest.
Age and education were included as continuous variable indi-
cating years. Unplanned pregnancy was assessed by a ques-
tion asking participants, “Was this pregnancy unplanned?”
with responses coded as 0 = no and 1 = yes. Those who indi-
cated they lived in a marriage or cohabiting union were coded
as 1, with those not in a union coded as 0. Race/ethnicity was
assessed using the two standard census questions. Due to
small cell counts in minority groups, dummy variables were
constructed for Black, Hispanic, and Native American as
compared with White. Only a few respondents indicating an
“other”race/ethnicity, and they were excluded from analyses.
Overview of Analyses
First, descriptive statistics and bivariate associations were cal-
culated for all variables. Second, structural equation modeling
was utilizedto construct the simultaneous mediating and mod-
erating role of resilience. Specifically, resilience was exam-
ined as a mediator in the association between PACEs and
pregnancy-specific stress, and as a moderator in the link be-
tween ACEs and pregnancy-specific stress. The model con-
trolled for (included as covariates) additional demographic
variables including age, race, education level, the presence
of a partner in the home, and whether the pregnancy was
unplanned. Simple slopes were constructed and examined
for moderation analyses. Missing data was handled through
Mplus using maximum likelihood (ML) modeling.
Results
Means and standard deviations for all variables appear in
Table 1, along with maximum and minimum values for each
variable. The average pregnancy-specific stress score was
18.79, which is near the midpoint of the range (2 to 44). On
average, participants reported nearly three (M=2.54) ACEs
and more than seven (M= 7.03) PACEs. The percentage of
participants endorsing individual ACEs and PACEs items
were examined. The most frequently endorsed ACEs items
were ones related to parents separated/divorced (48.6%), ver-
bal abuse (39%), emotional neglect (28%), and physical abuse
(27.7%). The most frequently endorsed PACEs items were
having a best friend (84.7%), living in a typically clean and
safe home (81.8%), and having someone who unconditionally
loved them (81.1%). Least frequently endorsed ACEs includ-
ed having a household member in prison (13%) and sexual
abuse (16.4%). Least frequently endorsed PACEs items were
having a hobby (43.7%) and engaging in service to help others
(52.8%). Participants reported moderate levels of resilience,
on average (M= 12.795). On average, participants were
25 years old and had a high school diploma. More than a third
(35.0%) reported their pregnancies were unplanned, and
46.3% were married or cohabiting. The sample was diverse,
with 39.5% of participants reporting their race/ethnicity as
White; 28.2% as Black, 13.6% as Hispanic, and 17.5% as
Native American.
Simple correlations among the variables appear in Table 2
and show statistical significance among conceptually related
variables. Pregnancy-specific stress was associated in the ex-
pected directions with ACEs (r=0.27,p< 0.01), PACEs (r=
−0.28, p< 0.01), and resilience (r=−0.51, p< 0.01). Only
PACEs was significantly correlated with resilience (r=0.18,
p< 0.05). ACEs and PACEs were not correlated with each
other. To further investigate the cooccurrence of ACEs and
PACEs, the association between ACEs and PACEs levels was
examined and depicted in Fig. 1. Results indicated that 2.5%
reported high ACEs (4+ items endorsed) and low PACEs (0–4
items endorsed), whereas 17% reported high ACEs and high
PACEs (8–10 items endorsed). Interestingly, 25% endorsed
low ACEs and high PACEs, while 8% endorsed low ACEs
and low PACEs.
Structural equation modeling was utilized using Mplus 8.0
(Muthén and Muthén, 1998-2017) to simultaneously and
comprehensively examine the mediating and moderating roles
of resilience. Specifically, resilience was examined as a medi-
ating variable in the association between PACEs and
pregnancy-specific stress, and as a moderating variable in
the association between ACEs and pregnancy-specific stress.
Table 1 Descriptive statistics of study variables (n=138)
M/ % SD Min Max
Pregnancy-specific stress 18.79 7.27 2 44
Early life experiences
ACEs 2.54 2.75 0 10
PACEs 7.03 2.92 0 10
Resilience 21.51 3.66 12 30
Age (years) 25.16 5.54 16 38
Education (years) 12.79 1.95 8 19
Unplanned pregnancy 35.0% –– –
Union (married/cohabiting) 46.3% –– –
Race/ethnicity
White 39.5% –– –
Black 28.2% –– –
Hispanic 13.6% –– –
Native American 17.5% –– –
ACEs Adverse Childhood Experiences Scale; PACEs Protective And
Compensatory Experiences Scale
299ADV RES SCI (2020) 1:295–305

The model controlled for demographic variables including
age, race, education level, the presence of a partner in the
home, and whether the pregnancy was unplanned. Of the de-
mographic variables, age was the only predictor significantly
associated with pregnancy-specific stress. Younger age was
predictive of higher pregnancy-specific stress (β=−0.27,
SE = 0.09, p< 0.01). Overall, the fit indices for the combined
model indicated acceptable fit according to widely used stan-
dards (Hooper et al., 2008), χ
2
= 12.21 (9), p=0.20;
RMSEA = 0.05; SRMR = 0.03; CFI = 0.96. The model pre-
dicted 41% of the variance in pregnancy-specific stress ac-
cording to R
2
. The model is depicted in Fig. 2.
Resilience was found to be a significant mediator in the
association between PACEs and pregnancy-specific stress,
as shown in Table 3. The results of the mediation analysis
supported the hypothesized indirect effect of PACEs on
pregnancy-specific stress via resilience, ab =−0.23, 95%
CI = [−0.41, −0.05].
Results also showed that resilience was a significant mod-
erator in the association between ACEs and pregnancy-
specific stress, with a statistically significant interaction term,
[ACEs × resilience], β=0.14,SE =0.04,p<0.01.Thesimple
slopes were examined under low, moderate, and high levels of
resilience, which represent the mean± 1 SD. Women with low
levels of resilience had consistently high levels of pregnancy-
specific stress across the range of ACEs scores. The simple
slopes between ACEs and pregnancy-specific stress were pos-
itive at moderate and high levels of resilience. High levels of
resilience were found to be protective against pregnancy-
specific stress at low and moderate levels of ACEs, compared
with women with low levels of resilience (mean differences in
pregnancy-specific stress between women with low and high
resilience were medium to large, with Cohen’sdvalues of
0.60 and 1.13 at moderate and low levels of ACEs, respec-
tively). At high levels of ACEs, pregnancy-specific stress
levels were approximately equal for all levels of resilience.
Figure 3shows the simple slopes for the moderation analyses.
For a sensitivity analysis, we also conducted the analysisin
an adult-only sample (those ages 18 and older), resulting in a
removal of 5 participants (ages 16 and 17). Results were con-
sistent with results from the full sample reported above.
Specifically, all significant and nonsignificant paths retained
their significance status and betas changed by an average of
0.01. Simple slopes also retained their pattern (findings not
presented).
Discussion
The current study aimed to understand the impact of early life
experiences on pregnancy-specific stress in a clinic-based co-
hort sample of pregnant women. We examined the associa-
tions of both adverse (ACEs) and protective (PACEs) early
life experiences on pregnancy-specific stress and investigated
the role of resilience in both relationships. We hypothesized
Table 2 Bivariate correlations among study variables
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
1. Pregnancy-specific stress –
2. ACEs 0.27
**
–
3. PACEs −0.28
**
0.00 –
4. Resilience −0.51
**
−0.09 0.18
*
–
5. Age −0.19
*
0.05 0.10 0.12 –
6. Education (years) −0.03 0.00 0.19
*
0.17
*
0.37
**
–
7. Unplanned pregnancy
a
0.10 0.14 0.04 −0.03 −0.09 0.00 –
8. Union 0.05 0.22
**
0.09 −0.01 0.02 0.12 −0.16
*
–
9. White 0.11 0.19
*
−0.04 −0.12 0.22
**
0.14 −0.17
*
0.16
*
–
10. Black −0.07 −0.21
**
−0.03 0.08 0.00 0.08 0.06 −0.28
**
−52
**
–
11. Hispanic 0.00 −0.03 0.01 0.00 −0.22
**
0.00 0.16
*
0.03 −0.33
**
−0.25
**
–
12. Native American −0.05 0.03 0.09 0.05 −0.08 −0.27
**
0.02 0.09 −0.38
**
−0.29
**
−0.19
*
*
p<0.05,
**
p<0.01
Fig. 1 The association between ACEs and PACEs categories
300 ADV RES SCI (2020) 1:295–305

resilience to be a significant mediator in the relationship be-
tween PACEs and pregnancy-specific stress, and to be a mod-
erator in the relationship between ACEs and pregnancy-
specific stress.
Exposure to ACEs among our participants was predictive
of pregnancy-specific stress, thereby confirming our hypoth-
eses and supporting numerous studies highlighting the delete-
rious effects of adverse childhood experiences (Danese et al.,
2009; Jaffee & Christian, 2014;Nemeroff,2004; Nurius et al.,
2015). However, resilience was a significant moderator of the
association between ACEs and pregnancy-specific stress, fur-
ther emphasizing the protective nature of resilience among
pregnant women as it relates to stress. Of note, high levels
of resilience were found to be protective against pregnancy-
specific stress at low and moderate levels of ACEs, but not at
high levels of ACEs. In other words, at high levels of ACEs,
resilience was not as effective at “counteracting”the negative
impact of adversity as it was at lower levels of ACEs. This
finding is similar to prior research suggesting resilience fac-
tors are not as protective at higher levels of ACEs (Crandall
et al., 2019). However, previous studies found other protective
factors to be significant moderators even at higher levels of
ACEs including social support and life satisfaction (Crandall
et al., 2019; Logan-Greene et al., 2014). Additional research is
needed to determine whether the impact of high levels of
ACEs on pregnancy-specific stress is moderated by different
types of protective factors. Moreover, previous literature sug-
gests a dose-response effect of ACEs; it is possible that resil-
ience has a similar graded effect, although it has not specifi-
cally been examined in this fashion. Overall, results under-
score the protective role of resilience against pregnancy-
specific stress among our sample of women who may be at
increased risk due to being socioeconomically disadvantaged
and medically underserved (Kingston et al., 2012).
Table 3 Model coefficients for
mediation and moderation
analyses
Β(SE) 95% CI
Mediation paths
PACEs ➔pregnancy-specific stress −0.38 (0.22) [−0.85, 0.00]
PACEs ➔resilience 0.24* (0.09) [0.06, 0.43]
Resilience ➔pregnancy-specific stress −0.93* (0.11) [−1.13, −0.71]
Moderation paths
ACEs ➔pregnancy-specific stress 0.56* (0.18) [0.19, 0.90]
ACEs × resilience ➔Pregnancy-specific stress 0.14* (0.04) [0.05, 0.22]
Simple slope (low resilience) 0.01 (0.26) [−0.54, 0.51]
Simple slope (medium resilience) 0.56* (0.18) [0.19, 0.90]
Simple slope (high resilience) 1.11* (0.24) [0.63, 1.57]
Covariates
Age ➔pregnancy stress −0.27* (0.09) [−0.45, −0.10]
Education ➔pregnancy-specific stress 0.47* (0.23) [0.01, 0.94]
Unplanned pregnancy ➔pregnancy specific stress 0.97 (0.97) [−0.94, 2.88]
Union ➔pregnancy-specific stress 0.60 (0.99) [−1.32, 2.49]
Black
a
➔pregnancy stress −1.26 (1.28) [−2.62, 2.41]
Hispanic
a
➔pregnancy stress −1.66 (1.50) [−4.74, 1.26]
Native American
a
➔pregnancy stress −0.54* (1.27) [−3.11, 1.96]
*
p< 0.05. Unstandardized path coefficients are reported. Low, medium, and high resilience = mean ± 1 SD.
a
Reference group = White
Fig. 2 Structural equation model examining resilience as a mediating and
moderating variable. Analyses controlled for age, race, education, union
status, and unplanned pregnancy. Standardized path coefficients are
reported. ACEs = Adverse childhood experiences; PACEs = Protective
and compensatory experiences
301ADV RES SCI (2020) 1:295–305

Also in support of our hypothesis, exposure to a greater
number of PACEs was associated with lower levels of
pregnancy-specific stress among our participants. Previous
literature (Hays-Grudo, & Morris, 2020; Wright et al., 2013)
documents the positive impact of early protective factors on
various outcomes in adulthood, and our results lend further
support with regard to benefits for pregnancy-specific stress.
Importantly, resilience mediated the observed link between
PACEs and pregnancy-specific stress, wherein greater expo-
sure to PACEs was associated with higher levels of resilience,
and in turn, higher resilience was associated with lower levels
of pregnancy-specific stress. These results are preliminary, yet
suggest a beneficial role of childhood protective and compen-
satory experiences as a mechanism that may foster resilience.
Moreover, these results replicate others that suggest that resil-
ience may be fostered through positive early life experiences
despite childhood adversity rather than an innate characteristic
(Masten, 2001). It is possible, therefore, that promoting posi-
tive experiences during childhood may play a critical role for
fostering resilience in adulthood.
Strengths
The current study has several strengths including examining
resilience in a sample of racially diverse, economically disad-
vantaged, and medically underserved pregnant women.
Although extant literature documents the buffering effects of
resilience against a host of negative outcomes, fewer investi-
gations have focused on women during pregnancy. Similarly,
there has been little focus in the literature given to pregnancy-
specific stress, even though stressamong pregnant women has
been predictive of a number of negative maternal and infant
outcomes (Andersson et al., 2006; Dunkel Schetter & Tanner,
2012), particularly for pregnant women of minority status and
who are undergoing socioeconomic challenges (Ciciolla et al.,
2019).
Further, the current study examined early positive and pro-
tective childhood experiences that are linked to resilience
among pregnant women. As the deleterious effects of ACEs
have been widely established in literature and policy, there is a
growing awareness of and need to understand early childhood
protective and compensatory experiences that may help offset
the impact of such adverse events. The examination of a num-
ber of protective and compensatory childhood experiences in
this study (PACEs scale) shed light on factors that may foster
resilience and thus can inform secondary and tertiary preven-
tion services (Oral et al., 2016).
Limitations and Future Directions
There are several limitations that should be considered when
interpreting the results of this study and addressed in future
studies. Most notably, data regarding childhood experiences
were reported retrospectively, suggesting that results may
consequently be affected by recall bias or lack of
comfortability with reporting past experiences. Additionally,
data were collected solely from the study participants on their
own childhood experiences. Although self-reports of traumat-
ic events in childhood are stronger predictors of psychological
outcomes in adulthood than informant-reports(Newbury et al.
2018), it is possible that their reports may be confounded by
mood or recall. Including measures at multiple time points or
by multiple informants may enhance the reliability or validity
of these findings. Further, the sample was recruited from ur-
ban-serving, low-income prenatal clinics in a small, metropol-
itan city. Although it included a diverse sample of women
from a variety of racial/ethnic backgrounds, it should be noted
that data was primarily collected from a single geographic
region in the USA. Thus, the mediation findings, although
supported byrelevant theory and guided temporal precedence,
should be considered as exploratory and not representative of
all pregnant women. Additionally, although this study
assessed individual-level resilience, resilience as a construct
may be influenced by broader systems, such as community
and societal factors. Thus, future research may benefit from
examining a broader conceptualization of resilience that in-
cludes aspects of the community and sociopolitical setting. It
would also be beneficial for future studies to examine the
Fig. 3 Associations between
ACEs and pregnancy-specific
stress at high, moderate, and low
levels of resilience (mean ± 1 SD)
302 ADV RES SCI (2020) 1:295–305

long-term role of resilience and examine if it has additional
promotive effects on pregnancy stress over time or on birth
outcomes. It is possible, for example, that the impact of resil-
ience may become more evident over time or more beneficial
during certain time periods, especially as it relates to maternal
and infant health during pregnancy and the postpartum period.
Further, it is important to note that this sample reported high
PACEs, even among those with high ACEs. Although results
were similar to other findings that suggested that resilience
factors are not as protective at higher levels of ACEs
(Crandall et al., 2019), it may be beneficial for future studies
to consider if there are any differences between low and high
PACES among individuals with low ACEs. This study also
highlights several implications for clinical practice related to
the health and well-being of pregnant women. First, future
work should consider maternal ACEs and PACEs in relation
to the prevention of elevated stress level during pregnancy.
For example, screening for pregnancy-specific stress and
known risk factors, such as ACEs, during the perinatal period
may help to identify mothers needing additional support and
intervention. Additionally, screening for protective factors,
such as PACEs and resilience, may be another critical element
in a comprehensive approach to intervention, as it may help to
identify additional protective factors that may be utilized to
support treatment goals or strengthened as part of treatment in
order to foster resilience over time. Second,
psychoeducational programs implemented with pregnant
women with a history of ACEs that aim to enhance the mental
health and pregnancy-related outcomes have shown participa-
tion to be beneficial (e.g., Seng et al., 2011). Thus, it may
benefit these programs to incorporate content related to build-
ing coping strategies and support systems crucial for postpar-
tum functioning. The concept of resilience is closely connect-
ed to aspects of security, closeness, and belonging; therefore,
interventions research that aims to promote interpersonal
skills and connectedness may be especially relevant for preg-
nant women exposed to high levels of stress and adversity.
Conclusion
In sum, findings from this study suggest that early child-
hood experiences play an important role in maternal psy-
chological health and well-being and may be important for
shaping maternal vulnerability to pregnancy-specific
stress. Resilience mediates the association between
PACES and pregnancy-specific stress and moderates the
association between ACEs and pregnancy-specific stress,
such that high levels of resilience are protective against
pregnancy-specific stress at low and moderate levels of
ACEs. The findings highlight the importance of early
childhood experiences on women’s well-being during
pregnancy and demonstrate how both ACEs and PACEs
contribute to the protective role of resilience against
pregnancy-specific stress.
Acknowledgments This research was supported by the National Institute
of General Medical Sciences of the National Institutes of Health
(P20GM109097; Jennifer Hays-Grudo, PI).
Funding Author blinded.
Availability of Data and Materials The datasets used and/or analyzed
during the current study are available from the corresponding author upon
request.
Compliance with Ethical Standards
Competing Interests The authors declare that they have no competing
interests.
Ethics Approval and Consent to Participate The Oklahoma State
University Institutional Review Board (IRB) approved this study.
Consent for Publication Not applicable.
Disclaimer 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 would like to thank the HATCH Project partici-
pating clinics, and particularly Drs. Karen Gold, Jameca Price, and Lance
Frye for their support.
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