# Rurality, socioeconomic status, and psychosocial health outcomes during pregnancy

## TL;DR

This study found that pregnant people with lower socioeconomic status experience worse psychosocial health, regardless of whether they live in rural or urban areas.

## Contribution

The study examines how psychosocial health outcomes during pregnancy vary by rurality and socioeconomic status, including their intersectionality.

## Key findings

- Low individual-level socioeconomic status was associated with worse psychosocial health outcomes in pregnancy.
- Rural residents with low socioeconomic status had the poorest psychosocial health outcomes, though intersectionality was not statistically significant.
- Adjusted models showed significant differences in depressive symptoms, nausea-related quality of life, and stress across socioeconomic statuses.

## Abstract

Depressive symptoms, quality of life related to nausea/vomiting, and perceived stress (i.e., psychosocial health outcomes) tend to worsen in pregnancy. Yet whether these differ between rural and urban areas or across socioeconomic statuses during pregnancy remains unclear. We investigated whether there are differences in psychosocial health outcomes during pregnancy by rurality, socioeconomic status, and their intersectionality.

Data were from Pregnancy 24/7, a pregnancy cohort study conducted from 2020 to 2024 among 497 participants recruited from three sites in the United States (Iowa City, Iowa; Pittsburgh, Pennsylvania; and Morgantown, West Virginia). Participants attended study visits in each trimester where they self-reported depressive symptoms (Center for Epidemiology Studies Depression), nausea- and vomiting-related (NV) quality of life (Nausea and Vomiting of Pregnancy Quality of Life Questionnaire), and perceived stress (Perceived Stress Scale). Rurality was based on home address as urban, micropolitan, and small town rural. Socioeconomic status was measured at the neighborhood level via the national Area Deprivation Index and at the individual level via latent classes (i.e., high, middle, or low) constructed from education, income, and insurance status. Unadjusted and adjusted mixed-effects linear regression models separately examined differences in psychosocial health outcomes between rurality and socioeconomic status. Intersectionality, defined as a compounding effect, was explored by evaluating an interaction term between rurality and socioeconomic status.

Though participants who were rural, had greater Area Deprivation Index, and had lower individual-level socioeconomic status had higher (worse) psychosocial health outcome scores in unadjusted models, significant differences only persisted across individual-level socioeconomic statuses after adjustment. Scores for high vs. low socioeconomic status were 5.41 vs. 7.56 for depressive symptoms (p < 0.001). Scores for high vs. middle socioeconomic status were 80.29 vs. 87.84 for NV quality of life (p = 0.02) and 12.15 vs. 14.16 for stress (p < 0.001). When exploring intersectionality, individuals in rural areas and the lowest socioeconomic latent class experienced the poorest psychosocial health outcomes; however, non-significant interaction terms suggested intersectionality was not present.

Individuals with low individual-level socioeconomic status had poorer psychosocial health in pregnancy. Population-specific strategies to improve psychosocial health in low socioeconomic status pregnant people should be explored, including in rural settings.

The online version contains supplementary material available at 10.1186/s12884-025-08492-1.