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Associations between food insecurity in high-income countries and pregnancy outcomes: A systematic review and meta-analysis [1]
['Zoë Bell', 'Population Health Sciences Institute', 'Faculty Of Medical Sciences', 'Newcastle University', 'Newcastle Upon Tyne', 'United Kingdom', 'Department Of Nutritional Sciences', 'King S College London', 'London', 'Giang Nguyen']
Date: 2024-09
Searches included 8 databases (MEDLINE, Embase, Scopus, Web of Science, PsychInfo, ASSIA, SSPC in ProQuest, and CINAHL), grey literature, forwards and backwards citation chaining, and contacting authors. Studies in high-income countries (HICs) reporting data on food insecurity in pregnancy and maternal or infant health, from January 1, 2008 to November 21, 2023 were included. Screening, data extraction, and quality assessment were carried out independently in duplicate. Random effects meta-analysis was performed when data were suitable for pooling, otherwise narrative synthesis was conducted. The protocol was registered on PROSPERO (CRD42022311669), reported with PRISMA checklist ( S1 File ). Searches identified 24,223 results and 25 studies (n = 93,871 women) were included: 23 from North America and 2 from Europe. Meta-analysis showed that food insecurity was associated with high stress level (OR 4.07, 95% CI [1.22, 13.55], I 2 96.40%), mood disorder (OR 2.53, 95% CI [1.46, 4.39], I 2 55.62%), gestational diabetes (OR 1.64, 95% CI [1.37, 1.95], I 2 0.00%), but not cesarean delivery (OR 1.42, 95% CI [0.78, 2.60], I 2 56.35%), birth weight (MD −58.26 g, 95% CI [−128.02, 11.50], I 2 38.41%), small-for-gestational-age (OR 1.20, 95%, CI [0.88, 1.63], I 2 44.66%), large-for-gestational-age (OR 0.88, 95% CI [0.70, 1.12] I 2 11.93%), preterm delivery (OR 1.18, 95% CI [0.98, 1.42], I 2 0.00%), or neonatal intensive care (OR 2.01, 95% CI [0.85, 4.78], I 2 70.48%). Narrative synthesis showed food insecurity was significantly associated with dental problems, depression, anxiety, and maternal serum concentration of perfluoro-octane sulfonate. There were no significant associations with other organohalogen chemicals, assisted delivery, postpartum haemorrhage, hospital admissions, length of stay, congenital anomalies, or neonatal morbidity. Mixed associations were reported for preeclampsia, hypertension, and community/resilience measures.
In HICs, food insecurity is a major public health concern given its wide-reaching significant impact on diet, nutrition, physical and mental health [ 13 ]. It is therefore important to understand the impact of experiencing food insecurity during critical periods of nutrition and development crucial for health across the generations [ 14 ]. One critical period is during the first 1,001 days of life (from conception until a child is 2 years of age), particularly during pregnancy. Suboptimal nutrition during pregnancy can contribute to poorer maternal and infant health outcomes [ 14 ]. During pregnancy and breastfeeding, women have more complex nutritional requirements, with increased potential health impacts from food insecurity [ 15 , 16 ]. Further, women are particularly vulnerable to experiencing food insecurity due to increased likelihood of working lower-paid, part-time jobs while maintaining caring responsibility of children and elderly within the family unit and/or heading a single parent household [ 17 – 19 ]. Within households, experiences of food insecurity may be unevenly distributed with women more affected than men [ 20 ]. Qualitative research shows women tend to be household food managers, thus experiencing the psychosocial costs from negotiating access to sufficient healthy food, often foregoing food to ensure others in their household are fed [ 21 – 23 ]. This increase in women’s susceptibility to food insecurity could have consequences for pregnancy physical and mental health outcomes. Qualitative research reports maternal changes to food behaviours such as restricting eating patterns, reducing portion size, skipping meals, and forgoing food. Further, a recent review exploring associations between maternal food insecurity and pregnancy weight and diet reported poorer diet quality such as reduced consumption of fruit and vegetables, increased red processed meats, and lower intakes of vitamin E, and significantly increased odds of maternal obesity [ 24 ]. Maternal obesity is highly prevalent in HICs and increases pregnancy complications such as large-for-gestational age (LGA) babies, preeclampsia, gestational diabetes mellitus (GDM), and in the longer-term type 2 diabetes [ 25 , 26 ], increased depression [ 27 , 28 ]. The recent review did not report associations between food insecurity and other pregnancy outcomes. Observational studies have found maternal food insecurity to be associated with poor maternal mental health and be a risk factor for adverse pregnancy and birth outcomes [ 29 – 31 ]; however, there is an absence of systematic reviews reporting meta-analysis of these associations in HICs contexts.
Food insecurity is “the limited or uncertain availability of nutritionally adequate or safe foods and limited or uncertain ability to acquire foods in socially acceptable ways” [ 1 ]. Poverty, unemployment, and low income are key drivers of food insecurity in both low- and middle-income countries (LMICs) and high-income countries (HICs) [ 2 ]. Further, the double burden of malnutrition with increasing rates of overweight, obesity, and noncommunicable diseases is also shared. However, it is important to consider HICs independently due to the vast differences not only in the food system, food supply, and food environment, but for many HICs, food insecurity was relatively hidden until after the 2008 global financial crisis and parallel rise in charitable food aid [ 3 ]. The global recession that followed led to increased poverty rates and unemployment in HICs [ 4 , 5 ]. Social and health inequalities have been further exacerbated from the Coronavirus pandemic, war, and ongoing cost-of-living crises meaning increased costs of food and energy prices [ 6 , 7 ]. Concurrently, lack of routine population measurement and use of noncomparable measurements has prevented accurate understanding of prevalence of food insecurity [ 8 ]. A study reporting prevalence in HICs between 2014 and 2018 estimated the prevalence of moderate or severe food insecurity as 6.5%, although there was a wide distribution at country level ranging from around 3% to 15% [ 9 ]. The study also reported sociodemographic patterns in prevalence, with age, gender, household occupancy, and income being important. More recently, the United Nations estimated that food insecurity doubled from the start to the end of 2020, impacting 135 to 265 million people worldwide [ 10 , 11 ]. During that period, the Coronavirus pandemic highlighted clear inequalities in access to food and health outcomes both between and within countries [ 12 ]. Ongoing since 2021, HICs have been experiencing a cost-of-living crisis, further pushing households experiencing financial hardship into poverty [ 7 ].
Meta-analysis was carried out when there were at least 3 studies reporting data suitable for pooling. If odds ratios (ORs) were not reported in the included papers, then they were calculated using reported frequency data or by contacting authors for the required data, with the aim of increasing the number of studies to pool in a meta-analysis. Summary ORs were calculated using the random effects model using Stata/MP version 18 [ 41 , 42 ]. Heterogeneity between studies was explored using I 2 [ 43 ], and >75% was considered significant heterogeneity [ 44 ]. The protocol included a plan to conduct meta-regression, sensitivity analysis, Eggers tests, and funnel plots for all meta-analyses; however, as no meta-analysis included 10 or more studies, these were not conducted [ 45 ]. Narrative synthesis was performed when meta-analysis was not possible due to too few studies reporting outcome data similar enough to pool, or when it was not possible to convert data reported to ORs [ 46 ]. Data were tabulated and grouped into thematic categories relating to maternal and infant health outcomes (a priori categories). Further data-driven thematic categories were developed based on the specific outcomes reported in the included studies (e.g., birth weight) and how these data were presented (e.g., birth weight for gestational age z-score). Narrative summaries accompany the tables to report associations between food insecurity in pregnancy and health outcomes.
The search results were deduplicated in EndNote 20 [ 38 ] and Rayyan [ 39 ]. Title and abstract screening were conducted in Rayyan by a team of 7 reviewers independently and in duplicate. Full-text screening for any potentially eligible studies was also carried out independently and in duplicate. Conflicts between reviewers screening decisions were resolved by group discussion. We contacted corresponding authors when required, including following up on published conference abstracts for any subsequent publication of full papers, or when there was missing information in the publication essential for the screening decisions (e.g., data collection time period). Data extraction and quality assessment were carried out independently in duplicate, with conflicts resolved by group discussion. The data extraction template included: type of publication, study type, country of study, data collection time period, study aim, measurement and definition of food insecurity, study participant information, and study outcomes. The Newcastle–Ottawa scale (NOS) cohort study tool was used to assess the quality of the included studies [ 40 ]. This scale assesses information and selection bias, for example, relating to participant identification, representativeness, and measurement of exposures and outcomes, and confounding variables which are the key factors to consider when assessing quality and bias in observational study designs. A quality scoring system was applied based on the number of “stars” awarded: 0 to 2 was categorised as low quality, 3 to 5 stars medium quality, and 6 to 8 stars high quality (see S4 Table ).
A modified version of the Population, Intervention, Control, Outcome, Study design (PICOS) framework: Population, Exposure, Comparison, Outcome, Study design (PECOS) [ 35 ] was used to develop eligibility criteria. The population (P) was pregnant women living in HICs (GNI per capita ≥$12,696 [ 36 ]). The exposure (E) was an explicit measure of food insecurity, and the comparison group (C) was food security/no food insecurity. Eligible study designs (S) were quantitative observational studies and primary observational data sources from grey literature. A date restriction was applied and aligned with the global financial crises which occurred in 2008. We excluded any studies where the data were primarily collected prior to 2008. There were no restrictions on reporting language to limit bias [ 37 ].
Database searches were completed November 21, 2023. A comprehensive search strategy was developed using search terms relating to “food insecurity” (exposure), “pregnancy” (population), and “observational” (study design) with Boolean operators (see S1 Table ). We did not include search terms relating to outcomes, as the aim was to be holistic and include studies reporting any pregnancy outcomes specific to maternal and infant health. No search terms were included relating to HICs, and studies in LMIC contexts were excluded during the screening stages. The search strategy was applied to MEDLINE, Embase, PsycInfo, Scopus, Web of Science, Applied Social Science Index, and Abstracts (ASSIA), Social Sciences Premium Collection (SSPC) in ProQuest and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from January 1, 2008 to November 21, 2023. To limit the potential impact of publication bias, additional searches were conducted with searches for grey literature carried out using Trove, Open Access Theses and Dissertations (OATD) and stakeholder websites (see S2 Table ). We also conducted forward and backwards citation chaining for all included studies using citationchaser (an R package and Shiny app [ 34 ]). We contacted authors when additional data was required to inform the screening or to include in meta-analysis (see S3 Table ). Supplementary searches and contacting authors were completed in March 2024.
Three high-quality studies reported data for NICU admission and could be pooled in the meta-analysis [ 30 , 50 , 51 ] with a pooled sample size of 2,367 women. Pooled analysis showed no association with food insecurity (OR 2.01, 95% CI [0.85, 4.78], I 2 70.48%) ( Fig 10 ). Four studies reported additional neonatal morbidity outcomes [ 30 , 48 , 50 , 57 ]. Studies reported no association between congenital anomalies and marginal (ARR 1.96, 95% CI [0.99, 3.86]) or moderate-severe food insecurity (ARR 1.13, 95% CI [0.52, 2.45]) [ 30 ]. Additionally, no association was reported between food insecurity and shoulder dystocia (OR 1.52, 95% CI [0.06, 37.49]) [ 48 ], respiratory distress (OR 1.36, 95% CI [0.29, 6.38]) [ 50 ], 5-min Apgar score <7 (OR 0.80, 95% CI [0.09, 6.45]) [ 50 ], glucose <40 mg/dl in first 24 h (OR 0.88, 95% CI [0.19, 4.01]) [ 50 ], or neonatal hypoglycaemia (OR 1.49, 95% CI [0.31, 7.06] [ 50 ] and OR 0.85, 95% CI [0.24, 2.97] [ 48 ]). Inconsistent patterns were reported for food insecurity and mortality: one study reported a positive association between food insecurity and stillbirth (ARR 2.71, 95%CI [1.13, 6.45]) [ 57 ] and one reported no association between food insecurity and neonatal death/stillbirth (OR 0.91, 95% CI [0.04, 19.06]) [ 48 ].
Three studies reported data for birth weight; 2 were high quality [ 53 , 55 ] and 1 medium quality [ 56 ] with a pooled sample size of 594 women. Four studies reported data for SGA and LGA, 3 high quality [ 30 , 50 , 67 ] and 1 medium quality [ 48 ] with a pooled sample size of 12,739 women. Pooled results showed no association between food insecurity and mean birth weight (MD −58.26 g, 95% CI [−128.02, 11.50], I 2 38.41%) ( Fig 6 ), SGA (OR 1.20, 95% CI [0.88, 1.63]) I 2 44.66%) ( Fig 7 ), or LGA (OR 0.88, 95% CI [0.70, 1.12] I 2 11.93%) ( Fig 8 ). Additional data reported that could not be pooled in the meta-analysis (see S9 Table ) showed no association with food insecurity and birth weight for gestational age z-score [ 53 ] or low birth weight (RR 1.21, p = 0.51 and OR 1.39, 95% CI [0.45, 4.29]) [ 29 , 50 ]. However, one study reported a positive association between food insecurity and high birth weight in 2 different adjusted models: AOR 2.07 (95% CI [1.07, 3.98]) when adjusting for child sex, race, ethnicity, parent age, education, income, and study site; and AOR 1.96 (95% CI [1.01, 3.82]) when adding poor neighbourhood food environment to the model ( S9 Table ) [ 52 ].
Other outcomes reported relating to food insecurity and mental health included increased common mental disorders (IRR 1.90, 95% CI [1.30, 2.80]) [ 61 ], and mental health symptoms (β 0.54, p < 0.001 reported in a path analysis) [ 53 ]. One study reported that women experiencing moderate-severe food insecurity had increased odds of poor/fair perceived mental health than food secure (AOR 3.79, 95% CI [1.52, 9.48]) and no association for marginal food insecurity (AOR 2.23, 95% CI [0.64, 7.78]) [ 68 ]. This study also reported no association between marginal and moderate-severe food insecurity and poor/fair perceived health generally (AOR 1.60, 95% CI [0.60, 4.26, and 1.52], 95% CI [0.82, 2.80]), or perceiving their health to be worse than the previous year (AOR 0.96, 95% CI [0.38, 2.39, and 0.91], 95% CI [0.54, 1.53]) [ 68 ]. There were poorer levels of resilience among food insecure women reported, including feeling no love, dissatisfied with life, despair and loss of control (ORs ranging from 2.24, 95% CI [1.38 to 3.65 to 9.33] 95% CI [3.39, 25.69]) [ 29 ], but no association between marginal and moderate-severe food insecurity and having a weak sense of community (AOR 1.08, 95% CI [0.72, 1.62, and 1.33], 95% CI [0.92, 1.92]), [ 68 ] or community status (β −0.02, 95% CI [−0.10, 0.02]) [ 54 ].
Six studies reported data on anxiety-related outcomes [ 49 , 53 , 56 , 59 , 68 , 69 ], all showing significant positive associations for women experiencing food insecurity. One study reported higher generalised anxiety in both acute and chronic food insecure groups compared with food secure (mean 6.00 (SD 5.50), 6.60 (SD 4.50), and 4.60 (SD 4.50), respectively, p < 0.001) [ 56 ]. Two studies found higher odds of diagnosed anxiety disorder among women experiencing food insecurity compared to food secure (AOR 2.49, 95% CI [1.09, 5.67]) [ 69 ] and among women experiencing moderate-severe food insecurity (AOR 3.23, 95% CI [1.92, 5.43]) but not for marginal food insecurity (AOR 1.82, 95% CI [0.94, 3.54]) [ 68 ]. Two studies reported a higher anxiety score for women experiencing food insecurity compared to food secure (MD 1.55, 95% CI [1.04, 2.05] [ 49 ] and mean 2.04 (SD 0.51), mean 1.71 (SD 0.32), respectively, p < 0.001) [ 54 ]. One study reported a positive association between food insecurity and feeling more anxious than usual due to the pandemic (APR 1.79, 95% CI [1.71, 1.88]) [ 59 ].
Narrative synthesis was conducted for the remaining mental health outcomes (see S8 Table ). Three studies reported data for depression [ 49 , 54 , 63 ]. Two showed a positive association with diagnosis of depression among women experiencing food insecurity compared with food secure (AORs 3.68, 95% CI [1.43, 9.43, and 4.42], 95% CI [2.33, 8.35]) [ 49 , 63 ]. One study showed a positive association between food insecurity and depression scale score (β 2.67, 95% CI [1.31, 4.04]) [ 54 ], whereas one reported no association between marginal food security and CES-D depression scores of >21 or >24 (AOR 2.97, 95% CI [0.85, 10.35, and 3.64], 95% CI [0.77, 17.31], respectively) [ 63 ]. Four studies reported a consistent positive association between depressive symptoms and varying degrees of food insecurity (ARRs ranging from 1.72, 95% CI [1.40, 2.11 to 3.26], 95% CI [2.46, 4.32]) [ 58 ]. Higher mean depressive symptom scores were reported by 2 studies for women with acute or chronic food insecurity compared with food secure (mean 11.10 (SD 7.80), 13.60 (SD 8.80), and 9.30 (SD 7.40), respectively, p < 0.001) [ 56 ], and for food insecure women compared with food secure women (mean 0.81 (SD 0.46), mean 0.49 (SD 0.32), respectively, p < 0.001) [ 53 ]. One study reported positive associations between food insecurity and feeling more depressed than usual due to the pandemic (APR 2.32, 95% CI [2.13, 2.53]) [ 60 ].
One study [ 65 ] reported significantly increased odds for a variety of oral health and dental care needs among women experiencing food insecurity, such as needing to see a dentist for a problem, not knowing it was important to care for teeth, and not talking about dental health with providers (AORs ranged from 1.29, 95% CI [1.04, 1.59 to 1.91], 95% CI [1.62, 2.25]). One study reported a positive association between serum perfluorooctane sulfonate (PFOS) concentrations among women with low/very low food security compared with marginal/high food security (β 0.27, 95% CI [0.04, 0.50]), but no association with any other organohalogen chemicals investigated [ 60 ]. Additional outcomes reported with no association with food insecurity were [ 50 , 51 ] postpartum haemorrhage (OR 1.80, 95% CI [0.48, 6.62]) [ 50 ], severe maternal morbidity (ARR 1.05, 95% CI [0.69, 1.60]) or non-transfusion severe maternal morbidity (ARR 1.12, 95% CI [0.60, 2.12]) [ 57 ], or assisted delivery (OR 0.96, 95% CI [0.11, 7.98]) [ 50 ]. There was no significant association or consistent pattern in direction of effect for food insecurity and hospital admissions or length of stay in one study [ 30 ].
Narrative synthesis (see S7 Table ) identified no consistent pattern in direction of effect for food insecurity and preeclampsia: 1 study reported significant association (OR 1.91, 95% CI [1.11, 3.29]) and 2 others did not (OR 1.78, 95% CI [0.77, 4.10] and ARR 0.91, 95% CI [0.8, 1.03] [for preeclampsia without severe features or gestational hypertension] and ARR 0.95, 95% CI [0.78, 1.16] [for preeclampsia with severe features]) [ 29 , 48 , 57 ]. Results for chronic or gestational hypertension also showed an inconsistent association with food insecurity, with 1 study reporting a positive association (OR 16.94, 95% CI [7.79, 36.85]) [ 48 ] and 2 others showed no association (OR 1.45, 95% CI [0.65, 3.24] [ 29 ] and OR 1.22, 95% CI [0.94, 1.59]) [ 67 ]. One study reported a combined outcome of hypertension or diabetes which showed no association with marginal or moderate/severe food insecurity compared with food security (ARR 0.99, 95% CI [0.51, 1.92] and 1.44, 95% CI [0.88, 2.35], respectively) [ 30 ].
All included studies reported associations between food insecurity and maternal health outcomes (n = 13 physical health [ 30 , 31 , 49 – 51 , 55 , 60 , 62 , 64 – 67 , 69 ] and n = 12 mental health [ 29 , 49 , 53 , 54 , 56 , 58 , 59 , 61 , 63 , 67 – 69 ]) and n = 13 infant health outcomes [ 29 – 31 , 48 , 50 – 53 , 55 – 57 , 64 , 67 ]. There were 17 included studies that reported adjusted models for some or all their analysis [ 30 , 49 , 51 – 55 , 57 – 59 , 62 – 65 , 67 – 69 ]. There was variation in variables included in adjusted models. Those most frequently included were maternal age and race or ethnicity (n = 15 each), followed by education (n = 13) and income (n = 10). Less frequently included were factors relating to housing or relationship status (n = 8 each), health insurance (n = 6), maternal BMI, previous pregnancy, clinical or research design factors (n = 5 each), WIC use or language spoken (n = 2 each), and immigration status or social support (n = 1 each).
While overall the studies reflected general maternity populations with their inclusion criteria, albeit usually singleton pregnancies and >18 years of age, there were some studies that applied criteria that may have excluded food insecure populations ( S5a Table ). These included restrictions to English speaking populations [ 29 , 50 , 53 , 60 , 66 ], exclusion of women in prisons [ 62 , 63 , 68 ], or First Nations reserves and settlements, Armed Forces, or living in care homes [ 68 ]. There were various and inconsistent participant characteristics reported by the included studies including mean, median, or categories of maternal age (n = 15); ethnic group or race (n = 25); parity, previous pregnancy, or having other children (n = 15); income brackets, quintiles, poverty line, and income need ratio (n = 15); various categories of educational attainment (n = 21); employment status (n = 9); relationship status (n = 16); and other socioeconomic indicators including measures of social security, WIC use, financial support, and housing tenure, occupancy, and neighbourhoods (n = 16) (see S5b Table ). The mean or median age ranged from 18.6 to 33 years. Ethnic and racial representation included white, black, Hispanic, Latina, Asian, Pacific Islander, Pakistani, Bangladeshi, Indian, American Indian, Alsakan, and Indigenous groups. Majority populations included in the studies were white (n = 10 studies), Hispanic or Latina (n = 5), black (n = 2), South Asian (n = 1), or equal distribution between 2 or more groups (n = 5). Education less than high school equivalent ranged from 8.7% to 34.7% of participants. Women were more likely to have had previous pregnancies and/or other children in 9 studies, and a first pregnancy in 4 studies. There were more studies reporting that their participants were either married or in a relationship (n = 13) than unmarried or single (n = 3). More studies also reported a higher proportion of their participants to be in employment (n = 6) than not employed (n = 3).
There were 25 studies that met the inclusion criteria ( Table 1 and see S5 Table ). Twenty-two included studies [ 29 – 31 , 48 – 66 ] were peer-reviewed journal articles and 3 [ 67 – 69 ] were masters or PhD theses. All were cohort studies published between 2012 and 2023: 15 were prospective cohort studies [ 29 , 48 , 49 , 51 – 57 , 60 , 62 , 63 , 66 , 69 ] and 10 retrospective cohort studies [ 30 , 31 , 50 , 58 , 59 , 61 , 64 , 65 , 67 , 68 ]. Nearly all studies were conducted in North America, with 20 studies conducted in the United States of America [ 29 , 31 , 49 – 60 , 62 – 67 ], 3 studies conducted in Canada [ 30 , 68 , 69 ], and 1 study in France [ 48 ] and the United Kingdom [ 61 ]. Included study sample sizes ranged from 70 [ 51 ] to 21,080 [ 65 ] women (pooled sample size n = 93,871; median 858, IQR 510 to 3,592). Food insecurity was primarily determined using the USDA Food Security Survey Module (n = 18 studies) [ 29 , 30 , 48 , 50 – 53 , 55 , 58 , 60 – 66 , 68 , 69 ], although varied criteria from 1 to 18 items applied [ 70 ]. Other studies used single or two-item questions from a Pregnancy Nutrition Questionnaire [ 56 ], a rapid assessment tool for prenatal care [ 67 ], the Hunger Vital Sign (n = 2) [ 49 , 57 ], Pregnancy Medical Home risk screening [ 31 ], an undefined questionnaire in the Chemicals in Our Body study [ 54 ] and a single food insecurity question that specifically ask for the pregnancy period: “Does not having enough money make it hard for you to eat healthy food during pregnancy?” [ 59 ]. All included studies achieved between 4 and 8 stars in the quality assessment; 17 were rated as high quality and 8 medium quality ( Table 1 ). All 25 studies were awarded a star for their representativeness of the exposed (food insecure) and non-exposed (food secure) cohorts (Q1 and 2), assessment of the exposure (Q3) and the duration of follow up (Q6). Nineteen (76%) were awarded a star for the comparability of cohorts on the basis of the design or analysis (Q4), and 18 (72%) for assessment of outcome (Q5). The lowest scoring element related to the adequacy of follow up (Q7; 44%, n = 11) indicating that loss to follow up and/or missing outcome data was a key limiting factor for study quality (see S6 Table ).
Discussion
This systematic review has extensively explored associations between women experiencing food insecurity in HICs post the 2008 global financial crisis, and pregnancy health outcomes for women and their infants. The meta-analysis identified positive associations between food insecurity and GDM, high stress levels, and mood disorder, but no association with birth weight, SGA, LGA, preterm delivery, NICU admission, or cesarean delivery. Narrative synthesis also identified patterns for associations between food insecurity and some maternal physical health outcomes including dental health, and serum PFOS, but evidence was limited for infant health outcomes. Further, there were highly consistent data for associations between food insecurity and a range of maternal mental health outcomes that could not be included in meta-analysis due to a limited number of studies reporting similar enough data for pooling. These included increased risks for depression, anxiety, and mental health disorders, and women experiencing food insecurity being more likely to also experience stress events, depressive symptoms, poor resilience, and lower perceived mental health.
The associations between food insecurity and maternal mental health outcomes could be a consequence of the compounded effect from intersecting and interconnected inequalities such as gender and class. In previous studies, women have described that due to a lack of income they are unable to participate in normal consumer routes for purchasing food, or participate socially, and describe feelings of tension between their nutritional desires and their inability to meet them in addition to ongoing uncertainty around access to food [23]. Pregnancy, birth, and early parenthood represent life-changing moments. Moments of change can instigate a period of poorer mental health or worsen preexisting mental health conditions [71]. Therefore, a concern is that women with food insecurity experience more severe mental health challenges (double burden on mental health) as they experience the mental health costs associated with food insecurity in addition to the potential mental health costs from pregnancy. Maternal mental health must be acknowledged, not only to improve maternal health and well-being but also because children exposed to maternal mental ill health are at increased risk of experiencing psychological and developmental disturbances [72,73]. The findings from this review make it evident that screening for food insecurity during pregnancy and mental health conditions in HICs is necessary to ensure care for mother and baby. The World Health Organisation (WHO) recognises the importance of screening, diagnosing, and managing perinatal mental health conditions, publishing new guidelines for integrating perinatal mental health into maternal and child health services in late 2022 [71]. Specific to poverty, WHO recommend health services monitor infants for malnutrition and forge links with community providers that provide services addressing the wider social determinants of health, such as housing associations. Further, they encourage women to form strong social networks that provide support during financially difficult times, a sentiment that will be difficult to achieve given the challenges of living with poverty, mental health, and pregnancy.
The finding that pregnant women experiencing food insecurity have significantly increased odds of GDM is concerning as developing GDM can result in poorer health outcomes for both mother and baby. These include LGA infants, complications at birth, and increased life course risk of developing T2DM for women and their children [74]. Children born to women with GDM could be at risk of metabolic disease later in life [75], thus food insecurity during pregnancy can have important potential life course implications for the child. Risk factors for GDM include maternal overweight and obesity. Women experiencing food insecurity during pregnancy are significantly more likely to be living with obesity [76] which in itself increases the risk of obesity development in the child [77]. Therefore, food insecurity compounds the potential increased risks for the child relating to both maternal obesity and GDM. Potential mechanisms underpinning the association between food insecurity and GDM include the wider determinants of maternal obesity such as housing conditions and food environment. Accounts of food insecurity report poor kitchen facilities and utensils to cook and store healthy meals [23]. Further, food insecurity is associated with energy-dense diets and living in obesogenic environments, thus increasing the risk of developing obesity and GDM [78,79]. Another potential mechanism explaining the association between food insecurity and GDM could be the dysregulated eating patterns characteristic of food insecurity which could alter metabolic regulation contributing to the development of GDM [80]. Eating patterns for those experiencing food insecurity are typified by food being consumed when food is available, and restricted when food shortages exist [23]. Cycles of food abundance at the beginning, then food shortages at the end of the month have been reported [81]. Thus, charitable food aid, social support, or income distributed weekly rather than monthly could help mitigate these eating patterns. A study has also shown food insecurity is indirectly linked with higher body mass index via maladaptive coping mechanisms such as emotional eating [82], which this review has identified could be triggered by significant high levels of stress women experience. Finally, among women, food insecurity is associated with nutritionally poor diets, lacking fruit and vegetables which could deprive food insecure women of the protective nutrients required to prevent disease such as GDM [83–85].
This review identified limited data for infant health outcomes, and data that were included showed a lack of association between food insecurity and SGA, LGA, preterm delivery, and NICU admission. Some of these data are in conflict with evidence from LMICs showing that low birth weight was higher in food insecure groups compared to food secure groups [86–88], potentially due to differences in context between LMICs and HICs relating to food insecurity and availability of types of foods. However, our meta-analysis was limited by the limited number of studies reporting infant outcomes and the context being in North America, which may have impacted on the lack of significance in pooled results despite an overall pattern towards positive directions of effect. The USA context may bias the results due to a potential intervention effect from the well-established Special Supplemental Nutrition Program (SNAP) for Women, Infants and Children (WIC) in the USA [89]. Evidence shows that WIC reduces food insecurity and can improve pregnancy outcomes such as gestational hypertension [90], preterm delivery [91], SGA and NICU admission [92,93]. However, other HICs do not have embedded support in place like WIC, thus further research in other contexts is needed to fully understand the impact of food insecurity on pregnancy outcomes.
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