Health-Related Functional Status in Pregnancy:

Relationship to Depression and Social Support

in a Multi-Ethnic Population
M. DIANE MCKEE, MD, MS, MADDY CUNNINGHAM, DSW,
KATHERINE R. B. JANKOWSKI, MA, AND LUIS ZAYAS, PhD
Objective: To describe perceived well-being and functional
status during uncomplicated late pregnancy among lowincome minority women, and to examine the relationship of
functional status to depression and social support.
Methods: Hispanic and black women with low-risk pregnancies completed an interview consisting of demographics,
the Medical Outcomes Study Short Form 36 (SF-36), Beck
Depression Inventory-II (BDI-II), and the Norbeck Social
Support Questionnaire.
Results: Of the 155 women who were eligible and asked to
participate, 41 refused for a participation rate of 74%. Results
of the SF-36 showed lowest perceived well-being in the
vitality and physical role dimensions. Depressive symptomatology was high, with a mean BDI score of 15 (standard
deviation 8.6). Using a BDI score of 14 as the cutoff point,
over half of the sample was categorized as having significant
depressive symptoms. Significantly lower functional status
was seen for depressed subjects in all subscales of the SF-36
compared with nondepressed subjects. Although functional
status was negatively correlated with BDI score in all dimensions (r .23.69), correlation of SF-36 scores with social
support was much weaker (r .06 .24).
Conclusion: Elevated levels of depressive symptomatology
are strongly correlated with lowered health-related functioning and perceived well-being. Social support is not associated with increased physical or emotional well-being but is
weakly associated with mental health as measured by the
SF-36. (Obstet Gynecol 2001;97:988 93. 2001 by The
American College of Obstetricians and Gynecologists.)

Though a joyful event for most women, pregnancy is

often a stressful period both physically and mentally.1
Even in normal pregnancies, physical and emotional
From the Department of Family Medicine, Albert Einstein College of
Medicine, Bronx, New York, and the Center for Hispanic Mental Health
Research, Graduate School of Social Service, Fordham University, New
York, New York.
This work was supported by grant R24 MH57936 from the National
Institute of Mental Health.

988 0029-7844/01/$20.00
PII S0029-7844(01)01377-1

changes can alter the ability of women to carry out their

usual roles.2 The primary goal of health care during
pregnancy is the achievement of the best possible
maternal and fetal outcome. There is evidence that
perceived well-being during pregnancy positively predicts the mothers early postnatal role adjustment.3,4
Prior studies have shown that the changes of pregnancy
may detract from overall quality of life.2 Hueston and
Kasik-Miller,5 in a cohort of white women with normal
pregnancies, found health-related functional status
changes for physical but not emotional aspects of health
as measured by the Medical Outcomes Study-Short
Form 36 (SF-36). This study found that sociodemographic factors such as employment, level of income,
and presence of spouse or partner support had only a
small influence on quality of life. Assessments of quality of life in other pregnant populations are limited.6
Depression is common among women of childbearing age, and is more common among low-income
ethnoracial minority groups.79 Rates of depression in
pregnancy have ranged from 10 30% depending on the
diagnostic criteria used and population studied.10,11
Depressed mood during pregnancy places women at
risk for postpartum depression,11 is associated with
adverse obstetric outcomes including low birth
weight12 and preeclampsia,10 and increases the likelihood that women will engage in adverse health behaviors such as smoking.13 Undiagnosed and untreated
depression is especially serious because of its potential
to affect parenting behavior and indirectly affect the
offspring.14,15
Wells et al16 found that depressive disorder and
depressive symptoms in the absence of disorder are
associated with limitations in multiple dimensions of
patient well-being. Thus, it may be important to direct
treatment during pregnancy toward improvement in
emotional and physical function and quality of life. The

Obstetrics & Gynecology

purpose of this study was to describe well-being (perceived quality of life and functional status) among
low-income minority women in late pregnancy, and to
assess the relationship of functional status to social
support and depression in this population.

Table 1. Dimensions in the Medical Outcomes Study Short

Form 36 Questionnaire
Dimension

Number of
items

Physical functioning

10

Role-physical

Bodily pain

General health

Vitality

Social functioning

Role-emotional

Mental health

Materials and Methods

This study was approved by the institutional review
boards of Fordham University, Albert Einstein College
of Medicine, and Montefiore Medical Center. Between
November 1998 and July 2000, we conducted chart
reviews of women over the age of 18 receiving prenatal
care at three community health centers serving lowincome populations in the Bronx, New York. Women
were excluded if greater than 32 weeks gestation at the
time of review, other than black or Hispanic, found to
have a major mental illness, active substance abuse, or
significant medical or obstetric complications of pregnancy, including any condition requiring referral to a
high-risk obstetric provider. Eligible subjects were invited to participate in a randomized trial of a social
work intervention during pregnancy. Subjects were
informed that they might receive services to help decrease the stresses they encounter in their lives which
sometimes lead to depression.
Subjects who consented to participate in the randomized trial completed a baseline interview, in English or
Spanish, consisting of demographic data and multiple
questionnaires assessing depression, social support,
functional status, life events, and perceived parenting
competency. The initial interview was administered by
black or Hispanic female research assistants in the late
second or early third trimester (mean 28.3 weeks, standard deviation [SD] 2.7). Initial data were collected at
this point in pregnancy because 1) depressive symptomatology peaks in late pregnancy,11 2) most exclusion
criteria have been identified, and 3) we sought inclusion
of as many women as possible (including late care
seekers). This analysis uses data from the baseline
interviews and questionnaires, completed before randomization, of all study participants.
Health-related functional status was measured using
the SF-36,1719 which obtains subject perceptions of
general health, bodily pain, physical role, emotional
role, social functioning, mental health, vitality, and
physical functioning. This measure has been used extensively to evaluate health-related functional status in
a variety of populations. It has been used to assess the
effects of physical and psychiatric problems on that
status.16,20 These dimensions are described in Table 1.
An absolute score for each dimension of health in the
SF-36 was transformed into a score of 0 100, indicating

VOL. 97, NO. 6, JUNE 2001

Definition
Extent to which health
interferes with a variety of
activities in life
Problems with work or other
daily activities as a result
of physical health
Extent of bodily pain in the
last 4 weeks
Personal evaluation of general
health
Perception of degree of
fatigue or energy
Extent to which health
interferes with normal
social activities
Problems with work or other
activities as a result of
emotional problems
General mood or affect,
psychological well-being in
the last 4 weeks

From Ware.17

the percentage of the possible score, with a score of 100

representing optimal health.
Depression was assessed using the Beck Depression
Inventory, second edition (BDI-II).21 The BDI-II is a
21-item self-report inventory that assesses intensity of
depressive symptomatology in such areas as mood,
pessimism, guilt, sense of failure, suicidal thoughts,
fatigue, and weight loss. A total depression score is
obtained by summing the ratings of the 21 items,
yielding a possible range from 0 63. The BDI is 86
100% sensitive for detecting depression in primary care
patients when a cutoff of 11 or greater is used.2223 Prior
studies have used the BDI in pregnancy,24 29 and have
established that it has satisfactory performance as a
screening test during pregnancy.25 Some overlap of
depressive symptoms and the somatic symptoms of
pregnancy (eg, fatigue, change in sleep, or appetite)
results in an increase in BDI scores during pregnancy.25
We adjusted the cutoff point to 14 for our operational
definition of depression to account for this increase.
Social support was assessed using the 1995 Norbeck
Social Support Questionnaire30,31 (NSSQ), an instrument developed for use in pregnancy. This measure
allows subjects to list and rate their own social support
network, first by naming all the persons available to
them for support and then indicating how much support is available from these people in certain everyday
situations. There are three summary variables derived
from the NSSQ: total functional support (ie, affect,

McKee et al

Functional Status in Pregnancy

989

affirmation, and aid), total network (total number in

network, frequency of contact, duration of relationships), and total loss (number of different types of
persons and amount of support lost).
Data were analyzed using the SPSS 9.0 (SPSS Inc.,
Chicago, IL) statistical program. Because of the ordinal
nature of the data from the BDI, NSSQ, and SF-36,
nonparametric statistics were used. Depressive symptoms as measured by the BDI were also treated as
dichotomous variables to compare depressed and nondepressed subjects with regard to social support and
functional status. Kruskal-Wallis one-way analyses of
variance were used to examine these group differences.
The relationships of health-related functional status,
depression, and social support were evaluated using a
Spearman correlation matrix to examine the scores.

Results
From the potential sample of women who initiated
prenatal care at the health centers during this period
(n 491), 230 were not eligible to participate. Nonmutually exclusive reasons for ineligibility included: age
less than 18 years (n 43), prior stillbirth or neonatal
death (n 13), human immunodeficiency virus infection (n 5), major mental illness (n 8), high-risk
pregnancies (n 41), and/or gestational age greater
than 32 weeks at the time of review (n 66). Some
eligible women (n 106) could not be contacted to be
recruited. Of the 155 women who were eligible and
asked to participate, 41 refused and 114 agreed, for a
participation rate of 74%. Of the 114 women who
participated, one had responses very different from the
average. This 38-year-old black subject had scores
greater than 4 SDs above the mean on several of the
measures. It was determined that she was an outlier
and her responses were excluded from data analysis.
Finally, eight subjects had missing data and were therefore not included in data analysis. This resulted in a
total of 105 participants.
Demographics of participants are described in Table
2. Women had a mean age of 24 years (standard
deviation 5.0). Subjects identified themselves as
Puerto Rican (43%), black (39%), Dominican (11%), and
other (7%). The majority reported that they grew up in
the United States. The majority of the subjects parents
were born in the United States, with the second largest
birth-place being Puerto Rico (30% of fathers and 27% of
mothers). Most subjects completed 12 years of schooling. Twenty-three percent of women were full-time
homemakers, 12% worked full time, 8% worked parttime, and the remainder were unemployed. Single
mothers made up just over half of subjects (52%).
Subjects began prenatal care at a mean of 13 weeks

990 McKee et al

Functional Status in Pregnancy

Table 2. Subject Demographics

Maternal ethnicity
Dominican
Puerto Rican
Mexican
Other Central/South American
Black (African American)
Jamaican
Living children
0
1
2
3
4
Marital status
Single
Married
Living with partner
Separated
Divorced
Time living at current address
1 y
13 y
46 y
6 y

Maternal age (y)

Maternal education

(%)

11
45
2
54
41
2

(10.5)
(42.9)
(1.9)
(3.8)
(39.0)
(1.9)

39
37
16
19
4

(37.1)
(35.2)
(15.2)
(8.6)
(3.8)

55
23
23
3
1

52.4
21.9
21.9
2.9
1.0

23
29
20
33

21.9
27.6
19.0
31.4

Mean

SD

Range

105
105

24.0
12.0

5.0
1.96

18 40
717

SD standard deviation.

gestation with a range of 5 to 27 weeks. A substantial

minority of subjects were nulliparous (37%).
The relationship between health-related functional
status, depression, and social support is seen in Table 3.
Depression is strongly negatively correlated with all
health-related functional status subscale scores of the
SF-36. Strongest correlations between the BDI score and
SF-36 subscale scores are seen on the mental health (r
.69), vitality (r .63), social functioning (r .62),
and role-emotional (r .54) subscales. Functional
status and social support do not show the same strength
of correlation. The total functional support score on the
NSSQ is only mildly related to mental health (r .24),
role-emotional (r .19), and social functioning scores
(r .14). Total network score is only mildly related to
mental health and role-emotional scores (both at r
.18), and total loss is only mildly correlated with general
health (r .15) and role-emotional (r .23) subscales. There is a mild negative correlation between the
total functional support score and depression (r
.21).
Our sample showed elevated levels of depressive
symptomatology, with a mean BDI-II score of 15 (standard deviation 8.6). Over half (51%) of participants
were categorized as depressed (BDI score 14 or higher).

Obstetrics & Gynecology

Table 3. Relationship Among Health-Related Functional Status, Depression, and Social Support in Minority Women in Late
Pregnancy
Phys
func
Phys func
Role-phys
Pain
Gen health
Vital
Social func
Role-emot
Mental health
BDI
TFS
TN
TL

Rolephys
0.32*
1

Pain

0.22
0.42*
1

Gen
health
0.36*
0.41*
0.38*
1

Vital
0.34*
0.46*
0.41*
0.41*
1

Social
func
0.19
0.40*
0.47*
0.40*
0.56*
1

Roleemot
0.16
0.63*
0.27*
0.34*
0.33*
0.44*
1

Mental
health

0.18
0.34*
0.39*
0.42*
0.59*
0.51*
0.51*
1

BDI

0.23
0.42*
0.42*
0.46*
0.63*
0.62*
0.54*
0.69*
1

TFS

TN

TL

0.07
0.06
0.09
0.06
0.12
0.14
0.19
0.24
0.21
1

0.02
0.08
0.03
0.02
0.04
0.08
0.18
0.18
0.14
0.94*
1

0.00
0.12
0.07
0.15
0.05
0.12
0.23
0.12
0.06
0.04
0.01
1

Medical Outcomes Study Short Form 36 Questionnaire subscales: Phys func physical functioning; Role-phys role-physical; Pain bodily
pain; Gen health general health; Vital vitality; Social func social functioning; Role-emot role-emotional; BDI Beck Depression Inventory;
Norbeck Social Support Questionnaire subscales: TFS total functional support; TN total network; TL total loss.
Spearman correlation: * P .01, P .05.

The scores on the health-related functional status subscales in this population were lowest for the vitality and
physical role subscales. Health-related functional status
scores were significantly lower for depressed pregnant
subjects on all of the eight subscales of the SF-36 (Table
4). There were no significant differences in total functional support, total social network, and total loss scores
between the two groups.

Discussion
Previous research by Hueston and Kasik-Miller5 has demonstrated that pregnancy has a predictable effect on physical, but not emotional dimensions of perceived functional
status in a sample of pregnant white women in the
midwest. Our results demonstrate that a low-income,
urban minority population is different in important re-

spects. Similar to Hueston and Kasik-Miller,5 we found a

decrease in vitality score compared with nonpregnant
women. However, in our sample, we also found reductions in perceived emotional well-being, indicated by
lowered scores in such dimensions as social functioning,
mental health, and emotional role functioning.
Over half of the healthy pregnant women in our
study showed elevated levels of depressive symptoms.
Our results are similar to Wells et al16 in that depression
is strongly related to a global reduction in the dimensions of perceived well-being. The number of depressive symptoms is strongly correlated with all measures
of physical and mental well-being as measured by the
SF-36. Of note, the decrease in functional status is not
limited to emotional dimensions, but is pronounced as
well in the physical subscales measured by the SF-36
instrument.

Table 4. Mean Values of Functional Status and Social Support for Depressed* and Nondepressed Pregnant Women
Dimension
Functional status
Physical functioning
Role-physical
Bodily pain
General health
Vitality
Social functioning
Role-emotional
Mental health
Social support
Total functional
Total network
Total loss

Overall

Depressed

Nondepressed

58.7 (20.8)
49.8 (38.5)
58.6 (27.0)
74.5 (19.7)
47.2 (22.0)
70.5 (25.4)
72.1 (36.7)
70.3 (20.7)

54.9 (21.3)
34.9 (33.7)
47.4 (26.0)
66.1 (20.0)
35.6 (18.4)
56.8 (24.3)
53.5 (39.4)
58.3 (19.8)

62.5 (19.8)
65.0 (37.5)
70.0 (23.2)
83.3 (15.4)
59.0 (18.9)
84.4 (18.0)
91.0 (21.0)
82.5 (13.2)

.059
.001
.001
.001
.001
.001
.001
.001

95.9 (49.1)
49.9 (26.0)
2.2 (3.4)

89.9 (49.2)
48.2 (25.0)
2.3 (3.5)

102.0 (48.8)
51.8 (27.2)
2.1 (3.3)

.128
.282
.807

Values presented as mean (standard deviation).

* Beck Depression Inventory score 14.

Analyses were based on one-way analysis of variance.

VOL. 97, NO. 6, JUNE 2001

McKee et al

Functional Status in Pregnancy

991

Prior studies have demonstrated that maternal depression may have a deleterious effect on childbearing
practices, and ultimately, infant behavioral outcomes.15,32 It is not known if the pronounced decrease
in multiple dimensions of health-related functional status and perceived well-being may also indirectly effect
the offspring. Substantial alterations in functional status
for many women may potentially affect health utilization in important ways such as adherence to treatment
recommendations and appointment keeping for mothers and their children. The increase in depressive symptoms and decrease in multiple dimensions of functional
status seen in our sample suggest that low-income
ethnoracial minority women may experience greater
levels of distress during pregnancy than other women.
Of note, the number of supports available was unrelated to functional status, ie, having more supports did
not help to reduce the impact of depression on functional status. This suggests not only a need for health
care providers to be sensitive to cultural factors, but that
case management services for these low-income women
may reduce the deleterious impact of depression during
pregnancy.
Some limitations of this research should be considered. Despite substantial experience with the BDI in
pregnancy, there is no consensus on the appropriate
cutoff point to identify depression during pregnancy.
Holcomb et al25 found that a cutoff of greater than 16 in
their population (with a mean BDI score of 11) resulted
in a positive predictive value of 0.5 and a negative
predictive value of 0.98. We chose to use 14 or higher,
increasing sensitivity at the expense of specificity. Nevertheless, the average score in our sample is substantially higher than previous studies with pregnant women24 29 suggesting that there is more distress in this
population. Similarly, the global decreases in functional
status seen among those who scored in the depressive
range on the BDI suggest that these symptoms have
clinical significance.
Because our sample was limited to low-income minority women, it is not possible to untangle the relative
contribution of ethnicity, environment, and poverty.
Thus, comparison of our findings to the Hueston and
Kasik-Miller sample5 is limited by population differences other than ethnicity. Future studies should compare functional status in pregnancy across socioeconomic class within the same ethnic group as well as
across various ethnic groups within the same socioeconomic class. We measured functional status at only one
point in pregnancy, though Hueston and Kasik-Miller5
demonstrated that the SF-36 scores are not static as
pregnancy progresses. Thus, our comparison is to the
average of the scores in the Hueston study though our
measurement was in the early third trimester. Future

992 McKee et al

Functional Status in Pregnancy

research should evaluate the relationship between functional status and depression at multiple points throughout pregnancy. Finally, subjects who entered prenatal
care in the third trimester may be a very different
population, not represented in our sample. Similarly,
we do not know whether those women who refused
participation had better, worse, or equal profiles.

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Address reprint requests to:

M. Diane McKee, MD, MS

Department of Family Medicine
Albert Einstein College of Medicine
1300 Morris Park Avenue
Bronx, NY 10461
E-mail: mckee@aecom.yu.edu

Received September 25, 2000.

Received in revised form January 24, 2001.
Accepted February 15, 2001.
Copyright 2001 by The American College of Obstetricians and
Gynecologists. Published by Elsevier Science Inc.

McKee et al

Functional Status in Pregnancy

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