Antenatal depressive symptoms are common during pregnancy and affect as many as 1 in 7 pregnant individuals in the United States (US) (Yin et al., 2021; Wisner et al., 2013; Gavin et al., 2005). Antenatal depressive symptoms are more likely to affect individuals who experience adverse social determinants of health (SDOH) (Norhayati et al., 2015). SDOH are defined by the World Health Organization and US Healthy People 2030 as the non-medical factors that influence health outcomes (Healthy People 2030, 2020). SDOH focus on the social, economic, political and environmental conditions that collectively represent an individual's ecosystem. Pregnant individuals who experience a higher burden of adverse SDOH and antenatal depressive symptoms are less likely to engage in prenatal care and are more likely to have disrupted interpersonal relationships and impaired maternal-infant bonding (Treatment and management of mental health conditions during pregnancy and postpartum: ACOG clinical practice guideline no. 5, 2023; Stein et al., 2014). In addition, pregnant individuals who experience adverse SDOH and untreated antenatal depressive symptoms are at increased risk of adverse pregnancy outcomes (APOs), severe maternal morbidity (Treatment and management of mental health conditions during pregnancy and postpartum: ACOG clinical practice guideline no. 5, 2023; Screening and diagnosis of mental health conditions during pregnancy and postpartum: ACOG clinical practice guideline no. 4, 2023), and worse long-term neurodevelopmental outcomes in the child exposed in utero (Rogers et al., 2020). Addressing antenatal depressive symptoms and providing treatment to those with antenatal depression, in particular for pregnant individuals who experience a high burden of adverse SDOH, is a public health priority (Blebu et al., 2024; O'Connor and Su, 2023).

SDOH can be measured and intervened upon both at an individual (Braveman and Gottlieb, 2014) and neighborhood level (Field et al., 2024). Individual-level SDOH include income, employment status, education status, food security, health insurance, experiences of systemic racism, and housing stability. In contrast, neighborhood-level SDOH can be characterized by standardized measures that assess the above factors within a broader community, such as area-level educational and employment status, poverty, housing quality, and socioeconomic inequality (Braveman and Gottlieb, 2014). The Area Deprivation Index (ADI) is an aggregate measure that quantifies the socioeconomic status of a neighborhood based on census-derived measures of income, education, and occupation of individuals living in the immediate geographic surroundings (Kind and Buckingham, 2018). Prior studies of pregnant individuals found associations between neighborhood-level SDOH measures, such as the ADI and APOs (Wang et al., 2020; Amjad et al., 2019; Blumenshine et al., 2010), as well as individual-level SDOH and depressive symptoms (Yin et al., 2021; O'Connor and Su, 2023; Wang et al., 2020). A recent cross-sectional study also found an association between the Neighborhood Deprivation Index (NDI, conceptually similar to the ADI) and postpartum depression (Onyewuenyi et al., 2023), which is consistent with prior data from non-pregnant adults (Sui et al., 2022; Barnett et al., 2018). However, the association between neighborhood-level SDOH at the start of pregnancy and antenatal depressive symptoms later in pregnancy remains to be evaluated. Whether such an association may exist has clinical and public health implications given increasing efforts aimed at universal screening for unmet social needs as part of prenatal care and antenatal depressive symptoms for which effective pregnancy interventions exist to mitigate their impact.

The objective of the current analysis was to examine the association between neighborhood-level socioeconomic disadvantage and mid-pregnancy depressive symptoms. Because the cumulative impact of greater socioeconomic disadvantage may be heightened due to other adverse SDOH that are more frequent among minoritized subgroups (Gilster, 2016; Grobman et al., 2023), we secondarily assessed whether the above association differed by race and ethnicity, which is understood as a social construct.