Hurricane María and prenatal maternal mental health: Variations in stress, social support, and depression across disaster recovery periods in Puerto Rico

Extreme weather events are increasingly associated with adverse mental health outcomes, but scarce research has examined these effects among pregnant populations. Pregnant women may be especially susceptible to psychological distress from disasters due to physiological demands of pregnancy and heightened sensitivity to environmental stressors. Using data from the PROTECT birth cohort in Puerto Rico, we assessed relationships between exposure to Hurricane María and assessments of perceived stress (PSS), depressive symptoms (CES-D), and social support (ESSI) among pregnant individuals at 28 ± 2 weeks gestation. Participants (n=2,231) were categorized into three groups based on study visit timing relative to Hurricane María: pre-hurricane (n=1097), 0-6 months post-hurricane (n=76), and >6 months post-hurricane (n=906). Multivariable linear regression and interaction models were used to assess differences across time periods and sociodemographic strata. Perceived stress scores were 0.52 points higher (SE=0.83, p=0.52) 0-6 months post-hurricane, but 1.11 points lower (SE=0.37, p<0.01) >6 months post-hurricane compared to pre-hurricane levels. Depression scores were 0.61 points higher (SE=1.04, p=0.56) initially but -2.07 points lower (SE=0.40, p<0.01) in the later period. Social support scores remained similar initially (0.06 points, SE=0.47, p=0.91) with higher scores >6 months post-hurricane (0.63 points, SE=0.17, p<0.01). Significant differences in stress scores were observed by age, education, and income, with greater impacts among older and higher-income participants. However, lower symptom scores post-hurricane may reflect adaptation, selection bias, or measurement limitations rather than true improvements. Findings underscore the need for disaster response efforts that prioritize maternal mental health and address structural inequities in recovery.