Maternal childhood adversity as an upstream vulnerability for prenatal alcohol use and maternal mental health

BACKGROUND: Maternal mental health and substance use during pregnancy often co-occur, yet antecedent factors contributing to both remain understudied. This analysis examined associations between maternal adverse childhood experiences (mACEs) and (a) alcohol use and (b) stress, mood, and trauma symptoms during pregnancy. METHODS: The ENRICH-2 cohort recruited pregnant individuals into mild-to-moderate Alcohol and Control groups. Alcohol use was assessed via prospective interviews and ethanol biomarkers. Maternal childhood adversity was measured with a 10-item Adverse Childhood Experiences (ACE) questionnaire, and maternal mental health was evaluated using the Perceived Stress Scale (PSS), Edinburgh Depression Scale (EDS), Generalized Anxiety Disorder-7 (GAD-7), and PTSD Checklist for DSM-5 (PCL-5). Prevalence of High mACEs (≥4) and specific ACE categories were compared using chi-squared tests. Spearman correlation examined the association between absolute alcohol per day (AAD) and mACEs in the Alcohol group. Mean mental health scores across Control, High mACEs, Alcohol, and Alcohol+High mACEs groups were compared by ANOVA and multivariable linear regression. RESULTS: Among 164 participants (58 Alcohol, 106 Control), the prevalence of High mACEs was almost double in the Alcohol compared to the Control group (37.9% vs. 20.8%, p = 0.02). For the Alcohol group, there was a positive correlation between AAD and mACEs (ρ = 0.18, p = 0.02). The mACEs categories of physical abuse, household exposure to substance use, and incarceration of a family member were significantly higher in the Alcohol group (all p < 0.05). Adjusted regression models demonstrated that both High mACEs and Alcohol groups were associated with increases in maternal mental health symptom scores, with the Alcohol+High mACEs group showing the largest model-estimated increases across all outcomes (all p values < 0.01). CONCLUSIONS: Results highlight mACEs as an upstream vulnerability associated with prenatal alcohol use and poorer maternal mental health, suggesting that mACEs-or their sequelae-may function as a contextual risk factor in pregnancy.