3.1. Depression Experienced by Perinatal WIC Clients

The first theme, Depression Experienced by Perinatal WIC Clients, illustrated the negative affect of maternal depression or depressive symptoms on their ability to care for themselves and their families. Subthemes such as social isolation, cycle of worries and concerns, and lack of mental health resources were identified as factors that exacerbate and perpetuate symptoms. When asked how mothers describe their depressive symptoms, one participant described the experience as:

“It’s like a cloud … They don’t see clear[ly] what’s going on … they need to [care for their family] … but they don’t have the energy. It’s not just affecting them; it’s affecting the whole family.”

In addition to the experience of depressive symptoms in the perinatal period, one WIC staff described their views on the relationship between maternal depression and food insecurity as an all-encompassing cycle of worries:

It goes to all those … daily stressors, every single day. So if … you are constantly worried about not having enough money, not having enough food, not having transportation. All of those things. And that feeds into depression and anxiety. It takes every single thing you have to get out of bed in the morning and get here. And maybe some days it’s not an option to get [to WIC] because you can’t.

From the perspective of the WIC staff, depression is not limited to the experience of depressed mood or anhedonia for these individuals; rather, the experience of lack of resources, daily stressors, and food insecurity during the perinatal period can exacerbate the mother’s emotional state. WIC staff also highlighted how depressive symptoms such as low energy or emotional withdrawal can uniquely affect a mother’s ability to activate in the face of food insecurity or psychosocial stressors. When describing how WIC clients recognize that they are food insecure while also experiencing perinatal depression, one participant shared:

It’s a hopelessness isolation ... I feel like the moms sense they don’t have food but [they don’t] have that urgency ... mentally. Mom can [go] through severe ... postpartum depression ... with good family support [but] they are feeling very isolated. They could have 10,000 people around [but they] encapsulate themselves, [so they] cannot really sense ... what’s surrounding them. It’s a protection ... mechanism. I see that a lot ... A lot of women do not speak [the] language, [and are] without transportation. They have to depend on [their] husband [to] drive them but [he] can be stuck in school ... I have [a mom] that experience[s] quite severe [depression], and she doesn’t even feed her baby. She doesn’t even remember the baby ... I mean you think rationally she loves her baby. She knows what she needs to do, but that’s what I [am] working [on] with her ... In my mind, [I] think about it like a lonely island. She’s there and ... she cannot see [a] way out. And then ... you can have so many people around her but that loneliness is very real to her.

Taken together, WIC staff identified perinatal depression as a significant concern in its own right, and that symptoms can both intensify a mother’s experience of food insecurity and be exacerbated by the many challenges this population faces.

3.2. Food Insecurity in Perinatal WIC Clients

The second theme, Food Insecurity in Perinatal WIC Clients, can be defined as challenges or barriers that WIC clients face in providing nutritious food for themselves and their families. In addition to the impact of depressive symptoms on food insecurity, financial concerns and the experience of stigma related to expressing the need for food were identified as subthemes. WIC staff primarily highlighted the disparity between health professionals’ expectations of dietary recommendations for food consumption in a given day per the USDA (2020) and the reality of the WIC clients’ experiences. One participant stated:

“In order to eat healthy like you’re supposed to, you’re supposed to eat six times a day … three good meals, three good snacks. These women don’t have that. They are lucky if they get one meal.”

Participants noted that perinatal WIC clients often cannot access sufficient nutrition for themselves or their families. Beyond the cost of the food itself, participants identified additional barriers that impede access to food. For example, participants noted that women experiencing depression might also find it difficult to mobilize or motivate themselves to go to the store or to the WIC office, or to cook for their families when they do have food.

A second barrier, lack of adequate transportation, was also identified by WIC staff. Participants noted that, some WIC clients have access to convenience stores within walking or bussing distance, yet these markets tend to lack the kinds of food needed for optimal nutrition (e.g., fruits, vegetables, whole grains). One participant described:

Even [if] they get coupons, they don’t have transportation [to] take them to the big supermarket to get the fresh produce. And that’s a hinder[ence] to access healthier food because they may have no transportation to get them to the big market where have more choice of fresh produce than if they go to little convenience store nearby the corner ... You drive through some ... low-income areas- you don’t see a green grocer but you see lots of convenience stores so those they’ll eat [those] foods. It’s not what’s ideal for their health. So that’s another thing I see. You can’t access food. The disparity is in ... accessing it because they don’t have transportation.

The third barrier identified reflects the stigma towards asking for help with obtaining food. WIC staff discussed the WIC clients’ emotional experiences with requesting help and the impact that it can have on accessing appropriate services. One focus group participant depicted the stigma some mothers experience:

It’s very shameful to have to go somewhere ... and feel like you are begging for [food]. And if you get judged by somebody, then you really feel bad. And somebody ... might have had a bad situation before they came [to WIC where they] asked for food and [were] treated bad. So they’re very cautious about talking to somebody about getting food.

WIC staff highlighted the need for nonjudgmental spaces where women in the perinatal period can feel safe enough to ask for and access the appropriate nutrition for themselves and their families. This theme underscores the challenges that WIC clients often face regarding food insecurity and food provision for themselves and their families.

3.3. Barriers Preventing Perinatal WIC Clients from Attaining Food Security and Necessary Mental Health Services

The third theme reflects the challenges faced when seeking resources aimed at overcoming food insecurity and depression. The challenges identified by WIC staff include: (1) cultural factors such as language, immigration status, and lack of familiarity with local foods; (2) lack of adequate mental healthcare services; (3) lack of adequate supportive services such as financial support, safe and affordable housing, local food pantries, crisis nurseries, appropriate referral networks, and coordinated care within systems; (4) stigma; and (5) physical isolation such as living alone or with low support.

The most consistent feedback from study participants is that WIC clients face many barriers to accessing both recommended foods (e.g., fruit, vegetables, whole grains) and adequate mental health services. Participants noted that, while there are some programs in place to provide services to low-income individuals:

“...[n]ot every agency accepts the medical card or ... does ... free based counseling without pay or sliding fee scale.”

Staff shared that many WIC-individuals could not afford the cost of therapy even with support from a sliding-scale system. Staff also highlighted that lack of coordinated care between mental health and medical providers significantly disrupts patient care and access to adequate treatment for women and pregnant people. Additionally, the lack of knowledge around available mental health resources or strategies for treating women and pregnant people with comorbid mental health concerns may exacerbate difficulties in coordinated care. As one participant stated:

We will call to try to make referrals for these women to our OBs … they will get denied access because the OBs don’t have knowledge of how to treat [women experiencing mental illness] and or they will start to treat them and they will call us and say we have got to discharge them because we just can’t handle their needs.

Participants stressed the need for improving access to mental health services and coordinated care due to the rising number of mothers and pregnant people presenting to WIC providers with a myriad of mental health concerns.

Another common response among WIC staff addressed the stigma of being a person who experiences food insecurity. Study participants noted that some individuals experience a pressure to present in a certain way to avoid judgment or be seen as lesser-than because of their socioeconomic circumstances. One participant recalled an interaction they had with a WIC client, and shared:

“...she was saying … ‘you don’t want to look poor, you don’t want anyone to perceive you as poor’ … [so] a lot of the time their stuff is … a smoke screen.”

Cultural factors such as language, familiarity with certain foods, and immigration status were also noted as potential barriers to care. For instance, participants shared that, for many, concern about becoming involved with immigration or other U.S. government entities can lead to considerable worry, and ultimately, prevent some individuals from asking for help. One participant recalled related experiences they had with WIC clients shared, “... when we start telling them … they can [get food delivered] if they’re not documented, then [they say] no … I don’t necessarily need [the food] because maybe they have [the] fear that somebody comes to [their] house.” Additionally, assumptions made around an individual’s level of familiarity with certain foods and their preparation, or around their fluency in reading the labels written in English, were identified as challenges that are often not considered. For example, one participant illustrated this point through an experience she had with a pregnant, WIC client who was diagnosed with gestational diabetes:

… she’s opening her pantries asking me, can I eat this? Can I eat that? And it was like … American food. They gave her the ingredients to make tacos. She pulled the sour cream out [and asked] ‘can I eat this?’ [I said] [n]o you don’t eat that, you put it on things. But the assumption was made that she would know how to cook tacos with it.

The discussion among study participants revealed several barriers to attaining food security and mental health treatment, including some that arise as consequences of assumptions made by supportive programming. Staff suggested that the barriers can result in perinatal WIC clients feel physically isolated from others, or as if they are on a “lonely island.”

The overarching theme of the focus-group discussions centered on the complexity of the experiences faced by WIC clients. Staff noted that it is often difficult to focus on any one issue when these individuals so often face a multitude of high-priority obstacles. As summarized by one participant:

[They will say] ‘I’m about to…be evicted from my apartment. There’s no food in the apartment. The power’s off. My refrigerator doesn’t work anyway because I don’t have any power …’ What takes precedence? So you know we can zero in on food. We can do something about that in most cases, but the other stuff is harder.