Telephone-Based Peer Support for the Prevention of Postpartum Depression:

A Multi-site Randomized Controlled Trial

Cindy-Lee Dennis, PhD Professor in Nursing and Psychiatry, University of Toronto

Canada Research Chair in Perinatal Community Health Shirley Brown Chair in Women’s Mental Health, Women’s College Hospital

Clinical Problem

• Approximately 13% of mothers will experience a depressive episode in the first 12 weeks postpartum (O’Hara and Swain, 1996)

−For women with a history of depression, the PPD

rate is estimated to be 25%

−For women with depression during pregnancy, the PPD rate is about 50%

Most frequent form of maternal morbidity following childbirth

• Unfortunately, PPD occurs at a time when the infant is: − maximally dependent on parental care − highly sensitive to the quality of the interaction

• Concern for infant development is

warranted as mood disorders can: − be incompatible with good parenting behaviour

− cause significant stress for children

Observational Research • Children of depressed mothers compared to those of non-

depressed mothers have: −lower scores on measures of intellectual and motor development

−more difficult temperaments

−less secure attachments to their mothers

−delayed development of self-regulatory strategies

−higher levels of behavioural problems

−poorer academic performance

−fewer social competencies

−increased risk for depression

• Detailed analyses of social variables in predictive studies clearly suggest social support deficiencies significantly increase the risk of postpartum depression (PPD), especially the lack of a confidant

• Both qualitative and quantitative research results indicate the provision of support from an experienced mother (peer) may be a simple intervention with the potential to prevent PPD

Purpose

• To evaluate the effect of peer (mother-to-mother) support on the prevention of PPD among mothers identified as high-risk

Research Questions • Primary Question: Among mothers at-risk for PPD

(Edinburgh Postnatal Depression Scale [EPDS] score >9), what is the effect of peer support on PPD at 12 weeks postpartum?

• Secondary Questions: Among mothers at-risk, what is the effect of peer support on:

−PPD at 24 weeks?

−Anxiety at 12 and 24 weeks?

−Health service utilization during the first 24 weeks?

Other Research Questions • What are mothers’ evaluations of their peer support

experience?

• What are peer volunteers’ evaluations of their peer support experience?

• What are peer volunteers’ reports of the type and intensity of their activities?

• What are the costs of peer support versus usual care, from a societal perspective?

Design Overview • A randomized controlled trial with stratification based on previous

history of depression

• Seven Ontario health regions participated in the trial:

−Halton −Ottawa −Peel −Sudbury −Toronto −Windsor −York

Trial Schema

Outcomes at 24 weeks

Outcomes at 12 weeks

Usual Postpartum Care

Outcomes at 24 weeks

Outcomes at 12 weeksEvaluation of Peer Support

Usual Postpartum CarePlus Peer Support

Randomization

Eligibility AssessmentConsent

Verbal consent for further contactContact details to DCC

EPDS > 9

No further contact

EPDS < 10

Public Health Nurse Screening

Inclusion/Exclusion Criteria • Inclusion Criteria

−live birth

−discharged from hospital

−< 2 weeks postpartum

−scored > 9 on the EPDS

−ability to speak English

• Exclusion Criteria

−infant not discharged home with mother

−current use of anti-depressant or anti-psychotic medication

Consent & Randomization • 701 (72%) eligible mothers agreed to participate

• Web-based randomization (www.randomize.net)

• 349 mothers → intervention group (usual care plus

telephone-based peer support) • 352 mothers → control group (usual care)

• No significant differences between groups on baseline

variables

Support Intervention

Volunteer Coordinator

1. Recruited and trained peer volunteers

2. Matched mothers with an appropriate peer volunteer (region & ethnicity)

3. Monitored intervention implementation

4. Provided support to peer volunteers

5. Managed electronic listserv

6. Developed peer volunteer newsletters

Recruitment of Peer Volunteers • Flyers were distributed and newspaper ads were placed

throughout the diverse communities to enlist peer volunteers

• Public health nurses also referred women

• Peer volunteer selection criteria was: −ability to speak and understand English −self-reported history of and recovery from PPD −not currently suffering from depression

• Over 205 peer volunteers were recruited and attended a 4-hour training session

• Provided with a 121 page training manual and a list of local community resources for new mothers

Intervention Implementation • Asked peer volunteer to initiate contact with the mother

within 24 to 48 hours of being matched

• Out of the 349 mothers randomized to the peer support group, the intervention was initiated with 328 (94%)

• 95 (25%) mothers who received peer support continued to interact with their peer volunteer longer than the monitored 12 weeks

Intervention Dosage • Mothers received a mean of 8.8 (SD=6.0) contacts with

their peer volunteer • 49.5% were telephone conversations initiated by the peer

volunteer • The mean duration of these discussions was 14.1 minutes

(SD=18.5) • 33.4% of contacts were messages were left on mothers’

answering machines • Only 6.5% contacts were initiated by the mothers

Follow-Up Rates • 12 week assessment

− 615 (87.7%) participants

• 24 week assessment − 600 (85.6%) participants

• All outcome data was collected by research nurses blinded to group allocation and was entered directly into a Microsoft Access database

Results

Sample Characteristics • 92.2% (n= 646) married/common-law • 81% (n = 586) Canadian • 41.1% (n = 288) NOT born in Canada • 42.6% (n = 122) in Canada < 5 years

• Education

−3.1% (n = 22) elementary −19.3% (n = 135) high school −25.7% (n = 180) college −37.4% (n = 262) university: undergraduate −14.6% (n = 102) university: graduate

• Household income −9.9% = 0-$19,999

−15.5% = $20,000-$39,999

−15.2% = $40,000-$59,999

−17.4% = $60,000-$79,000

−41.4% = $80,000 or more

• 59.3% (n = 416) primiparous

• 31.1% (n = 218) history of depression

Postpartum Depression: EPDS > 12 at 12 weeks

Peer Group n (%)

Control Group n (%)

χ2 p OR 95% CI

40 (14%)

78 (25%) 12.5 0.0004 2.11 1.38-3.20

Number needed to treat = 8 Relative risk reduction = 0.46 (0.24-0.62)

Anxiety: STAI > 44 at 12 weeks

Peer Group n (%)

Control Group n (%)

χ2 p OR 95% CI

61 (20.6)

85 (26.9) 3.33 0.06 1.42 0.97-2.06

Health Service Utilization

• 24 Week Assessment −Mothers in the control group received more visits by a nurse in the “Healthy Babies Healthy Children” program than mothers in the peer group (mean 4.36 vs 3.22, p = 0.03)

Maternal Satisfaction (N=221)

Item Strongly Agree/

Agree n (%)

I had very few problems with the support I received 160 (82)

I liked my peer 184 (92)

I was able to talk to my peer when I needed to 144 (73)

I liked the support over the telephone 157 (79)

I would recommend this type of support to a friend 166 (83)

Overall, I am satisfied with my peer support experience 161 (81)

Peer Volunteer Perceptions • 121 peer volunteers (PVs) completed the Peer Volunteer

Experience Questionnaire via mail

• 94% PVs felt the training prepared them to be a volunteer • 31% PVs referred a mother to a health professional • 88% felt they grew as an individual (bidirectional support) • 80% felt they had enough support • 92% would be a PV again if they could do it over again • Overall 94% satisfied with PV program

Discussion

• Telephone-based peer support may be effective in preventing PPD among high-risk mothers

• Mothers who received peer support were at half the risk to develop PPD

• This trial is consistent with a Cochrane review that suggested interventions to prevent PPD are more likely to be successful if they are:

−Individually-based −Initiated postnatally −Target high-risk women

• Results are consistent with research linking depressive symptoms with:

−smaller social networks

−fewer close relationships

−lower perceived adequate support

• Provide additional evidence that lay people who have experienced a similar health problem or stressor can have a positive effect on psychological well-being

Training and Recruitment of Peer Volunteers

• Ads in local newspapers

• Ongoing process – lots of screening

• 4 hour–training is appropriate

• Focus on how to: −Develop a relationship

−Referral to health services or programs for mothers

Published

• Dennis, C-L., Hodnett, E., Kenton, L., Weston, J., Zupancic, J., Stewart, D., & Kiss, A. (2009). The effect of peer support on prevention of postnatal depression among high-risk women: a multi-site randomized controlled trial. British Medical Journal, 338:a3064, doi: 10.1136/bmj.a3064 (Published 15 January).

Questions?

cindylee.dennis@utoronto.ca