Research report
Towards parenthood: An antenatal intervention to reduce depression, anxiety and parenting difficulties

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Abstract

Background

There have been few antenatal interventions aimed at preparing women for the transition to parenthood and previous attempts to intervene antenatally to prevent postnatal depression and anxiety have had limited impact.

Methods

We evaluated the effectiveness of an antenatal intervention which targeted risk factors for poor postnatal adjustment, with the dual aim of reducing both postnatal symptoms of depression/anxiety and parenting difficulties (a nine-unit self-guided workbook with weekly telephone support). Based on an initial feasibility study (n = 200) which confirmed a low level of help-seeking among distressed women during pregnancy, an additional community networking component was developed aimed at increasing social support and access to health professionals to facilitate treatment of current antenatal depression/anxiety, if present. In the evaluation of a second version of the intervention, pregnant women (n = 143) were randomly allocated to receive either the intervention or routine care.

Results

Following the antenatal intervention there were significantly fewer cases scoring above threshold for mild-to-severe depression/anxiety symptoms postnatally compared to routine care, along with a trend towards reduced parenting stress. The community networking component appeared helpful and women with higher baseline depression scores showed higher levels of help-seeking in both intervention and routine care groups.

Limitations

It was not possible to evaluate the efficacy of individual program components separately.

Conclusions

The findings provide support for the effectiveness of the Towards Parenthood intervention both as a preparation for parenthood program and in reducing symptoms of postnatal depression/anxiety.

Introduction

Throughout pregnancy approximately 9% of expectant mothers are depressed at any one time (according to the best meta-analytic estimates: Gavin et al., 2005). Similarly, among newly-delivered mothers 12.9% will be depressed at 3 months postpartum (Gavin et al., 2005). The impact on women's lives is profound. Depression and associated feelings of despair and hopelessness are frequently accompanied by co-morbid anxiety and consequences include poor partner relationships (Hickey et al., 2005). Furthermore, antenatal depression (AND) and anxiety have been associated not only with poor self-care and poor obstetric outcomes (Chung et al., 2001, Dayan et al., 2006, Zuckerman et al., 1989) but also with suboptimal infant outcomes (Talge et al., 2007). Postnatal depression (PND) in turn is often accompanied by an impaired mother–infant relationship linked to poor child cognitive, behavioural and social development (Milgrom et al., 2006, Milgrom et al., 2004, Murray et al., 2003). The development and validation of effective early interventions and, if possible, preventative programs are therefore highly desirable.

The weight of current evidence suggests that antenatal programs developed to date, have limited impact at preventing postnatal depression and anxiety. Psycho-education, cognitive–behavioural therapy, interpersonal therapy, non-directive counselling and problem-solving, supportive interventions and increased social support (via telephone, home or clinic), have all been evaluated, delivered either individually or in group-format (Austin et al., 2008, Brugha et al., 2000, Buist et al., 1998, Dennis and Creedy, 2004, Elliott et al., 2000, Hayes et al., 2001, Hayes et al., 2004, Munoz et al., 2007, Stamp et al., 1995, Webster et al., 2003, Zlotnick et al., 2001). However, methodological quality varies widely (see Dennis and Creedy, 2004) and small sample sizes, varying definitions of PND, different target populations (universal versus high risk) and the diversity of previous approaches make comparison difficult. Similarly, a review of antenatal classes (of varied content) found no compelling evidence of a consistent intervention effect (Gagnon and Sandall, 2007). However, some individual programs appear promising. For example, a single intervention session added to antenatal classes that focused on psychosocial issues related to becoming a parent has shown some promise (but only for women with low self-esteem: Matthey et al., 2004). Non-identification and non-treatment of existing AND in some studies further complicates interpretation of results and evidence is also scant for the effectiveness of treatment interventions for existing AND (Dennis et al., 2007). However, programs with a focus on active treatment of existing difficulties, and those delivered on an individual basis may show the most promise. Notably, very few interventions have focused specifically on strengthening the mother–infant relationship.

We aimed to develop an effective depression, anxiety and parenting preparation program that could be offered to all new mothers and have wide population coverage by:

  • i)

    maximizing the potential for population uptake by developing the program as an accessible self-help workbook with regular individual telephone support from a psychologist or postgraduate psychology trainee (telephone-based support has been shown to be effective in the perinatal period: Bullock et al., 1995),

  • ii)

    focusing directly on the reduction of risk factors for PND, anxiety and parenting dysfunction and on the strengthening of protective factor for these problems. In addition, as partner relationships are themselves a risk factor, we aimed to include a component supporting the couple in the transition to parenthood, inclusive of partners' issues,

  • iii)

    facilitating treatment of current depression and/or anxiety where present and fostering access to help and continuity of care,

  • iv)

    providing problem-solving skills for coping with future parenting and emotional health difficulties should they arise. This program was anticipated to be helpful not only for PND, but also for women who experience parenthood as stressful, who do not necessarily have significant symptoms of depression and anxiety (Miller et al., 2009).

In short, the approach aims at reducing the impact of risk factors, strengthening relationships and providing problem-solving skills for future emotional health and for the complex demands of parenting.

The core element of this approach is the targeting of known risk factors, in order to ameliorate both the symptoms of PND and vulnerability to early parenting dysfunction. The major risk factors for PND identified in meta-analytic studies (Beck, 1996, Beck, 2001, O'Hara and Swain, 1996) include: previous history of depression and/or anxiety, major negative life events, low social support, existing antenatal depression, poor partner support and low self-esteem. A recent study using data from 40,333 women also confirmed AND, antenatal anxiety, poor partner support and previous depression history as specific antenatal risk factors for PND (Milgrom et al., 2008).

Some major risk factors for parenting difficulties (Gottlieb and Pancer, 1988) overlap with major risk factors for depression (e.g., lack of social support and negative life events) as well as with other factors described in the literature including: young age, poor education, low income, other mental health problems, substance and sexual abuse, and negative cognitive style (Bailham and Joseph, 2003, Baydar et al., 2003, Buist, 1998, Combs-Orme et al., 2004, Harrison and Sofronoff, 2002, Kettinger et al., 2000, Milgrom and Beatrice, 2003). Some of these experiences can render women more vulnerable to parenting difficulties including, at the extreme, child neglect (Banyard et al., 2003). Poor levels of maternal–fetal attachment have also been linked to abuse of young children (Tsujino and Higa, 2004).

From this list we targeted issues related to risk factors that appeared amenable to change: existing depression, anxiety, reviewing stressful life events and providing problem-solving, cognitive and behavioural strategies, rethinking childhood experiences in the context of parenting, earlier family relationships, communication with partner, isolation and lack of practical support, self-esteem, parenting skills, expectations of motherhood, and perceptions of and attachment to infant.

In this paper we report the systematic process of program development and evaluation we undertook and report on the outcomes of our major aims:

  • 1)

    To conduct a feasibility study of a first version program.

  • 2)

    To produce a second version program in accord with feedback on consumer satisfaction, barriers to uptake and shortcomings in the content and format of the first version.

  • 3)

    To evaluate, in a randomised controlled trial (RCT), the effectiveness of the second version Towards Parenthood program in reducing postnatal levels of clinical depression and anxiety and in minimising potential early parenting difficulties.

Section snippets

Formative development

Seven clinical psychologists collaborated in selecting potential intervention targets based on empirical review of known risk factors for PND and parenting difficulties. Local and international parenting support programs were searched for additional targets. A prototype program was developed drawing on cognitive behavioural theory and clinical experience to target risk factors. Mothers' and fathers' workbooks were produced, each with nine units — eight antenatal and one postnatal. Couples read

Results

Fig. 1 shows the flow of participants through the RCT. Seventy-one women were randomised to the intervention and 72 to routine care. Table 2 shows the characteristics of both groups at baseline. As is appropriate in a RCT (Moher et al., 2010), no between-group tests of significance were conducted on baseline variables. Whilst the groups appeared reasonably balanced, the frequency of post-high school education was approximately 1.4 times higher in the intervention group, a potentially important

Discussion

Parenthood is a major life transition and a substantial number of new parents have difficulty navigating this period of change. The prevalence of depression in the perinatal period highlights that many women experience significant mental health difficulties; in addition, adjustment and parenting difficulties at this time are not uncommon. Because of the uncertainty involved in attempting to define, in advance, which individuals might benefit most, we developed an inclusive intervention aimed at

Role of funding source

Beyondblue had no involvement in the design, writing or the decision to submit the paper for publication.

Conflict of interest

All of the authors declare that they have no conflicts of interest in regards to this work.

Acknowledgement

We thank the beyondblue Victorian Centre of Excellence in Depression and Related Disorders for funding this project. We thank Bronwyn Leigh, Yolanda Romeo, Elizabeth Loughlin, the late Rachael McCarthy, and Bella Saunders all of whom co-authored the Towards Parenthood workbook together with JM and JE. Melina Ramp oversaw recruitment and data collection for the feasibility study. The feasibility study was carried out with the assistance of staff at the Royal Women's Hospital.

We thank Jan Ryan,

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