DOI: 10.17605/osf.io/wqkgj
title: Investigating the effects of a perinatal psychologist (PEPO) in current perinatal care on maternal mental wellbeing at 6 weeks postpartum

description: While the postpartum period is often seen as something joyful, it is also a period of great vulnerability. The importance of a healthy first 1000 days -the time spanning roughly between conception and the second birthday- for a person’s lifelong mental and physical health has been shown time and time again (De Weerth, 2018; Davis & Narayan. 2020; Russ et al. 2014). A key factor contributing to a healthy first 1000 days is having a mother free from mental health complaints. However, during the prenatal period, more than 1 in 5 women in community populations have clinically meaningful maternal mental health (MMH) problems (Browne et al. 2020). Moreover, in the postpartum, 10-17% of all mothers experience depression, 6-15% experience anxiety symptoms, and 5-38% experience stress symptoms (Shorey et al. 2018; Dennis et al. 2017; Hahn-Holbrook et al. 2018; Miller et al. 2006; Yelland et al. 2010). In addition, up to 30% experience post-traumatic stress symptoms that are related to giving birth (Alcorn et al. 2010; Haagen et al. 2015; Soet et al. 2003). Women with low educational level, from low socio-economic background, with little social support, having a multiparous pregnancy, and having a history of mental illness themselves or in the family are known to be even more at risk for experiencing mental health problems in the peripartum period (Yang et al. 2022; Rich-Edwards 2006; Furtado et al. 2018). 
Unfortunately, these MMH problems frequently still go unnoticed and untreated; e.g., of the 22% pregnant women in community care with clinically relevant mental health symptoms, 85% received no treatment whatsoever (Browne et al. 2020). For some of these women symptoms will increase, possibly developing into psychiatric illnesses with far-reaching consequences for both mother and child. Indeed, maternal mental health symptoms have previously been related to suboptimal physical and mental child development in the short- and long-term (Kingston et al.2012; Slomian et al. 2019). Postpartum MMH problems are also linked to decreased caregiving behavior, mother-infant bonding, and earlier discontinuation of breastfeeding (Field 2010, Slomian et al. 2019, Dubber et al. 2015). Maternal mental health problems and their associated consequences also have an impact on society as a whole, as a study in the United Kingdom (UK) showed that perinatal anxiety, depression and psychosis add up a total cost for society of 8.1 billion pounds per year. This amounts to a little under 10.000 pounds for each birth. These costs are a combination of healthcare costs for both mother and child, but also delayed or cancelled return to work after maternity leave (Bauer et al. 2014). Early prevention and treatment of MMH problems is hence efficient and of large societal value. 
Previous research on (early) prevention and treatment of MMH problems shows promising outcomes. Antenatal depression screening with the pre-admission midwife appointment program (PMAP) in Australia showed that of the 485 women included 4.1% was suffering from depressive symptoms measured with the Edinburgh Postpartum Depression Scale (EPDS) and 19% were currently suffering from other perinatal mental health problems. Women were 13% more likely to be referred to support after antenatal depression screening with this PMA program and all women showed decreased depressive symptoms from 10 weeks to 9 months postpartum (Kohlhoff et al. 2023). Moreover, De Graaff et al. 2020 showed that using a brief, transdiagnostic, non-specialist helper delivered psychological intervention significantly improved symptoms of depression and anxiety in 30 Syrian refugees. Similarly, a review by Werner et al. 2024 showed that four different preventive counseling interventions (Mother and Babies (MB) program, ROSE, PREPP, and MBCT-PB) were effective in the prevention of perinatal mood and anxiety disorders (PMAD). Even online interventions targeting perinatal mood and depressive symptoms were shown to be effective in reducing depression, anxiety, and stress symptoms (Haga et al, 2019; Lau et al. 2022). However, the overall quality of evidence found in the various studies was low (Lau et al. 2022), and while there is sufficient evidence for the effectiveness of these interventions for women at risk or women with severe psychological symptoms, effectiveness of these interventions for universal perinatal populations remains unclear (Missler et al. 2021). 
While in recent years there is an increase in awareness of mental health in the perinatal care, with programs stimulating screening for depression and other maternal mental health problems during pregnancy as well the postpartum period being set up, the percentage of perinatal women with unattended MMH problems remains high. Factors contributing to this remaining high percentage are diverse and complicated. Using two systematic reviews Webb et al. 2024 disentangled the barriers and facilitators of implementing and accessing perinatal mental healthcare, establishing multiple levels of barriers and facilitators (Webb et al. 2024). At an individual level different factors, such as not knowing who to go to, not knowing about or recognizing mental health problems and fear of judgement are holding women back from accessing mental health care (Webb et al. 2024; Browne et al. 2020). At the healthcare professional level, despite a study showing that midwives would be the best professionals to play the role of case managers in (Dutch) maternity care (Vacaru et al. 2020), these midwives are not schooled in screening for MMH problems (Browne et al. 2020; Webb et al. 2024), nor do they have the necessary specialized psychological knowledge of treatment and referral options (Baker et al. 2020; Webb et al. 2024). Moreover, both midwives and obstetricians are justifiably focused on the clients’ and fetal physical health and lack the necessary time during consultations to give sufficient attention to MMH problems (Baker et al. 2020; Webb et al. 2024). In addition, to date, there is no perinatal professional in integral maternity care with expertise in MMH problems. Namely, the Dutch standards for integral perinatal care do not include mental health experts in the perinatal care team (Groenen et al. 2017). Finally, there is no linking pin within the current perinatal care team that is in charge of ensuring standardized, fluid communication about MMH and psychosocial problems between all relevant professionals. This lack of systematic communication is experienced as problematic by the perinatal professionals themselves (Warmelink et al. 2020). 

This study aims to investigate the effects of the newly developed role of perinatal psychologist (PEPO; in Dutch ‘PErinatale Psychische Ondersteuner) in standard perinatal care. The roles of this PEPO entail an introductory meeting at 18-20 weeks pregnancy, screening for mental health problems using short screening questionnaires at three times in the peripartum period (at 13 weeks and 32 weeks pregnancy and at 6 weeks postpartum), if needed support in the form of psychoeducation, evidence-based supportive care, and referrals to more specialized care, and communicating, if needed, with the other professionals in perinatal care. These roles and the working method of the PEPO were specified during focus groups with all stakeholders involved. Based on the outcomes of these focus groups a protocol with the roles and working methods of the PEPO was specified. 
This current intervention study will investigate whether the PEPO intervention group compared to care-as-usual (CAU) influenced maternal mental health at 6 weeks postpartum using a two-period cross-over design. Specifically, we will look at the relation between the PEPO intervention on maternal postpartum depression, anxiety, stress, postpartum specific anxiety, post-traumatic stress symptoms, and parental self-efficacy. Besides, we will investigate the effect of the PEPO intervention, compared to care-as-usual (CAU), on health consumption. 

In addition to investigating the effect of the availability of the PEPO we will investigate the effect of receiving support after initial introduction from the PEPO on maternal anxiety and depression trajectories from 18 weeks pregnancy to 6 weeks postpartum. Lastly, if there is sufficient variability within the intervention group, we will investigate whether demographics (ethnicity, marital status, socio-economic status, and parity), and details of PEPO care (number of sessions, prenatal or postpartum sessions, online or in-person sessions, and the person carrying out the PEPO role) moderate this relation.