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Postpartum depression (PPD) is a leading cause of complications of pregnancy and childbirth. Prevalence estimates can vary widely depending on the screening or diagnostic tool selected, cutoff point utilized, or target population. It is estimated that one in seven women in the U.S. experience PPD with higher rates found among younger women, women in lower income households, women with less than 12 years of education, unmarried women, and women experiencing stressful life events in the past year. Nearly half of all mothers who screen positive for PPD do not receive treatment. Black, Latina, and women on Medicaid during pregnancy are less likely to attend a psychiatric visit compared to white, non-Hispanic women. There is a lack of rigorous research among primarily non-white racially diverse populations comparing the effectiveness of interventions in the home setting compared to that of traditional therapeutic interventions at a clinic with a psychiatrist.
Methods: This pilot study used a randomized control trial design to measure the effectiveness of an alternative treatment option for a racially and economically diverse population who screened positive for PPD. Recruitment criteria included: living within the 48 pre-selected zip codes that were within 10 miles of the psychiatrist’s office, Edinburgh Postnatal Depression Screening (EPDS) score between 10 and 20 indicating mild to moderate symptoms, and infant age of 4 months or younger at the time of screening. A total of 156 women were randomized to either an alternative program of home visits to reduce PPD symptoms or to the standard of care protocol, referral to perinatal psychiatry. Ninety-one women were randomized to the home-visit program and 65 to psychiatry. The home visit program used a five-session program using the Problem Solving Tools For PPD (PST4PPD) model delivered by master’s level social workers. Analysis of covariance (ANCOVA) was conducted to assess the effectiveness of home visitation (intervention) and psychiatry (control) at reducing PPD symptoms measured by the EPDS. Secondary analysis included ANCOVA to assess the effectiveness of the two interventions on maternal-infant bonding and maternal self-efficacy. The interventions were evaluated using intent-to-treat analyses.
Results: Statistically significant reductions were noted in the EPDS scores for both conditions (p < .001); however, after controlling for baseline EPDS scores, there was no significant difference between the mean 6-month postpartum EPDS score across groups (p=.310). After controlling for baseline maternal self-efficacy scores, home visitation maternal self-efficacy scores at 6-months postpartum were significantly higher than psychiatric scores (p=.057).
Conclusions & Implications: Our study adds promising evidence that home visitation with a social worker for mild to moderate symptoms of PPD is not only feasible, but as effective as being treated by a psychiatrist in the clinic. With a higher proportion of mothers completing home visit sessions than psychiatry visits, greater accessibility to treatment is indicated. Social workers must consider not only effectiveness, but also, accessibility. Home visitation for maternal mental health, that literally meet the mother where she is, have the potential to increase health equity by decreasing barriers such as access, stigma and cost.