Using Home Visitors to Address Postpartum Depression in Low-Income Women

It is estimated that 20% of low-income women suffer from postpartum depression, with another 30-45% of low-income women exhibiting elevated depressive symptoms. These prevalence rates make postpartum depression more common than gestational diabetes, preterm labor, low birthweight, pre-eclampsia, and hypertension. Despite their disproportionate prevalence (double that of higher SES women), low-income women are less likely to receive mental health services in the perinatal period due to multiple factors including stigma and lack of access to community-based mental health providers, especially in rural communities. Home visiting (HV) programs provide services to pregnant women and new mothers, with over 1 million women receiving HV across all 50 states, making HV one of the largest avenues where women engage with services during the perinatal period. Most HV programs nationally use paraprofessional home visitors (i.e., lay health workers) to provide services. The Mothers and Babies Course (MB) is an evidence-based intervention with demonstrated efficacy in reducing depressive symptoms and preventing the onset of major depression for perinatal women when implemented in a group format by mental health professionals (e.g., social worker, psychologist). Recently, MB has been adapted to be delivered via a 1-on-1 format (MB 1-on-1), in which home visitors deliver MB 1-on-1 in 12, 15-20 minute sessions during regularly scheduled home visits. This project will evaluate MB 1-on-1 when delivered by home visitors to low-income women in all 32 Healthy Start Coalitions. U.S. Census Bureau data indicate that 46% of Florida counties have poverty rates >20%. The “typical” model for providing mental health services to HV program clients is referral to external mental health providers or clinicians co-located within an agency. There is consistent evidence showing limited uptake of services when postpartum clients are referred to external mental health providers, and limitations to co-location models (e.g., no pre-existing relationship to promote uptake, costly behavioral health staff, and inconsistent availability of clinicians in rural areas). This project will disrupt “business as usual” by: 1) delivering MB 1-on-1 within the structure of an already existing service (HV); 2) using staff already salaried by HV programs to deliver the intervention, thereby eliminating costs associated with hiring clinical staff; and 3) promoting development of the home visitor workforce by developing their capacity to address mental health issues among their clients. While community health workers have successfully delivered perinatal mental health interventions outside the U.S., this project will be the first to do so in the U.S. We will conduct a cluster randomized controlled trial (RCT) using an effectiveness-implementation hybrid Type 1 research design to determine the effectiveness of MB 1-on-1 on key maternal and child health outcomes, and to understand the context for intervention implementation. 2000 (1000 intervention, 1000 control) English or Spanish-speaking pregnant women, > 16 years old, with elevated depressive symptoms will be enrolled. A stepped wedge design will be used, allowing all 32 sites to serve as both control and intervention sites. Surveys will be conducted pre-intervention and 6 months later and will assess maternal and child outcomes including depressive symptoms and episodes, perceived stress, responsive parenting practices, and infant socioemotional development. Implementation outcomes related to acceptability, feasibility, fidelity, costs, a