IJERPH | Free Full-Text | A Supported Online Resilience-Enhancing Intervention for Pregnant Women: A Non-Randomized Pilot Study

IJERPH | Free Full-Text | A Supported Online Resilience-Enhancing Intervention for Pregnant Women: A Non-Randomized Pilot Study

1. Introduction

The perinatal period, from conception to one year after childbirth, entails significant physical, psychological and social challenges [1]. Although several parents adapt well to the changes and challenges that they face, the perinatal period is an important time where parents are at increased risk of developing mental health problems [2]. Prevalence rates of maternal mental health problems (MMHPs) are around 20% [3,4], and are associated with adverse obstetric outcomes (e.g., preterm birth) [5,6,7]. Furthermore, offspring exposed to maternal distress in utero show an increased risk of developmental and mental health problems during childhood, adolescence and adulthood [8,9].
Studies regarding treatment interventions for MMHPs showed evidence for cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT) [10]. The effect sizes for CBT and IPT approaches were larger in populations with a diagnosed psychiatric disorder, mainly perinatal depression [11]. Studies directed to non-clinical populations with possible subclinical symptoms suffered from low adherence rates and high demands on time and costs [12]. A possible explanation may be that these interventions might be too intensive, time-consuming or be experienced as stigmatising for women with no or subclinical symptoms [13].
Therefore, preventive interventions targeting pregnant women may be beneficial in reducing the risk of developing MMHPs. A recent review and meta-analysis of Waqas et al. [14] including 21 studies (12 randomized controlled trials (RCTs), 6 pilot RCTs, 2 quasi-experimental studies and 1 cluster RCT) investigated non-pharmacological preventive interventions for perinatal anxiety and depression. Specifically, psychosocial and psychological interventions have been effective in reducing the risk of developing MMHPs [14]. However, none of these interventions directly assessed or tried to enhance resilience.
To address this gap, a 28-week, supported, online resilience-enhancing intervention for pregnant women was developed. Resilience is known as an important protective factor against stress and the development of common mental health problems [15]. In general, resilience is defined as the ability to cope with challenges, stress and adversities in life [16]. Within the perinatal context, resilience is studied as a multi-factorial construct influenced by individual, socio-cultural and environmental factors [17]. We conducted a concept analysis and two-round Delphi survey on perinatal resilience, which defined resilience as: “a circular process towards a greater wellbeing in the form of personal growth, family balance, adaptation or acceptance when faced with stressors, challenges, or adversity during the perinatal period” (p. 11). Five main attributes of perinatal resilience were identified: social support, sense of mastery, self-efficacy, self-esteem, and personality [18].
The intervention development process was based on this conceptual model of perinatal resilience [18] and informed by the Behaviour Change Wheel (BCW) framework [19]. The intervention consisted of resilience-enhancing exercises, three online group sessions and an online peer support platform. An online method of delivery was chosen, offering the advantages of accessibility, flexibility and reduced stigma. Women were not required to attend time-consuming face-to-face sessions and can more easily combine their participation with their daily activities. Online interventions offer a certain degree of anonymity which might help women overcome the stigma regarding perinatal mental health problems [20]. The process of intervention development is described extensively elsewhere [21].
This study enrolled during the outbreak of the COVID-19 pandemic, where professional support became more critical but at the same time less accessible [22]. Building resilience is an important element of mental health promotion interventions for pregnant women, especially in such crises as the COVID-19 pandemic [23,24]. By integrating a resilience-oriented approach into prevention strategies, we expect to contribute to the wellbeing of pregnant women and their families.

The aim of this pilot study is to examine the potential effectiveness of the developed intervention for pregnant women in enhancing resilience and promoting maternal mental health. The present study explored the changes in resilience, resilience attributes and maternal mental health from pregnancy up to 12 months after childbirth among women who received the intervention and those who received care-as-usual. We will study within- and between-group differences.

4. Discussion

This paper describes the potential effectiveness of a supported online intervention for pregnant women aimed to enhance resilience and promote maternal mental health. The study compared changes in resilience, resilience attributes and mental health between the intervention and control group. Despite no statistically significant differences between the two groups, interesting within-group trends were observed.

First, resilience remained stable in the intervention group, contrasting with a significant decrease in the control group. All participants in this study faced the COVID-19 pandemic, including the exceptional quarantine measures, social deprivation, fear of infection and concerns around childbirth (e.g., presence of their partner). These additional sources of stress, on top of the challenges associated with future parenthood, can negatively impact the emotional wellbeing of women and put their resilience under pressure [32,33]. In the study of Preis et al. [34], nearly a third of pregnant women experienced elevated levels of stress related to the COVID-19 pandemic [34]. Despite the fact that the results showed no significant increase in resilience, stability in resilience scores within the intervention group may be clinically significant within the COVID-19 context. The meta-analysis of Janitra et al. [35] showed that the prevalence of low resilience in the general population increased from 21% in the period January–March 2020 to 29% in April–June 2020, with a peak of 46% in the period of January–March 2021 [35]. Furthermore, we observe a decline in resilience transitioning from pregnancy to the first year after childbirth, highlighting the impact of childbirth and the challenges associated with this significant life event. Moreover, we see that the 12-week mark after childbirth (T4) represents a crucial point in the first postpartum period. Within the Belgian context, this point coincides with work resumption after maternity leave. This additional stressor can put further pressure on women’s resilience during a period already characterized by several changes and adjustments. Yet, overall resilience levels were relatively high at baseline (intervention group—M = 69.09, maximum = 100). Possibly, due to the self-referral recruitment, this intervention attracted the most resilient and motivated women. The use of a healthy, low-risk, sample of pregnant women might provide little room for improvement.
Second, perceived social support was significantly higher in the control group at baseline. This difference can be attributed to recruitment timing, with the intervention group experiencing stricter pandemic restrictions at that time. The recruitment phase for the intervention group coincided with the first and second wave of the COVID-19 pandemic. Quarantine restrictions in Belgium were strong, with a strict lockdown of three months at the start of the pandemic. At the time of recruitment for the control group, social restrictions were less severe and there were more opportunities for support. In addition, it is possible that they who expressed interest in the intervention were looking to strengthen their social support network in times of social restriction, since peer support was one of the main components of the intervention. The decrease in social support between postintervention and follow-up at six months after childbirth in the intervention group might be linked to the ending of the group sessions and reduced activity on the peer support platform. The loss of the feeling ‘we are all in this together’ that prevailed during the group sessions, may have contributed to lower perceived social support [36]. This supports the results of other studies, confirming the strong need to implement social interventions among new parents [23,33,36].
Another important finding of this study is the low attrition rate (19%) compared to other web-based interventions and interventions for treating postpartum depression in primary care [37,38]. At postintervention, 81% participants were still actively involved in the intervention. A possible explanation may be that the usual perinatal care services were limited due to the COVID-19 measures. Additionally, the online format and the human support approach may contribute to the high adherence rate. Pregnant women find online interventions acceptable and appealing [12,39,40,41]. Health-related apps or online sources with information related to physical health in pregnancy, foetal development and practical aspects of the transition to parenthood are widely used and frequently accessed by pregnant women [42]. However, studies on online interventions focusing on the psychological and social aspects of (future) parenthood are limited [43,44]. Participants in this study reported that the online format facilitated participation, encouraged them to share experience and fostered a sense of openness due to anonymity. The developed intervention incorporated a large human support component, designed to stimulate peer support and foster interaction between participants and researchers (psychologist and midwife). Supported web-based interventions focusing on perinatal mental health may be promising approaches in the prevention of MMHPs [20,45].
Additionally, the intervention was specifically designed for expectant mothers incorporating multiple components: resilience-enhancing exercises, online group sessions and a peer support platform. These components were selected based on the needs of mothers whose resilience was under pressure during pregnancy and the first year after childbirth [46]. Ayers et al. [47] stated that intervention research needs to move away from a ‘one-size fits all’ approach [47]. Therefore, the developed intervention in this study combines a range of different strategies to offer a personalised approach tailored to the needs of the participants. This may also be an explaining factor for the high adherence rate within this study. Giving the preventive approach, the intervention was designed to promote mental health rather than to reduce existing symptoms. This might explain the nonsignificant findings on maternal mental health outcomes.

4.1. Strengths and Limitations

A first strength of this study is its innovative focus on resilience attributes using a longitudinal design and directly assessing resilience through the CD-RISC. In contrast to prior research, this study broadens the perspective on perinatal mental health by not only investigating negative outcomes (e.g., depression) but also examining positive outcomes such as resilience and resilience attributes. A second strength is the intervention’s thorough development process [21], which is based on the perinatal resilience model [18] and informed by the BCW framework [19], preceded this pilot study. Third, the accessibility, online delivery method, and easily applicable nature of the intervention, either as a whole or based on the individual components, increase the potential for widespread implementation.
However, certain limitations need to be considered. First, recruitment relied mainly on individual’s motivation and most participants entered the study through self-referral. This may have led to a relatively homogeneous sample of Caucasian, well-educated women with widespread access to technology which limits the generalizability of the findings [48]. Second, the lack of randomization induced the risk of bias due to the unequal distribution of confounders between the groups. Additionally, there is a potential for bias when considering the impact of the pandemic on the intervention and control groups, given their distinct circumstances during this period. The COVID-19 restrictions changed during the data collection period, varying from strict lockdowns to more lenient rules. This variability holds the potential to influence the experiences of participants during and after pregnancy and childbirth, particularly considering the sequential recruitment of the intervention and control groups. Consequently, it may have implications for outcome measures (e.g., perceived social support). Furthermore, participation intensity (e.g. uptake of exercises) was not registered and thus not controlled for in the analysis. Another limitation is that we exclusively relied on self-reported measures. It is acknowledged that there was a risk of participant fatigue with the number of questionnaires. However, it was anticipated that the online survey might take no longer than 15–20 min in total to complete. Unfortunately, a technical malfunction led to incomplete control group follow-up data at 12 months after childbirth (T6). At last, given the exploratory nature of this pilot study testing a novel intervention, a power analysis was not conducted. Sample size determination was driven by pragmatic considerations, potentially resulting in a sample size that might be insufficient to detect a clinically significant difference.

4.2. Recommendations for Future Research

Future research needs to evaluate whether supported web-based interventions are acceptable and effective for pregnant women from other ethnicities and other education groups, who may be less likely to self-refer and interact differently with online services and interventions. Another party that is currently missing in perinatal mental health research is the partner. Further research on the needs and experiences of fathers, co-mothers or other parenting dyads might be of value to include. Within future studies, a randomized controlled trial is preferable in further investigating the effects of resilience and resilience attributes on the mental health of (expectant) parents. Also, adding biological measures (e.g., heart rate variability) may be interesting to include for validation measures. An adaptation of the current intervention in which the framework of Acceptance and Commitment Therapy (ACT) is included may be interesting. This approach is increasingly popular for the prevention and treatment of perinatal mental health problems and comprises resilience factors such as psychological flexibility and mindfulness.

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