HEALTH TECHNOLOGY ASSESSMENT · 2019. 3. 12. · Professor John Powell Consultant Clinical Adviser, National Institute for Health and Care Excellence (NICE), UK Professor James Raftery

HEALTH TECHNOLOGY ASSESSMENTVOLUME 20 ISSUE 37 MAY 2016

ISSN 1366-5278

DOI 103310hta20370

A systematic review evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness the cost-effectiveness safety and acceptability of interventions to prevent postnatal depression

C Jane Morrell Paul Sutcliffe Andrew Booth John Stevens Alison Scope Matt Stevenson Rebecca Harvey Alice Bessey Anna Cantrell Cindy-Lee Dennis Shijie Ren Margherita Ragonesi Michael Barkham Dick Churchill Carol Henshaw Jo Newstead Pauline Slade Helen Spiby and Sarah Stewart-Brown

A systematic review evidence synthesisand meta-analysis of quantitative andqualitative studies evaluating the clinicaleffectiveness the cost-effectivenesssafety and acceptability of interventionsto prevent postnatal depression

C Jane Morrell1 Paul Sutcliffe2 Andrew Booth3

John Stevens3 Alison Scope3 Matt Stevenson3

Rebecca Harvey3 Alice Bessey3 Anna Cantrell3

Cindy-Lee Dennis4 Shijie Ren3 Margherita Ragonesi2

Michael Barkham5 Dick Churchill6 Carol Henshaw7

Jo Newstead8 Pauline Slade9 Helen Spiby1

and Sarah Stewart-Brown2

1School of Health Sciences University of Nottingham Nottingham UK2Division of Health Sciences Warwick Medical School University of WarwickCoventry UK

3School of Health and Related Research University of Sheffield Sheffield UK4Lawrence S Bloomberg Faculty of Nursing University of Toronto TorontoON Canada

5Clinical Psychology Unit Department of Psychology University of SheffieldSheffield UK

6School of Medicine University of Nottingham Nottingham UK7Division of Psychiatry Institute of Psychology Health and SocietyUniversity of Liverpool Liverpool UK

8Nottingham Experts Patients Group Clinical Reference Group for PerinatalMental Health Nottingham UK

9Institute of Psychology Health and Society University of LiverpoolLiverpool UK

Corresponding author

Declared competing interests of authors none

Published May 2016DOI 103310hta20370

This report should be referenced as follows

Morrell CJ Sutcliffe P Booth A Stevens J Scope A Stevenson M et al A systematic review

evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical

effectiveness the cost-effectiveness safety and acceptability of interventions to prevent postnatal

depression Health Technol Assess 201620(37)

Health Technology Assessment is indexed and abstracted in Index MedicusMEDLINE ExcerptaMedicaEMBASE Science Citation Index Expanded (SciSearchreg) and Current ContentsregClinical Medicine

Health Technology Assessment HTAHTA TAR

ISSN 1366-5278 (Print)

ISSN 2046-4924 (Online)

Impact factor 5027

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Editorial contact nihreditsouthamptonacuk

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Criteria for inclusion in the Health Technology Assessment journalReports are published in Health Technology Assessment (HTA) if (1) they have resulted from work for the HTA programme and (2) theyare of a sufficiently high scientific quality as assessed by the reviewers and editors

Reviews in Health Technology Assessment are termed lsquosystematicrsquo when the account of the search appraisal and synthesis methods (tominimise biases and random errors) would in theory permit the replication of the review by others

HTA programmeThe HTA programme part of the National Institute for Health Research (NIHR) was set up in 1993 It produces high-quality researchinformation on the effectiveness costs and broader impact of health technologies for those who use manage and provide care in the NHSlsquoHealth technologiesrsquo are broadly defined as all interventions used to promote health prevent and treat disease and improve rehabilitationand long-term care

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This reportThe research reported in this issue of the journal was funded by the HTA programme as project number 119503 The contractual start datewas in November 2012 The draft report began editorial review in August 2014 and was accepted for publication in June 2015 The authorshave been wholly responsible for all data collection analysis and interpretation and for writing up their work The HTA editors and publisherhave tried to ensure the accuracy of the authorsrsquo report and would like to thank the reviewers for their constructive comments on the draftdocument However they do not accept liability for damages or losses arising from material published in this report

This report presents independent research funded by the National Institute for Health Research (NIHR) The views and opinions expressed byauthors in this publication are those of the authors and do not necessarily reflect those of the NHS the NIHR NETSCC the HTA programmeor the Department of Health If there are verbatim quotations included in this publication the views and opinions expressed by theinterviewees are those of the interviewees and do not necessarily reflect those of the authors those of the NHS the NIHR NETSCC the HTAprogramme or the Department of Health

copy Queenrsquos Printer and Controller of HMSO 2016 This work was produced by Morrell et al under the terms of a commissioningcontract issued by the Secretary of State for Health This issue may be freely reproduced for the purposes of private research andstudy and extracts (or indeed the full report) may be included in professional journals provided that suitable acknowledgementis made and the reproduction is not associated with any form of advertising Applications for commercial reproduction should beaddressed to NIHR Journals Library National Institute for Health Research Evaluation Trials and Studies Coordinating CentreAlpha House University of Southampton Science Park Southampton SO16 7NS UK

Published by the NIHR Journals Library (wwwjournalslibrarynihracuk) produced by Prepress Projects Ltd Perth Scotland(wwwprepress-projectscouk)

Editor-in-Chief

Health Technology Assessment

NIHR Journals Library

Professor Tom Walley Director NIHR Evaluation Trials and Studies and Director of the HTA Programme UK

NIHR Journals Library Editors

Professor Ken Stein Chair of HTA Editorial Board and Professor of Public Health University of Exeter Medical School UK

Professor Andree Le May Chair of NIHR Journals Library Editorial Group (EME HSampDR PGfAR PHR journals)

Dr Martin Ashton-Key Consultant in Public Health MedicineConsultant Advisor NETSCC UK

Professor Matthias Beck Chair in Public Sector Management and Subject Leader (Management Group) Queenrsquos University Management School Queenrsquos University Belfast UK

Professor Aileen Clarke Professor of Public Health and Health Services Research Warwick Medical School University of Warwick UK

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Dr Peter Davidson Director of NETSCC HTA UK

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Professor Geoffrey Meads Professor of Health Sciences Research Health and Wellbeing Research and

Professor John Norrie Health Services Research Unit University of Aberdeen UK

Professor John Powell Consultant Clinical Adviser National Institute for Health and Care Excellence (NICE) UK

Professor James Raftery Professor of Health Technology Assessment Wessex Institute Faculty of Medicine University of Southampton UK

Dr Rob Riemsma Reviews Manager Kleijnen Systematic Reviews Ltd UK

Professor Helen Roberts Professor of Child Health Research UCL Institute of Child Health UK

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Editor-in-Chief

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Professor Jonathan Ross Professor of Sexual Health and HIV University Hospital Birmingham UK

NIHR Journals Library wwwjournalslibrarynihracuk

Abstract

A systematic review evidence synthesis and meta-analysisof quantitative and qualitative studies evaluating the clinicaleffectiveness the cost-effectiveness safety and acceptabilityof interventions to prevent postnatal depression

C Jane Morrell1 Paul Sutcliffe2 Andrew Booth3 John Stevens3

Alison Scope3 Matt Stevenson3 Rebecca Harvey3 Alice Bessey3

Anna Cantrell3 Cindy-Lee Dennis4 Shijie Ren3 Margherita Ragonesi2

Michael Barkham5 Dick Churchill6 Carol Henshaw7 Jo Newstead8

Pauline Slade9 Helen Spiby1 and Sarah Stewart-Brown2

1School of Health Sciences University of Nottingham Nottingham UK2Division of Health Sciences Warwick Medical School University of Warwick Coventry UK3School of Health and Related Research University of Sheffield Sheffield UK4Lawrence S Bloomberg Faculty of Nursing University of Toronto Toronto ON Canada5Clinical Psychology Unit Department of Psychology University of Sheffield Sheffield UK6School of Medicine University of Nottingham Nottingham UK7Division of Psychiatry Institute of Psychology Health and Society University of LiverpoolLiverpool UK

8Nottingham Experts Patients Group Clinical Reference Group for Perinatal Mental HealthNottingham UK

9Institute of Psychology Health and Society University of Liverpool Liverpool UK

Corresponding author JaneMorrellnottinghamacuk

Background Postnatal depression (PND) is a major depressive disorder in the year following childbirthwhich impacts on women their infants and their families A range of interventions has been developed toprevent PND

Objectives To (1) evaluate the clinical effectiveness cost-effectiveness acceptability and safety ofantenatal and postnatal interventions for pregnant and postnatal women to prevent PND (2) applyrigorous methods of systematic reviewing of quantitative and qualitative studies evidence synthesis anddecision-analytic modelling to evaluate the preventive impact on women their infants and their familiesand (3) estimate cost-effectiveness

Data sources We searched MEDLINE EMBASE Science Citation Index and other databases (frominception to July 2013) in December 2012 and we were updated by electronic alerts until July 2013

Review methods Two reviewers independently screened titles and abstracts with consensus agreementWe undertook quality assessment All universal selective and indicated preventive interventions forpregnant women and women in the first 6 postnatal weeks were included All outcomes were includedfocusing on the Edinburgh Postnatal Depression Scale (EPDS) diagnostic instruments and infant outcomesThe quantitative evidence was synthesised using network meta-analyses (NMAs) A mathematical modelwas constructed to explore the cost-effectiveness of interventions contained within the NMA forEPDS values

DOI 103310hta20370 HEALTH TECHNOLOGY ASSESSMENT 2016 VOL 20 NO 37

copy Queenrsquos Printer and Controller of HMSO 2016 This work was produced by Morrell et al under the terms of a commissioning contract issued by the Secretary of State forHealth This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed the full report) may be included in professional journalsprovided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising Applications for commercial reproduction should beaddressed to NIHR Journals Library National Institute for Health Research Evaluation Trials and Studies Coordinating Centre Alpha House University of Southampton SciencePark Southampton SO16 7NS UK

Results From 3072 records identified 122 papers (86 trials) were included in the quantitative review From2152 records 56 papers (44 studies) were included in the qualitative review The results were inconclusiveThe most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by themean 12-month EPDS score difference of ndash143 (95 credible interval ndash400 to 136)] person-centredapproach (PCA)-based and cognitivendashbehavioural therapy (CBT)-based intervention (universal) interpersonalpsychotherapy (IPT)-based intervention and education on preparing for parenting (selective) promotingparentndashinfant interaction peer support IPT-based intervention and PCA-based and CBT-based intervention(indicated) Women valued seeing the same health worker the involvement of partners and access toseveral visits from a midwife or health visitor trained in person-centred or cognitivendashbehavioural approachesThe most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal)PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated) althoughthere was considerable uncertainty Expected value of partial perfect information (EVPPI) for efficacy datawas in excess of pound150M for each population Given the EVPPI values future trials assessing the relativeefficacies of promising interventions appears to represent value for money

Limitations In the NMAs some trials were omitted because they could not be connected to the mainnetwork of evidence or did not provide EPDS scores This may have introduced reporting or selection biasNo adjustment was made for the lack of quality of some trials Although we appraised a very large numberof studies much of the evidence was inconclusive

Conclusions Interventions warrant replication within randomised controlled trials (RCTs) Several interventionsappear to be cost-effective relative to usual care but this is subject to considerable uncertainty

Future work recommendations Several interventions appear to be cost-effective relative to usual carebut this is subject to considerable uncertainty Future research conducting RCTs to establish whichinterventions are most clinically effective and cost-effective should be considered

Study registration This study is registered as PROSPERO CRD42012003273

Funding The National Institute for Health Research Health Technology Assessment programme

ABSTRACT

Contents

List of tables xvii

List of figures xxi

List of boxes xxvii

Glossary xxix

List of abbreviations xxxi

Plain English summary xxxiii

Scientific summary xxxv

Chapter 1 Background 1Description of health problem 1

Prevalence 2Impact of health problem 2

Current service provision 3Variation in service and uncertainty about best practice 3Identification of postnatal and antenatal depression 3Current service costs 4

Description of technology under assessment 4Preventive interventions for postnatal depression 4

Evidence of preventive interventions 5Psychological approaches to the prevention and treatment of depression 5Educational interventions 6Social support 6Pharmacological interventions or supplements 7Complementary and alternative medicine 7

Summary 8

Chapter 2 Definition of the decision problem 9Decision problem 9Overall aim and objectives of assessment 9

Service user involvement 10

Chapter 3 Review methods 13Overview of review methods 13Methods for reviewing and assessing clinical effectiveness 13

Search strategies for identification of studies 13Search strategy for randomised controlled trials and systematic reviews 13

Review protocol 16Inclusion and exclusion criteria for quantitative studies 16

Search strategy and outcome summary for the qualitative studies 20Electronic databases 20

Study selection 20Study selection criteria and procedures for the quantitative review 20Study quality assessment checklists and procedures for the randomised controlled trials 20Data extraction for randomised controlled trials 20Data synthesis of randomised controlled trials 21

Meta-analysis of randomised controlled trials 21Methods of evidence synthesis 21Methods for the estimation of efficacy 22

Methods for reviewing and assessing qualitative studies 27Study selection criteria and procedures for the effectiveness review 27Inclusion and exclusion criteria for qualitative studies 28Study quality assessment checklists and procedures for qualitative studies 29Data extraction strategy for qualitative studies 29Data synthesis for qualitative studies 29

Synthesis drawing upon realist approaches 29Identification of key potential CLUSTERs 29Searching for CLUSTER documents 30Synthesis and construction of a theoretical model 30

Integrating quantitative and qualitative findings 32

Chapter 4 Overview of results for quantitative and qualitative studies 33Literature search for the quantitative review 33

Quantitative review study characteristics 33Yield of systematic reviews 33Quantitative review study characteristics 33Outcome assessment 35Quality of quantitative studies 35Quality of systematic and other reviews 36

Literature search for the qualitative review 36Qualitative studies level of preventive intervention 36Qualitative review study characteristics 44Qualitative review study characteristics personal and social support strategy studies 44Quality of the qualitative intervention studies 45Certainty of the review findings intervention studies 45Overview of main findings from qualitative intervention studies (all levels) 45Quality of the qualitative personal and social support strategy studies 51Qualitative studies further analysis by level of preventive intervention universalselective and indicated 51

Chapter 5 Results for universal preventive intervention studies 53Characteristics of randomised controlled trials of universal preventive interventions 53

Description of qualitative studies of universal preventive interventions 53Universal preventive interventions psychological interventions 55

Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of psychological interventions 55Description and findings from qualitative studies of universal preventive interventionsof psychological interventions 55

Universal preventive interventions educational interventions 61Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of educational interventions 61

CONTENTS

Universal preventive interventions social support 61Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of social support 61Description and findings from qualitative studies of universal preventive interventionsof social support 61

Universal preventive interventions pharmacological agents or supplements 69Characteristics and main outcomes of randomised controlled trials of universalpreventive intervention of pharmacological agents or supplements 69

Universal preventive interventions midwifery-led interventions 69Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of midwifery-led interventions 69Description and findings from qualitative studies of universal preventive interventionsof midwifery-led interventions 76

Universal preventive interventions organisation of maternity care 79Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of organisation of maternity care 79Description and findings from qualitative studies of universal preventive interventionsof organisation of maternity care 79

Universal preventive interventions complementary and alternative medicine or other 85Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of complementary and alternative medicine or other 85Description and findings of qualitative studies of universal preventive interventions ofcomplementary and alternative medicine or other 85

Results from network meta-analysis for universal preventive interventions for EdinburghPostnatal Depression Scale threshold score 89

Results for universal preventive interventions for Edinburgh Postnatal Depression Scalethreshold score at 6 weeks postnatally 90Results for universal preventive interventions for Edinburgh Postnatal Depression Scalethreshold score at 3 months postnatally 92Results for universal preventive interventions for Edinburgh Postnatal Depression Scalethreshold score at 6 months postnatally 92Results for universal preventive interventions for Edinburgh Postnatal Depression Scalethreshold score at 12 months postnatally 95Summary of results from network meta-analysis for universal preventive interventionsfor Edinburgh Postnatal Depression Scale threshold score 97

Results from network meta-analysis for universal preventive interventions for EdinburghPostnatal Depression Scale mean scores 97

Summary of results from network meta-analysis for universal preventive interventionstudies for Edinburgh Postnatal Depression Scale mean scores 101

Summary of results for universal preventive interventions for Edinburgh PostnatalDepression Scale threshold and Edinburgh Postnatal Depression Scale mean scores 102

Overall summary of results for universal preventive interventions for EdinburghPostnatal Depression Scale threshold and Edinburgh Postnatal Depression Scalemean scores 102

Chapter 6 Results for selective preventive intervention studies 103Characteristics of randomised controlled trials of selective preventive interventions 103

Description of qualitative studies of selective preventive interventions 104Selective preventive interventions psychological interventions 105

Characteristics and main outcomes of randomised controlled trials of selectivepreventive interventions of psychological interventions 105Description and findings from qualitative studies of selective preventive interventionsof psychological interventions 105

Selective preventive interventions educational interventions 111Characteristics and main outcomes of randomised controlled trials of selectivepreventive intervention of educational interventions 111Description and findings from qualitative studies of selective preventive interventionsof educational interventions 111

Selective preventive interventions social support interventions 117Characteristics and main outcomes of randomised controlled trials of selectivepreventive interventions of social support 117

Selective preventive interventions pharmacological agents or supplements 122Characteristics and main outcomes of randomised controlled trials of selectivepreventive interventions of pharmacological agents or supplements 122

Selective preventive interventions midwifery-led interventions 122Characteristics and main outcomes of randomised controlled trials of selectivepreventive interventions of midwifery-led interventions 122Description and findings from qualitative studies of selective preventive interventionsof midwifery-led interventions 122

Selective preventive interventions organisation of maternity care 127Selective preventive interventions complementary and alternative medicine orother interventions 127Results from network meta-analysis for selective preventive interventions for EdinburghPostnatal Depression Scale threshold score 127

Results from network meta-analysis for selective preventive intervention for EdinburghPostnatal Depression Scale threshold score at 6 weeks postnatally 128Results from network meta-analysis for selective preventive intervention for EdinburghPostnatal Depression Scale threshold score at 3 months postnatally 130Results from network meta-analysis for selective preventive intervention for EdinburghPostnatal Depression Scale threshold score at 6 months postnatally 132Summary of results from network meta-analysis for selective preventive interventionsEdinburgh Postnatal Depression Scale threshold score 132

Results from network meta-analysis for selective preventive interventions for EdinburghPostnatal Depression Scale mean scores 135

Summary of results from network meta-analysis for selective preventive interventionsfor Edinburgh Postnatal Depression Scale mean scores 138

Chapter 7 Results for indicated preventive intervention studies 139Characteristics of randomised controlled trials of indicated preventive interventions 139

Description and findings from qualitative studies of indicated preventive interventions 139Indicated preventive interventions psychological interventions 141

Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of psychological interventions 141

Indicated preventive interventions educational intervention 141Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of educational interventions 141

Indicated preventive interventions social support 141Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of social support 141Description and findings from qualitative studies of indicated preventive interventionsof social support 158

Indicated preventive interventions pharmacological agents or supplements 158Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of pharmacological agents or supplements 158

CONTENTS

Indicated preventive interventions midwifery-led interventions 158Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of midwifery-led interventions 158

Indicated preventive interventions organisation of maternity care 163Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of organisation of maternity care 163Description and findings of qualitative studies of selective preventive interventions ofthe organisation of maternity care 163

Indicated preventive interventions complementary and alternative medicine orother interventions 165

Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of complementary and alternative medicine orother interventions 165

Results from network meta-analysis for indicated preventive interventions for EdinburghPostnatal Depression Scale threshold score 165

Results from network meta-analysis for indicated preventive intervention forEdinburgh Postnatal Depression Scale threshold scores at 6 weeks postnatally 168Results from network meta-analysis for indicated preventive intervention forEdinburgh Postnatal Depression Scale threshold scores at 3 months postnatally 169Results from network meta-analysis for indicated preventive intervention forEdinburgh Postnatal Depression Scale threshold scores at 4 months postnatally 171Results from network meta-analysis for indicated preventive intervention forEdinburgh Postnatal Depression Scale threshold scores at 6 months postnatally 172Summary of results from network meta-analysis for indicated preventive interventionfor Edinburgh Postnatal Depression Scale threshold scores 174

Results from network meta-analysis for indicated preventive intervention for EdinburghPostnatal Depression Scale mean scores 174

Summary of results from network meta-analysis for indicated preventive interventionfor Edinburgh Postnatal Depression Scale mean scores 177

Chapter 8 Results of realist synthesis what works for whom 179Introduction to Best Fit Realist Synthesis 179Results of the review 179Synthesis drawing upon realist approaches 179

Description of included personal and social support strategy studies 179Study respondents in the personal and social support strategy studies 180Study setting of the personal and social support strategy studies 180

Synthesis of findings across personal and social support strategy studies 180Searching for CLUSTER documents for realist synthesis 181Preliminary synthesis and construction of a theoretical model 181

Identification of provisional lsquobest fitrsquo conceptual framework for realist synthesis 183Population of the conceptual framework 183Identification of existing theory underpinning specific mechanisms 183

Development of a programme theory 191Group-based interventions 191Continuity of care 191Individual-centred interventions 192Considerations shared by group-based and individual-centred interventions 192Support to providers 193Components of the interventions 193Sustainability 194

Construction of pathways or chains from lsquoifndashthenrsquo statements 194Mechanisms for improving appropriateness of strategies 194On adverse effects 195

Testing of the programme theory and integrating quantitative and qualitative findings 196Response from the service user group to optimal characteristics identified from thequalitativerealist reviews 197

Modifications to the list 197Additions to the list 197Additional nuances emerging from the consultation 200

Summary of findings from realist synthesis review 200

Chapter 9 Assessment of cost-effectiveness 203Systematic review of existing cost-effectiveness models 203

Identification of cost-effectiveness studies 203Study selection criteria and procedures for the health economics review 204Overview of papers included in the health economics review 204Population considered in the health economics review 204Interventions in the health economics review 209Health-related quality-of-life data in the health economics review 209Costs and health-care resources reported in the health economics review 210Main results reported in the health economics review 218Summary of appropriateness of previously published models 218

The de novo model 218The conceptual model 218Model parameters 220The effectiveness data for each intervention 220The incremental costs associated with each intervention 220The relationship between utility and Edinburgh Postnatal Depression Scale scores 226The relationship between total health costs and Edinburgh Postnatal DepressionScale scores 229The analyses undertaken 231

Results 232The estimated quality-adjusted life-year gain compared with usual care foreach intervention 232Calculating cost per quality-adjusted life-year values 235Producing cost-effectiveness acceptability curves 240Interpretation of the cost-effectiveness results produced 242Interventions for the universal preventive interventions 243Interventions for the selective preventive interventions 243Interventions for indicated preventive interventions 243Assessing the impact of using total health-care costs when these were availablerather than intervention costs 243

Value of information results 244Expected value of perfect information results 244Expected value of partial perfect information results 245Discussion of the assessment of cost-effectiveness of interventions 246

Chapter 10 Discussion 247Introduction 247Description of the interventions 247Levels of preventive intervention 248Conceptualisation of postnatal depression and the potential for prevention 248Focus of the included interventions 248

CONTENTS

Network meta-analyses 249Clinical effectiveness of universal preventive interventions 249

Psychological interventions 249Pharmacological or supplements 249Midwifery-led interventions 250Universal preventive interventions not included in the network meta-analysis 250Summary of qualitative findings for universal preventive interventions 251

Clinical effectiveness of selective preventive interventions 251Psychological interventions 251Educational interventions 252Social support 252Summary of qualitative findings for selective preventive interventions 252

Clinical effectiveness of indicated preventive interventions 252Indicated preventive interventions not included in the network meta-analysis 252Social support 253Pharmacological or supplements 253Complementary and alternative medicine or other interventions 253Summary of qualitative findings for indicated preventive interventions 253

Economic analysis 253Limitations of the quantitative evidence base 254

Replication of interventions 254Moderators and mediators 254

Limitations of the included trials 255Quality of the trials 255Heterogeneity of trial participants 255Intervention provider 255Usual care in the UK 255Measures of depression 255Treatment end points 256Infant outcomes 256

Strengths of the review 256Limitations of the review 257Discussion of all qualitative findings 257The implications of the main findings of this review 258

Findings associated with the evidence base methodological implications 258Implications for future research in the prevention of postnatal depression 258

Implications for individual interventions 259

Chapter 11 Conclusion 261Implications from this review for further research 261Implications from this review for service provision 261Suggestions for research priorities 262

Acknowledgements 263

References 265

Appendix 1 Literature search strategies 297

Appendix 2 Randomised controlled trials and systematic reviews number retrieved 319

Appendix 3 Key journals hand-searched via electronic alerts 321

Appendix 4 Qualitative studies and mixed-methods studies number retrieved 323

Appendix 5 Reason for exclusion of quantitative studies 325

Appendix 6 Data extraction 335

Appendix 7 Synthesis of findings from personal and social support strategy studies 339

Appendix 8 Included systematic reviews 351

Appendix 9 Qualitative review participant characteristics 353

Appendix 10 Studies omitted from the network meta-analysis 369

Appendix 11 Sensitivity analysis of Edinburgh Postnatal Depression Scalethreshold score data using vague prior distribution for the between-studystandard deviation 379

Appendix 12 Similarities and differences between group- and individual-basedapproaches 387

Appendix 13 Findings relating to a potential serviceintervention 389

Appendix 14 CLUSTERs receiving detailed examination 393

Appendix 15 Examples of lsquoifndashthenrsquo propositions used to refine lsquobest fitrsquo analyticframework 395

Appendix 16 TIDieR checklists for focal interventions 401

CONTENTS

List of tables

TABLE 1 Risk of bias for included universal preventive intervention RCTssummary judgments about each risk-of-bias item 37

TABLE 2 Risk of bias for included selective preventive intervention RCTssummary judgments about each risk-of-bias item 39

TABLE 3 Risk of bias for included indicated preventive intervention RCTssummary judgements about each risk-of-bias item 40

TABLE 4 Qualitative studies quality assessment of the studies of universalpreventive interventions 45

TABLE 5 Synthesis of findings across all intervention studies what helped 47

TABLE 6 Synthesis of findings across all intervention studies what did not help 48

TABLE 7 Synthesis of findings across all intervention studies service delivery 49

TABLE 8 Synthesis of findings across all intervention studies service deliverybarriers to participation 49

TABLE 9 Synthesis of findings across all intervention studies health-careprofessionalsrsquo views on what helped 49

TABLE 10 Synthesis of findings across all intervention studies health-careprofessionalsrsquo views on what did not help 50

TABLE 11 Synthesis of findings across all intervention studies health-careprofessionalsrsquo views on service delivery 50

TABLE 12 Qualitative studies quality assessment of PSSSs 50

TABLE 13 Universal preventive interventions short-version descriptive labels 54

TABLE 14 Universal preventive interventions characteristics and main outcomesof RCTs of psychological interventions 56

TABLE 15 Qualitative study of universal preventive interventions description ofstudy evaluating a psychological intervention 60

TABLE 16 Universal preventive interventions characteristics and main outcomesof RCTs of educational interventions 62

TABLE 17 Universal preventive interventions characteristics and main outcomesof RCTs of social support 66

TABLE 18 Qualitative studies of universal preventive interventions description ofstudies evaluating social support 68

TABLE 19 Universal preventive interventions characteristics and main outcomesof RCTs of pharmacological agents or supplements 70

TABLE 20 Universal preventive interventions characteristics and main outcomesof RCTs of midwifery-led interventions 72

TABLE 21 Qualitative studies of universal preventive interventions description ofstudies evaluating midwifery-led interventions 77

TABLE 22 Universal preventive interventions characteristics and main outcomesof RCTs of organisation of maternity care 80

TABLE 23 Qualitative studies of universal preventive interventions description ofstudies evaluating organisation of maternity care 84

TABLE 24 Universal preventive interventions characteristics and main outcomesof RCTs of CAM or other 86

TABLE 25 Qualitative studies of universal preventive interventions description ofstudies evaluating CAM or other 88

TABLE 26 Universal preventive interventions NMAs overall summary of maineffects of interventions relative to usual care 102

TABLE 27 Selective preventive interventions short-version descriptive labels 104

TABLE 28 Selective preventive interventions characteristics and outcomes ofRCTs of psychological interventions 106

TABLE 29 Qualitative study of selective preventive interventions characteristicsof studies evaluating psychological interventions 110

TABLE 30 Selective preventive interventions characteristics and outcomes ofRCTs of educational interventions 112

TABLE 31 Qualitative studies characteristics of studies evaluatingeducational interventions 116

TABLE 32 Selective preventive interventions characteristics and outcomes ofRCTs of social support interventions 118

TABLE 33 Selective preventive interventions characteristics and outcomes ofRCTs of pharmacological agents or supplements 123

TABLE 34 Selective preventive interventions characteristics and outcomes ofRCTs of midwifery-led interventions 124

TABLE 35 Qualitative studies of selective preventive interventions description ofstudies of midwifery-led intervention 126

TABLE 36 Selective preventive interventions NMAs overall summary of maineffects of interventions relative to usual care 134

LIST OF TABLES

TABLE 37 Indicated preventive interventions short-version descriptive labels 140

TABLE 38 Indicated preventive interventions characteristics and outcomes ofRCTs of psychological interventions 142

TABLE 39 Indicated preventive interventions characteristics and outcomes ofRCTs of educational interventions 154

TABLE 40 Indicated preventive interventions characteristics and outcomes ofRCTs evaluating social support 156

TABLE 41 Qualitative studies of indicated preventive interventionscharacteristics of studies evaluating social support 159

TABLE 42 Indicated preventive interventions characteristics and outcomes ofRCTs evaluating pharmacological interventions or supplements 160

TABLE 43 Indicated preventive interventions characteristics and outcomes ofRCTs evaluating midwifery-led interventions 162

TABLE 44 Qualitative studies of indicated preventive interventionscharacteristics of studies evaluating organisation of maternity care 164

TABLE 45 Indicated preventive interventions characteristics and outcomes ofRCTs evaluating CAM or other 166

TABLE 46 Indicated preventive interventions NMAs overall summary of maineffects of interventions relative to usual care 178

TABLE 47 Thirteen focal interventions for exploration by realist review principles 180

TABLE 48 Results for citation searches of index papers for realist synthesis 182

TABLE 49 Dimensions of the featured interventions how it is delivered 183

TABLE 50 Dimensions of the featured interventions who is involved 183

TABLE 51 Specific theories underpinning mechanisms 185

TABLE 52 Programme theories for preventing PND 187

TABLE 53 Mechanisms and underpinning theory for generic group and one-to-oneapproaches 188

TABLE 54 Matrix indicating presence or absence of reported features withoverall assessment of effectiveness 198

TABLE 55 Reasons for exclusion of full papers in the health economics review 204

TABLE 56 Economic evaluations and the cost study included in the healtheconomics review 205

TABLE 57 Economic decision models included in the health economics review 208

TABLE 58 Costs used in economic evaluations included in the healtheconomics review 211

TABLE 59 Costs by matrices A B and C derived from trial of midwiferyredesigned postnatal care 216

TABLE 60 Staff costs from the Unit Costs of Health and Social Care 221

TABLE 61 Assumed intervention costs for the universal preventive interventions 223

TABLE 62 Assumed intervention costs for the selective preventive interventions 224

TABLE 63 Assumed intervention costs for the indicated preventive interventions 225

TABLE 64 Assumed relationship between EPDS and SF-6D scores used withinthe model 231

TABLE 65 Illustration of EVPI calculation 232

TABLE 66 Cost per QALY values for the universal preventive interventionsbase case 235

TABLE 67 Cost per QALY values for the selective preventive interventions base case 236

TABLE 68 Cost per QALY values for the indicated preventive interventions base case 237

TABLE 69 Cost per QALY values for the universal preventive interventionssensitivity analysis 238

TABLE 70 Cost per QALY values for the selective preventive interventionssensitivity analysis 239

TABLE 71 Cost per QALY values for the indicated preventive interventionssensitivity analysis 240

LIST OF TABLES

List of figures

FIGURE 1 Overview of review methods 14

FIGURE 2 The Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) flow chart of studies included in the quantitative review 34

FIGURE 3 Risk-of-bias graph for all included RCTs authorrsquos judgements abouteach risk-of-bias item 42

FIGURE 4 The Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) flow chart of studies included in the qualitative review 43

FIGURE 5 Universal preventive interventions EPDS threshold score at 6 weekspostnatally network of evidence 90

FIGURE 6 Universal preventive interventions EPDS threshold score at 6 weekspostnatally odds ratios for all treatment comparisons 91

FIGURE 7 Universal preventive interventions EPDS threshold score at 6 weekspostnatally probability of treatment rankings (ranks 1ndash6) 91

FIGURE 8 Universal preventive interventions EPDS threshold score at 3 monthspostnatally network of evidence 92

FIGURE 9 Universal preventive interventions EPDS threshold score at 3 monthspostnatally odds ratios for all treatment comparisons 93

FIGURE 10 Universal preventive interventions EPDS threshold score at 3 monthspostnatally probability of treatment rankings (ranks 1ndash5) 93

FIGURE 12 Universal preventive interventions EPDS threshold score at 6 monthspostnatally odds ratios all treatment comparisons 94

FIGURE 17 Universal preventive interventions EPDS mean scores networkof evidence 98

FIGURE 18 Universal preventive interventions EPDS mean scores meandifferences of treatment comparisons vs usual care across all time points 99

FIGURE 19 Universal preventive interventions EPDS mean scores probability oftreatment rankings at 6ndash8 weeks postnatally (ranks 1ndash6) 100

FIGURE 20 Universal preventive interventions EPDS mean scores probability oftreatment rankings at 3ndash4 months postnatally (ranks 1ndash7) 100

FIGURE 22 Universal preventive interventions EPDS mean scores probability oftreatment rankings at 12 months postnatally (ranks 1ndash4) 101

FIGURE 23 Selective preventive interventions EPDS threshold score at 6 weekspostnatally network of evidence 128

FIGURE 24 Selective preventive interventions EPDS threshold score at 6 weekspostnatally odds ratios all treatment comparisons 129

FIGURE 25 Selective preventive interventions EPDS threshold score at 6 weekspostnatally probability of treatment rankings (ranks 1ndash4) 130

FIGURE 26 Selective preventive interventions EPDS threshold score at 3 monthspostnatally network of evidence 130

FIGURE 27 Selective preventive interventions EPDS threshold score at 3 monthspostnatally odds ratios all treatment comparisons 131

FIGURE 28 Selective preventive interventions EPDS threshold score at 3 monthspostnatally probability of treatment rankings (ranks 1ndash4) 132

FIGURE 32 Selective preventive interventions EPDS mean scores network of evidence 135

FIGURE 33 Selective preventive interventions EPDS mean scores meandifferences of treatment comparisons vs usual care across all time points 136

FIGURE 34 Selective preventive interventions EPDS mean scores probability oftreatment rankings at 6ndash8 weeks postnatally (ranks 1ndash3) 136

FIGURE 35 Selective preventive interventions EPDS mean scores probability oftreatment rankings at 3ndash4 months postnatally (ranks 1ndash3) 137

LIST OF FIGURES

FIGURE 37 Selective preventive interventions EPDS mean scores probability oftreatment rankings at 12 months (ranks 1ndash4) 138

FIGURE 38 Indicated preventive interventions EPDS threshold score at 6 weekspostnatally network of evidence 168

FIGURE 39 Indicated preventive interventions EPDS threshold score at 6 weekspostnatally odds ratios all treatment comparisons 168

FIGURE 40 Indicated preventive interventions EPDS threshold score at 6 weekspostnatally probability of treatment rankings (ranks 1ndash5) 169

FIGURE 41 Indicated preventive interventions EPDS threshold score at 3 monthspostnatally network of evidence 169

FIGURE 42 Indicated preventive interventions EPDS threshold score at 3 monthspostnatally odds ratios all treatment comparisons 170

FIGURE 43 Indicated preventive interventions EPDS threshold score at 3 monthspostnatally probability of treatment rankings 170

FIGURE 46 Indicated preventive interventions EPDS threshold score at 4 monthspostnatally probability of treatment rankings (ranks 1ndash3) 172

FIGURE 50 Indicated preventive interventions for EPDS mean scores networkof evidence 174

FIGURE 51 Indicated preventive interventions EPDS mean scores meandifferences of treatment comparisons vs usual care across all time points 175

FIGURE 52 Indicated preventive interventions EPDS mean scores probability oftreatment rankings at 6ndash8 weeks postnatally (ranks 1ndash5) 176

FIGURE 53 Indicated preventive interventions EPDS mean scores probability oftreatment rankings at 3ndash4 months postnatally (ranks 1ndash6) 176

FIGURE 55 Indicated preventive interventions EPDS mean scores probability oftreatment rankings at 12 months (ranks 1ndash4) 177

FIGURE 56 Analytical framework to evaluate group visits 184

FIGURE 57 The ways in which lsquoifndashthenrsquo statements might illuminate pathways forindividual approaches 194

FIGURE 58 The ways in which lsquoifndashthenrsquo statements might illuminate pathways forgroup approaches 195

FIGURE 59 The PRISMA flow chart of studies included in the healtheconomics review 203

FIGURE 60 An illustrative example of calculating the area under the curve whendata for an intervention are available for all time points 219

FIGURE 61 An illustrative example of calculating the area under the curve whendata for an intervention are available only at time point 3 219

FIGURE 62 The relationship between EPDS and SF-6D scores at 6 weeks 227

FIGURE 63 The relationship between EPDS and SF-6D scores at 6 months 227

FIGURE 65 The relationship between EPDS and SF-6D scores using data at both6 and 12 months 228

FIGURE 66 The relationship between EPDS score and total health costs at 6 weeks 229

FIGURE 67 The relationship between EPDS score and total health costs at 6 months 230

FIGURE 68 The relationship between EPDS score and total health costs at12 months 230

FIGURE 69 The estimated incremental QALYs per woman compared with usualcare associated with each universal preventive intervention 233

FIGURE 70 The estimated incremental QALYs per woman compared with usualcare associated with each selective preventive intervention 234

FIGURE 71 The estimated incremental QALYs per woman compared with usualcare associated with each indicated preventive intervention 234

FIGURE 72 The CEAC for the universal preventive interventions 241

FIGURE 73 The CEAC for the selective preventive interventions 241

FIGURE 74 The CEAC for the indicated preventive interventions 242

LIST OF FIGURES

FIGURE 75 The EVPI associated with the universal preventive interventions 244

FIGURE 76 The EVPI associated with the selective preventive interventions 244

FIGURE 77 The EVPI associated with the indicated preventive interventions 245

FIGURE 78 Results of the EVPI and EVPPI analyses 245

List of boxes

BOX 1 Symptoms indicating a major depressive episode 1

BOX 2 Population dimension of the PICOS framework for quantitative review 16

BOX 3 Intervention dimension of the PICOS framework for quantitative review 17

BOX 4 Outcome dimension of the PICOS framework for quantitative review 18

BOX 5 Study design dimension of the PICOS framework for quantitative review 19

BOX 6 Population dimension of the PICOS framework for qualitative studies 28

BOX 7 Study design dimension of the PICOS framework for the qualitative studies 28

Glossary

Beck Depression Inventory A 21-item self-report scale used to determine depression severity Items arescored on a 0ndash3 scale giving a total score range of 0ndash63 Total scores within the 1ndash9 range indicateminimal depression 10ndash18 indicate mild depression 19ndash29 indicate moderate depression and 30ndash63indicate severe depression

Center for Epidemiological Studies Depression Scale A short self-report scale designed to measuredepressive symptomology in the general population The 20-item scale has a possible range of scores from0 to 60 with higher scores indicating more symptoms weighted by frequency of occurrence during thepast week

Cognitivendashbehavioural therapy The pragmatic combination of concepts and techniques from cognitiveand behaviour therapies common in clinical practice Cognitivendashbehavioural therapy aims to facilitatethrough collaboration and guided discovery recognition and re-evaluation of negative thinking patternsand practising new behaviours

Edinburgh Postnatal Depression Scale The most widely used self-report scale designed to measurepostnatal depression symptomology The scale consists of a 10-item Likert format relating to depressionand anxiety symptomology Items are scored on a 0ndash3 scale to give a total range of 0ndash30 Total scoreswithin the 12ndash30 range suggest significant depression

Indicated preventive interventions Interventions offered to women at high risk of developing postnataldepression on the basis of psychological risk factors above-average scores on psychological measures orother indications of a predisposition to postnatal depression but who did not meet diagnostic criteria forpostnatal depression at that time

Interpersonal psychotherapy A time-limited structured and psychoeducational therapy which linksdepression to role transitions interpersonal disputes interpersonal sensitivity or losses It facilitatesunderstanding of recent events in these interpersonal terms and explores alternative ways of handlinginterpersonal situations

Multipara A woman who has given birth two or more times

Network meta-analysis An extension of a standard meta-analysis which enables a simultaneouscomparison of all evaluated interventions in a single coherent analysis Thus all interventions can becompared with one another including comparisons not evaluated within individual studies To perform anetwork meta-analysis each study must be linked to at least one other study through having at least oneintervention in common

Postnatal depression (also known as postpartum depression) A non-psychotic depressive episodemeeting standardised diagnostic criteria for a minor or major depressive disorder beginning in orextending into the postnatal period

Selective preventive interventions Interventions offered to women or subgroups of the populationwhose risk of developing postnatal depression was significantly higher than average because they had oneor more social risk factors

Universal preventive interventions Interventions available for all women in a defined population notidentified on the basis of increased risk for postnatal depression

List of abbreviations

AMED Allied and ComplementaryMedicine Database

ASSIA Applied Social Sciences Indexand Abstracts

BDI Beck Depression Inventory

CAM complementary and alternativemedicine

CASP Critical Appraisal Skills Programme

CBA cognitivendashbehavioural approach

CBT cognitivendashbehavioural therapy

CEAC cost-effectiveness acceptabilitycurve

CENTRAL Cochrane Central Register ofControlled Trials

CERQual Confidence in the Evidence fromReviews of Qualitative research

CES-D Center for Epidemiologic StudiesDepression scale

CINAHL Cumulative Index to Nursing andAllied Health Literature

CLUSTER Citations Lead authorsUnpublished materials Scholarsearches Theories Early examplesRelated projects

CODA Convergence Diagnostic andOutput Analysis

CORE-OM Clinical Outcomes in RoutineEvaluation-Outcome Measure

CPCI-S Conference Proceedings CitationIndexndashScience

CRCT cluster randomised controlled trial

CrI credible interval

DARE Database of Abstracts of Reviewsof Effects

DHA docosahexaenoic acid

DSM-IV Diagnostic and Statistical Manualof Mental Disorders-Fourth Edition

DSM-V Diagnostic and Statistical Manualof Mental Disorders-Fifth Edition

EP Expert Patient

EPA eicosapentaenoic acid

EPDS Edinburgh Postnatal DepressionScale

EVPI expected value of perfectinformation

EVPPI expected value of partial perfectinformation

GP general practitioner

HADS Hospital Anxiety and DepressionScale

HIV human immunodeficiency virus

HTA Health Technology Assessment

ICD-10 International Classification ofDiseases Tenth Edition

ICER incremental cost-effectiveness ratio

IPT interpersonal psychotherapy

MBE mindndashbody exercise

MCS mental component summary

MDU Midwifery Development Unit

MIDIRS Midwives Information andResource Service

NHS EED NHS Economic Evaluation Database

NICE National Institute for Health andCare Excellence

NMA network meta-analysis

NMB net monetary benefit

PCA person-centred approach

PCS physical component summary

PHQ Patient Health Questionnaire

PICOS population interventioncomparators outcomes studydesigns

PND postnatal depression

PoNDER PostNatal Depression Economicevaluation and Randomisedcontrolled trial

PPI patient and public involvement

PRISM Program of Resources Informationand Support for Mothers

PRISMA Preferred Reporting Items forSystematic Reviews andMeta-Analyses

PSA probabilistic sensitivity analysis

PSI Parenting Stress Index

PSS Perceived Stress Scale

PSSS personal and social supportstrategy

QALY quality-adjusted life-year

RCT randomised controlled trial

ROSE Reach Out Stand strong Essentialsfor new mothers

SCAN Schedule for Clinical Assessmentin Neuropsychiatry

SCID Structured Clinical Interview forDiagnostic and Statistical Manualof Mental Disorders

SD standard deviation

SF-12 Short Form questionnaire-12 items

SF-6D Short-Form 6-Dimensions

STAI StatendashTrait Anxiety Inventory

TIDieR template for interventiondescription and replication

LIST OF ABBREVIATIONS

Plain English summary

What was the problem

Mental health problems during pregnancy and after childbirth can have an enduring effect on women andtheir developing babies It is important to identify women with mental health problems as early as possiblein order to help them and their children

What did we do

This research reviewed studies which looked at preventing depression in mothers with a baby less than1 year of age The studies examined interventions offered (1) to all women (which we called lsquouniversalrsquo)(2) to women at risk because of social circumstances (lsquoselectiversquo) and (3) to women at higher risk becauseof a link to depression (lsquoindicatedrsquo) We also reviewed what made interventions acceptable to women andwhether or not interventions made the best use of NHS resources Women who had experienceddepression in pregnancy and after childbirth were involved in the research

What did we find

The included studies did not reveal a clear pattern Extra visits from a midwife a health visitor trainedin person-centred approaches (PCAs) or cognitivendashbehavioural therapy (CBT)-based approaches helped inuniversal coverage Education on preparing for parenting or interpersonal therapy-based interventionseemed useful in the selective group Helping parents interact with their baby peer support andapproaches based on CBT or PCA seemed favourable in the indicated group The interventions whichappeared to be most cost-effective were midwifery redesigned postnatal care (universal) education onpreparing for parenting (selective) and PCA-based intervention (indicated)

The research confirmed that women valued seeing the same health-care worker (building trustingrelationships) and their partnersrsquo involvement

What does this mean

It is difficult to conclude on the value of these interventions and further research is necessary We needbetter ways of measuring depression and its costs and need to involve more women in future research

xxxiii

Scientific summary

Background

Postnatal depression (PND) is a serious public health issue affecting 7ndash13 of women in the yearfollowing childbirth The strongest predictors of PND are antenatal anxiety depression history lack ofsocial support low self-esteem stressful life events poor marital relationship and domestic violenceSevere PND is associated with suicide and infanticide especially when a woman has psychotic symptoms

The prevention of PND is an important neglected area in the UK with NHS effort directed towardstreatment rather than prevention A range of psychological educational pharmacological social supportalternative and other interventions has been explored to minimise the development intensity and durationof maternal depressive symptoms and their potential impact on the infant Previous systematic reviewsprovided conflicting reports about the effectiveness of PND preventive interventions

Preventive approaches relevant to PND are

l universal preventive interventions targeting a population not at increased risk for PNDl selective preventive interventions for women perceived to be at risk for PND because of social factorsl indicated preventive interventions for women at risk of PND because of history predisposition or above

average scores on psychological measures but not meeting diagnostic criteria

Aims and objectives

The aims of this study were to

1 evaluate the clinical effectiveness cost-effectiveness acceptability and safety of antenatal and postnatalinterventions to prevent PND in pregnant and postnatal women

2 apply rigorous methods of systematic reviewing of quantitative and qualitative studies evidencesynthesis and decision-analytic modelling to evaluate the preventive impact on women their infants andtheir families

3 and estimate cost-effectiveness

The objectives were to

(a) determine the clinical effectiveness of antenatal and postnatal interventions for preventing PND(systematic review of quantitative research)

i to identify moderators and mediators of the effectiveness of preventive interventionsii to undertake a network meta-analysis (NMA) of available evidence as appropriate

(b) provide a detailed service user and provider perspective on uptake acceptability and potential harmsof antenatal and postnatal interventions (systematic review of qualitative research)

i to examine the main service models for prevention of PND in relation to the underlying programmetheory and mechanisms focusing on group- and individual-based approaches (realist synthesis)

(c) to undertake a systematic review of economic evaluations in the area and identify other evidenceneeded to populate an economic model

(d) to determine the potential value of collecting further data on input parameters (expected value ofinformation analysis)

Clinical effectiveness review methods

Data sourcesA comprehensive search of MEDLINE MEDLINE In-Process amp Other Non-Indexed Citations EMBASE TheCochrane Library (Cochrane Systematic Reviews Database of Abstracts of Reviews of Effects CochraneCentral Register of Controlled Trials NHS Economic Evaluation Database Health Technology Assessmentdatabases) Cumulative Index to Nursing and Allied Health Literature PsycINFO Science Citation Index andConference Proceedings (Web of Science) National Institute for Health Research Health TechnologyAssessment Programme Applied Social Sciences Index and Abstracts Allied and Complementary MedicineDatabase and Midwives Information and Resource Service Reference Database (from inception to July 2013)in December 2012 and electronic alerts update until July 2013 The following trial databases weresearched (from inception to July 2013) Current Controlled Trials ClinicalTrialsgov and the World HealthOrganizationrsquos International Clinical Trials Registry Platform Reference tracking of relevant studies wasperformed Reference lists of relevant reviews were scrutinised Searches were restricted to English-language literature with no restriction by date

Inclusionexclusion criteria

PopulationThe study population comprised all pregnant women (universal) pregnant women at risk of developingPND because of social factors (selective) pregnant women at risk of developing PND because ofpsychological risk factors above average scores on psychological measures indications of a predispositionto PND (indicated) all postnatal women in their first 6 postnatal weeks (universal) (or first postnatal yearfor the qualitative review) postnatal women at risk of developing PND because of social factors (selective)and postnatal women at risk of developing PND because of psychological risk factors above averagescores on psychological measures and indications of a predisposition to PND but not diagnosed withdepression (indicated)

InterventionsAll interventions suitable for pregnant women and women in the first 6 postnatal weeks were included

ComparatorsAll usual care and enhanced usual-care control and active comparisons were considered

OutcomesIn the review of the quantitative and the qualitative research all outcomes reported were includedKey outcomes were measures of depressive symptoms such as the Edinburgh Postnatal Depression Scale(EPDS) depression diagnostic instruments and infant outcomes

Data extractionThe general principles recommended in the Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) statement were used For the quantitative studies two independent reviewersscreened all records and extracted data disagreements were resolved through consensus The risk of biasof included randomised controlled trials (RCTs) was assessed using Cochranersquos risk-of-bias tool For theincluded qualitative studies data extraction was undertaken by one reviewer using a tailored dataextraction framework developed to elicit data extraction elements related directly to the review questionand 20 of extractions were checked by a second reviewer The methodological quality of individual

SCIENTIFIC SUMMARY

studies was appraised by two reviewers independently using an abbreviated version of the CriticalAppraisal Skills Programme (CASP) quality assessment tool for qualitative studies and the CERQual(Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess the certaintyof the findings

Data synthesisExtracted data and quality assessment variables were presented in tables with narrative descriptionThe evidence was synthesised using a NMA which enabled a simultaneous comparison of all evaluatedinterventions in a single coherent analysis Evidence from RCTs presenting data at any assessment time upto 12 months postnatally was relevant to the decision problem The analysis of the EPDS score data wasconducted in two stages (1) a treatment-effects model in which the effect of each intervention wasestimated relative to usual care and (2) a baseline (ie usual-care) model in which the absolute responseto usual care was estimated The estimates of treatment effects relative to usual care were combined withthe baseline model to provide estimates of absolute responses for each intervention these estimates wereused as inputs to the economic model

Qualitative meta-synthesis was undertaken by highlighting womenrsquos and service providersrsquo issues aroundthe acceptability of interventions elucidating evidence around personal and social support strategies(PSSSs) employed by women using the data extraction framework and thematic synthesis to aggregate thefindings Evidence about interventions from women and from service providers and evidence about PSSSswere presented separately

Clinical effectiveness summary results

For the quantitative studies 3072 records were identified through electronic searches In total 122 papers(representing 86 unique studies of preventive interventions) were included of which 37 studies were ofuniversal preventive interventions 20 were of selective interventions and 30 were of indicated interventions(one study included both indicated and universal preventive interventions) The highest levels of assessedrisk of bias were for selection bias [9 of 86 RCTs (105)] and for attrition andor analysis bias [8 of 86 RCTs(93)] The universal preventive intervention studies had greater risks of bias than the selective andindicated preventive interventions this was most notable for selection bias and attrition bias There was aconsistent lack of clarity about the allocation method the use of a non-random process how the baselinewas defined and how this affected initiation of an intervention

A further 23 relevant systematic reviews were identified which revealed one additional study

Universal preventive interventionsThe results were inconclusive from the set of interventions which formed a network The mostbeneficial interventions at 12 months shown by difference in the mean EPDS score appeared to bemidwifery redesigned postnatal care [ndash143 95 credible interval (CrI) ndash400 to 136] person-centredapproach (PCA)-based intervention (ndash097 95 CrI ndash354 to 171) and cognitivendashbehavioural therapy(CBT)-based intervention (ndash078 95 CrI ndash341 to 191)

Selective preventive interventionsNot all interventions were evaluable and the treatment effects were inconclusive Interpersonalpsychotherapy (IPT)-based intervention appeared to be beneficial as indicated by difference in mean3-month EPDS score (ndash185 95 CrI ndash560 to 214) Education on preparing for parenting appeared to bebeneficial as indicated by the difference in mean 6-month EPDS score (ndash132 95 CrI ndash354 to 110)

xxxvii

Indicated preventive interventionsNot all interventions were evaluable and the NMA showed that in general the treatment effects wereinconclusive The difference in mean 6-month EPDS score was ndash425 (95 CrI ndash778 to 043) for IPT-basedintervention The difference in 12-month mean EPDS score was ndash218 (95 CrI ndash539 to 115) for PCA-basedintervention and ndash218 (95 CrI ndash539 to 115) for CBT-based intervention The difference in the 6-weekmean EPDS score was ndash112 (95 CrI ndash435 to 193) for promoting parentndashinfant interaction for peer supportand the difference in 3-month EPDS score was ndash093 (95 CrI ndash511 to 332)

Cost-effectiveness review methods

A comprehensive search of published economic evaluations was performed One reviewer independentlyscreened titles and abstracts with discussion about uncertainty and consensus agreement A mathematicalmodel was constructed to explore the cost-effectiveness of interventions contained within the NMA versususual care An area under the curve approach was employed alongside mapping from the EPDS valuesto a preference-based utility score Short Form 6-Dimensions (SF-6D) The time horizon was 1 yearamended to 2 years in a sensitivity analysis Expected value of partial perfect information (EVPPI) analyseswere undertaken for efficacy data and for mapping the EPDS values to utility

Cost-effectiveness summary results

No economic evaluations were identified as appropriate for answering the decision problem and hence ade novo model was constructed The cost of the interventions relative to usual care ranged from costsaving to an increase of pound1200 per woman Assuming a willingness to pay of pound20000 per quality-adjustedlife-year (QALY) the most cost-effective interventions were estimated to be midwifery redesigned postnatalcare PCA-based intervention and CBT-based intervention (universal) education on preparing for pregnancy(selective) and PCA-based intervention (indicated) If a benefit of 2 years was assumed then an IPT-basedintervention was the most cost-effective indicated preventive intervention However there wasconsiderable uncertainty in these results The EVPPI for efficacy data was very large in excess of pound150Mfor each population

Qualitative review summary results

For the qualitative studies 2152 records were identified through all searches There were 56 recordsincluded (representing 44 unique studies) which were examined at full text In addition 27 papers(representing 21 unique studies of preventive interventions) were included of which 14 studies were ofuniversal preventive interventions three were of selective interventions and four were of indicatedinterventions The studies varied in quality Only six studies showed evidence of researcher reflexivityNo findings were assessed as being of high certainty by the CERQual approach The remaining 29 papers(23 studies) were concerned with PSSSs to prevent PND

Social support interventions provided emotional and informational support to women and group-basedapproaches may be a useful supplement provided that they do not prove to be too resource intensive orcreate unrealistic expectations of services Continuity of care was confirmed as an important operatoracross several interventions in that it enabled women to build up a relationship of trust with theirhealth-care provider

SCIENTIFIC SUMMARY

xxxviii

Discussion

We undertook a rigorous systematic review and identified all relevant publications concerning the clinicaleffectiveness and cost-effectiveness interventions to prevent PND Although we appraised and summariseda very large number of studies the results of the review were inconclusive It is possible that usual carecould be the most effective intervention in all three populations

StrengthsThe analysis approach differs from that used in previous Cochrane reviews which did not distinguish betweeninterventions within studies in terms of control comparator or preventive approach Previous reviews usedstandardised effect sizes rather than EPDS values and also tended to not take into account the assessmenttime often taking the latest assessment time The qualitative review identified helpful features from thewomenrsquos and service providersrsquo perspectives as well as preferences for potential improvement

LimitationsThe NMA offers an advance on previous reviews Nevertheless there are some limitations with the currentanalysis (1) some studies were omitted because they did not provide EPDS values which may haveintroduced reporting or selection bias (2) no adjustment was made for the lack of quality associated withsome trials and treatment effects may therefore be overstated (3) the analysis assumed independence ofoutcomes within studies and independence of intervention effects between studies and (4) infantoutcomes were not examined in detail because of insufficient infant outcome data

Limitations with the cost-effectiveness analyses are that (1) interventions that did not report EPDS valueswere omitted from the analyses (2) the incremental costs for each strategy have by necessity beenestimated in a simplistic manner and costs of restructuring services have not been included (3) thepossibility of erroneous grouping of trials as a single intervention within indicated preventive interventionsand (4) simplistic assumptions have been made in estimating the area under the curve when data were notavailable for all time points

Limitations with providing a conclusion regarding the most cost-effective intervention are (1) absoluteQALY gains estimated are small for all interventions and (2) there is considerable uncertainty in thedirection of the estimates of QALY change compared with usual care for all interventions

The values of future research into the relative effectiveness of interventions were shown to be very high inall populations in the order of hundreds of millions of pounds which would be sufficient to cover the costof such research Although the relationship between EPDS values and utility was not shown to influencethe decision given current information future research should include collection of utility data In additiondetailed costing data for each intervention should be recorded

Research recommendationsOwing to the uncertainty associated with the results and the limitations highlighted above our overallresearch recommendations and conclusions are tentative Given the poor quality of the clinicaleffectiveness and cost-effectiveness evidence available replication of some studies is needed withingood-quality RCTs

l as a universal preventive intervention midwifery redesigned postnatal care PCA-based interventionand CBT-based intervention

l as a selective preventive intervention education on preparing for parenting peer support andIPT-based intervention

l as an indicated preventive intervention promoting parentndashinfant interaction peer support(telephone-based and Newpin volunteer support) and CBT- PCA- and IPT-based interventions

Conclusions

As far as we are aware this is the most comprehensive review of the clinical effectiveness andcost-effectiveness acceptability and safety of antenatal and postnatal interventions for pregnant andpostnatal women to prevent PND Despite this no definitive conclusions can be drawn regarding the mostclinically effective or cost-effective intervention because of the uncertainty about the relative effectivenessof the interventions Several interventions would warrant replication Future RCTs estimating theeffectiveness of interventions considered acceptable to pregnant and postnatal women and the clinicalcommunity should be undertaken using the EPDS Given the EVPPI values future trials assessing therelative efficacies of promising interventions would appear to represent value for money

Study registration

This study is registered as PROSPERO CRD42012003273

Funding

Funding for this study was provided by the Health Technology Assessment programme of theNational Institute for Health Research

SCIENTIFIC SUMMARY

Chapter 1 Background

This chapter details the background to the report and presents an overview of postnatal depression(PND) the size and importance of the problem the need for prevention current service provision and

the approaches to interventions to prevent the condition

Description of health problem

Depression is a leading cause of life lived with disability PND also termed postpartum depression isdefined using standardised diagnostic criteria as a major depressive disorder in the year followingchildbirth1 PND has a wide range of symptoms measured in clinical practice and in research usingsymptom self-reports as a proxy for clinical assessment1 It is distinguished from the more transientlsquobaby bluesrsquo and the rarer and more acute puerperal psychosis Severe PND is associated with suicide andinfanticide especially when the woman has psychotic symptoms2

The Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V)3 does not recognise PNDas a separate diagnosis so to be diagnosed women must meet the criteria for depression The specifier islsquowith peripartum onsetrsquo (the most recent episode occurring during pregnancy and in the 4 weeks followingdelivery)4 The following symptoms must be present for at least 2 weeks to fulfil the criteria for majordepression a depressed mood or a loss of interest or pleasure in daily activities which represents a changefrom normal mood and a clinically significant distress or impairment in social occupational educational orother important areas of functioning Five or more of the symptoms in Box 1 must also be present for amajor depressive episode to be determined

In contrast the World Health Organizationrsquos International Classification of Diseases Tenth Edition (ICD-10)diagnosis code F53 is for mental disorders associated with the puerperium that is postnatal or postpartumdepression commencing within 6 weeks of delivery that do not meet the criteria for disorders classifiedelsewhere5 ICD-10 also requires several symptoms to be endorsed for a diagnosis of depression and mostcases of PND will meet criteria for disorders classified elsewhere ICD-10 uses key symptoms of persistentsadness or low mood andor loss of interest or pleasure fatigue or low energy at least one of thesesymptoms most days most of the time for at least 2 weeks If any of these are present associatedsymptoms such as disturbed sleep poor concentration or indecisiveness low self-confidence poor orincreased appetite suicidal thoughts or acts agitation or slowing of movements and guilt or self-blamedefine the degree of depression

BOX 1 Symptoms indicating a major depressive episode

1 Depressed mood most of the day almost every day indicated by subjective report or othersrsquo observations

2 Reduced interest or pleasure in all (or nearly all) activities for most of the day almost every day

3 Significant weight loss or weight gain or decrease or increase in appetite almost every day

4 Insomnia or hypersomnia almost every day

5 Psychomotor agitation or retardation almost every day

6 Fatigue or loss of energy almost every day

7 Feelings of worthlessness or excessive or inappropriate guilt almost every day

8 Diminished ability to think or concentrate or indecisiveness almost every day

9 Recurrent thoughts of death recurrent thoughts of suicide without a plan a plan for committing suicide or

a suicide attempt

PrevalencePostnatal depression is a public health problem46 which occurs in most cultures6ndash8 The prevalence of bothmajor or minor depression during the first postnatal year is 7ndash139 Among a sample of more than8000 women in England 13 scored 13 or more (the threshold to identify women with probable majordepression)2 on the Edinburgh Postnatal Depression Scale (EPDS)10 on at least one postnatal assessment11

Some women recover by the time their infant is 6 months old but in 50 of women depression can lastfor more than 6 months12 Although PND is defined as depression within the 12 months after the birth ofan infant a significant number of women remain depressed for over 1 year13 and some women remaindepressed for 4 years12

Although depression postnatally may not be different from depression occurring in non-pregnant womensome women become depressed for the first time postnatally some experience postnatal recurrence ofprevious depression13 and for others depression begins antenatally and continues postnatally14ndash16

Antenatal depression is the strongest predictor of PND14 being as common as PND with 184 of womenhaving depressive symptoms throughout pregnancy17 Antenatal anxiety is commonly comorbid withantenatal depression and also increases the likelihood of PND141518

Additional factors have consistently been associated with PND Some PND may be biologically mediatedand specifically linked to childbirth1 Some women with PND may be genetically more reactive to theenvironmental trigger for depression19 In other women who have a general vulnerability to depressionPND may occur because childbirth is a stressor1 The strongest predictors of PND are antenatal anxiety andantenatal depression14 lack of social support a history of depression neuroticism low self-esteemstressful life events during pregnancy poor marital relationship and domestic violence12021 Womenthemselves have reported that the causes of their PND were lack of support pressure to do things righttheir personality (prone to mental health problems) pressure (work or money) hormonal changes andresurfaced memories22 As the aetiology is diverse it is difficult to predict accurately which women willdevelop PND

Impact of health problemThe burden of PND can extend in its most severe form to suicide and less frequently infanticide23

The impact of PND on mothers is compounded by impairments to the motherndashinfant interaction24 andimpairments to the infantrsquos longer-term emotional cognitive behavioural and social development2526

The impact of withdrawn behaviour24 and vocally communicated sadness27 appears to be worsened whenwomen live in poorer socioeconomic circumstances and is worse if the infant is a boy2829 or if depressionbecomes a chronic problem3031 Additional later risks for infants are mediated through the effect of chronicdepression on the hypothalamicndashpituitaryndashadrenal axis functioning in offspring into adolescence253233

Depressed pregnant women have a greater risk of delivering a low-birthweight infant34 Antenataldepression is a risk factor for infant mood3335 and for depression in offspring at 18 years of age withhigher risk among offspring whose mothers are less educated1636 There is a potential impact on fathersaround 10 of whom are at risk of depression particularly during the 3ndash6 months after the infant isborn37 This depression is moderately positively correlated with maternal depression but it is unclear ifthere is an association or a causal influence and the direction of the influence if any is unknown37

Furthermore postnatal paternal depression is associated with depression in offspring16

BACKGROUND

Current service provision

Variation in service and uncertainty about best practiceFree maternity care in the UK delivered predominantly by midwives and obstetricians providesopportunities for women to have contact with health-care services The National Institute for Health and CareExcellence (NICE) provides evidence-based guidelines for antenatal intrapartum and postnatal care and forantenatal and postnatal mental health38 Among those at low obstetric and medical risk nine antenatalconsultations are recommended for women expecting their first baby and seven consultations for thoseexpecting a subsequent child39 Most women give birth in hospital maternity units or in free-standing oralongside midwifery units and stay in for less than 2 days fewer than 3 give birth at home40

Traditionally in the UK hospital midwives have provided care in hospital for antenatal labouring and postnatalwomen Community midwifery teams have provided antenatal care in the community and postnatal careduring visits to the womanrsquos home community health centres and childrenrsquos centres for up to 28 days afterbirth Care is usually transferred on postnatal day 10 to the health visiting service and is provided by healthvisitors specially trained public health nurses Most health visitors now offer antenatal visits

National Institute for Health and Care Excellence guidance38 recommends that primary health-careprofessionals should routinely enquire about past and current mental illness and family history of perinatalmental illness at a womanrsquos first appointment in early pregnancy and postnatally (4ndash6 weeks and 3 or4 months) to identify predictive risk factors NICE guidance38 also recommends that midwives enquirewithin the first 24 hours after birth about a womanrsquos experience of her labour In some locationsmidwife-provided services have developed to provide an opportunity for women to discuss their birthexperiences but these do not always include access to formal psychological support

The community midwifersquos role includes an increased focus on improving public health and currentpre-registration midwifery education covers the identification of potential mental health issues forchildbearing women The Maternal Mental Health Pathway41 guidance focuses on the health visitorrsquos rolein maternal mental health and wellbeing during pregnancy and postnatally recognising the contribution ofmidwives mental health practitioners and general practitioners (GPs)

Other maternity support roles include maternity support workers and volunteers such as breastfeedingpeer supporters counsellors and doula support (women who provide support to other women) duringpregnancy labour and birth and the early postnatal period

Infrequently in the UK and more commonly in the USA and a small number of other countriesCenteringPregnancyreg (Centering Healthcare Institute Boston MA USA) is available4243 TheCenteringPregnancy44 approach provides group care to women at similar stages of pregnancy by means ofa health assessment and provision of education and peer support Health-care professionals help womento participate in their own care and to learn from each other about pregnancy and care of the new infant

Identification of postnatal and antenatal depressionThere has been a lack of consistency in the routine approach to the identification of PND94546 by primaryhealth-care professionals47 NICE advocates a case-finding approach for depressive symptoms38 based ontwo questions the Patient Health Questionnaire (PHQ)-2 from the PHQ-9 as follows4849 lsquoOver the last2 weeks how often have you been bothered by any of the following problemsrsquo (1) lsquoLittle interest orpleasure in doing thingsrsquo and (2) lsquoFeeling down depressed or hopelessrsquo49 The EPDS10 the Hospital Anxietyand Depression Scale (HADS)50 and the full PHQ-9 are to be used as follow-up tools as part of a fullerassessment process The EPDS is frequently used as it performs well for major and minor depression45 and isacceptable to women and health-care professionals51 The EPDS is not used systematically throughout theUK to identify depressive symptoms during pregnancy or postnatally partly because it lsquodoes not satisfy theNational Screening Committeersquos criteria for the adoption of a screening strategy as part of nationalhealth policyrsquo52

Current service costsApart from the distress for women and the potential long-term consequences for infants there areadditional public health social and economic consequences of maternal depression4 The cost of PND tothe UK government is estimated as pound45M53 to pound61M per year4 For each exposed child the estimatedcumulative economic costs of adverse child development linked to a motherrsquos depression is pound819054

The health-care costs associated with postnatal paternal depression have been estimated for fathers withdepression as pound11041 for fathers at high risk of developing depression as pound1075 and for fathers withoutdepression as pound945 at 2008 prices55 In New Zealand the potential value for money of implementation ofa PND screening programme was assessed and the programme was found to be cost-effective56 Incontrast following a cost-effectiveness analysis a system to identify PND in the UK was reported not torepresent value for money based on the assumed cost of false positives57 Little is known about theeconomic consequences of PND or the cost-effectiveness of interventions aiming to prevent or alleviatePND symptoms58 Substantial economic returns have been estimated for investment in the prevention ofmental health problems with potential long-term pay-offs continuing into adulthood59

Despite the lsquocase-findingrsquo approach to identify women at greater risk of PND mainly based on earlierexperience of mental health problems little attention is paid to the prevention of PND and no specificinstruments are available to reliably predict PND among asymptomatic women Some health visitors in theUK use the EPDS but this practice varies nationally It is likely that even less attention is paid to identifyingdepression and anxiety antenatally than postnatally

Description of technology under assessment

Preventive interventions for postnatal depressionThis section provides an overview of the rationale for the prevention of PND and a description ofapproaches that have been explored to prevent PND There is evidence of the effectiveness ofpharmacological60 and psychological interventions61ndash63 to treat PND within four main approaches generalcounselling interpersonal psychotherapy (IPT) cognitivendashbehavioural therapy (CBT) and psychodynamictherapy1 Prevention of a major depressive episode implies reducing the intensity duration and frequencyof depressive symptoms64

NHS England has provided a pound18M budget for public health responsibilities covering screeningimmunisation and health-visiting services65 Less than 5 of NHS funding in England is spent onprevention of all conditions65 The Marmot et al66 review aims to strengthen the role and impact ofill-health prevention prioritising prevention and early detection of mental health conditions and earlyintervention Traditionally primary secondary and tertiary prevention activities are designed respectivelyto reduce the risk of developing health problems to identify and manage pre-symptomatic ill health and toreduce the impact of the disease

Three levels of preventive intervention are relevant to the prevention of PND67

1 Universal preventive interventions are available to all women in a defined population not identified onthe basis of increased risk for PND

2 Selective preventive interventions are offered to women or subgroups of the population whose risk ofdeveloping PND are significantly higher than average because they have one or more social risk factors

3 Indicated preventive interventions are offered to women at high risk of developing PND on the basis ofpsychological risk factors above-average scores on psychological measures or other indications of apredisposition to PND but who do not meet diagnostic criteria for PND at that time

BACKGROUND

Universal preventive approaches may be less stigmatising than selective preventive interventions but littleattention has been paid to universal prevention in pregnant women partly because the cost of a universalprogramme is likely to be high63 compared with a selective approach to identify higher-risk women Forexample 81 of women do not have an EPDS score 13 or more during pregnancy14 However there is arationale for providing a preventive intervention to women with subthreshold symptoms of depression whomay otherwise go on to develop depression1864

The outcomes for a selective intervention depend on how the population and risks are identified anddefined63 Although indicated preventive interventions for PND could be regarded as addressing prodromalsymptoms and therefore are not actually preventive they could be regarded as early intervention68

The rationale for antenatal prevention of PND is based on data from the Avon Longitudinal Study ofParents and Children study14 showing that 437 of women with an EPDS score 13 or more at 32 weeksof pregnancy experienced elevated symptoms postnatally Aiming to prevent identify and treat antenataldepression presupposes that this will lead to a reduction in antenatal maternal morbidity and severitydeleterious effects on the developing infant postnatal maternal morbidity and severity and other adverseoutcomes in the offspring1669 Hence investment during pregnancy and postnatally may yield futurebenefits and financial savings in different areas of health and social care

Evidence of preventive interventions

A wide range of support and treatment approaches have been explored because of the diverse aetiologyof PND (physiological social or psychological) with the aim of changing the mechanisms leading to PND68

Several interventions to prevent PND have been developed as modifications of promising interventions totreat PND These are classified as psychotherapeutic biological pharmacological educational or socialsupport Cochrane and other systematic reviews have provided some contradictory findings about thepotential to prevent PND Not enough is known about the effectiveness of these preventive interventions

Psychological approaches to the prevention and treatment of depressionThe psychological literature attests to the large effort expended on research into differing psychologicalapproaches to the prevention70 and treatment of depression71ndash75 Although depression has often been theinitial target condition for testing psychological approaches it has equally often proved to be a morechallenging condition when attempting to establish mechanisms of change that are specific to particularmodels of therapeutic interventions A review of 101 randomised controlled trials (RCTs) on the treatmentof major depression concluded that IPT CBT and behaviour therapy are effective while brief dynamictherapy and emotion-focused therapy are possibly effective72

A different body of literature suggests relatively small differences between the outcomes of differentpsychological interventions for depression An earlier review which controlled for researcher allegiance(belief in the superiority of a treatment) found small effect sizes from comparisons between specifictherapies73 This finding has been broadly supported in a meta-analysis of 58 outcome studies fordepression which made direct comparisons between specific therapies which yielded similarly small effectsizes74 However arguments suggesting that researcher allegiance bias is related to treatment effects havebeen both supported76 and challenged77

A wide-ranging review of the efficacy and effectiveness of psychological therapies in general concluded thatthey were broadly effective for depression with little difference between theoretically diverse interventions78

Estimates of the proportion of outcome variance attributable to components of therapy comprised thefollowing extra-therapeutic factors 40 (eg delivered individually or in a group or the number of sessions)relationship 30 placeboexpectancy effects 15 and specific techniques 157879 A subsequentmeta-analysis in which common factor control groups were employed supported these estimates80

Extensive efforts have been afforded in relation to the development of measures81 and the measurementof outcomes82 in psychotherapeutic interventions and the role of non-specific (common) factors such ascongruence positive regard and empathy has long been recognised8384 The account of broadly similaroutcomes despite diverse therapeutic interventions (termed the equivalence paradox)85 has yieldedsophisticated accounts to explain this phenomenon with the existence of common factors persisting asone major explanatory source85 However others have argued that there is no clear evidence supporting acausal link between common factors and therapeutic outcomes86 The debate is not so much focused onthe validity of the concept but rather on the absence of experimental manipulation as a route todetermining which common factors if any impact on therapeutic change The concepts of hope andexpectancy among others have been posited as common factors but the main focus for research hasbeen on the concept of the therapeutic relationship or alliance

Educational interventionsAttention has been paid to developing preventive strategies or interventions that focus on couplecommunication or parenting skills to ease the transition to parenthood87 Antenatal preparation forparenthood has traditionally focused on aspects of the womanrsquos pregnancy and on preparation forchildbirth with less attention paid to what to expect when the infant arrives or to couple communicationor parenting8889 Dyadic relationship quality is adversely affected90 in 67 of new mothers91 and 45 ofnew fathers92 during the first year of parenthood Despite the central role of partner support in maternalmood93 new parent couples have reported being shocked by and unprepared for adverse changes in theirrelationship feeling sad and bemused that no one had talked to them about the changes they wouldexperience in their relationships94

Some preventive educational interventions have been delivered universally to all expectant parents makinguse of the opportunities to access this population through established antenatal care pathways therebyreaching couples who may not otherwise seek such support95 These and more targeted approachescover a variety of levels of intensity and format and timings

Social supportSocial support is a multidimensional concept that incorporates appraisal companionship informationalmotivational and instrumental support that is lsquo information leading the subject to believe that they arecared for and loved esteemed and a member of a network of mutual obligationsrsquo96 Social supportinvolves both social relationships that are embedded such as relationships with family members or friendsand those that are created97

There are several pathways through which social relationships and social support can affect mental healthSocial support can operate to promote health directly by enhancing feelings of well-being or by bufferingthe negative influences of stressful events Integration in a social network might also directly producepositive psychological states including sense of purpose belonging and recognition of self-worth98 Thesepositive states in turn might benefit mental health because of an increased motivation for self-care aswell as the modulation of the neuroendocrine response to stress98 Being part of a social networkenhances the likelihood of accessing various forms of social support which in turn protects againstdistress99 Members of a social network can exert a salutary influence on mental health by role modellinghealth-relevant behaviours100

Several different psychosocial mechanisms link aspects of social relationships to physical and emotionalwell-being social influencesocial comparison social control role-based purpose and meaning (mattering)self-esteem sense of control belonging and companionship and perceived support availability101 Giventhe importance of social support on mental health outcomes enhancing social support has been used as astrategy for both the prevention and treatment of PND

BACKGROUND

Pharmacological interventions or supplementsSome of the earliest interventions for the treatment and prevention of PND were hormonal Uncontrolledstudies used progesterone102ndash104 but no controlled studies have been conducted of progesterone oroestradiol as either a treatment or prevention

Compared with the results of trials supporting antidepressant treatment for major depression there is relativelylittle evidence to guide the clinician in treating or preventing PND The mainstay of treatment has beenantidepressant medication but women are reluctant to take antidepressants60 as they are concerned abouttheir safety when breastfeeding and the potential for side effects to disturb their interaction with their infant105

It has been reported that fish consumption and omega-3 status after childbirth are not associated withPND106 but there is still interest in exploring the role of omega-3 fatty acids in PND alone or combinedwith supportive psychotherapy107

Complementary and alternative medicineThis review adopts a generic definition of complementary and alternative medicine (CAM) lsquoA group ofdiverse medical and health-care systems practices and products that are not presently considered to bepart of conventional medicinersquo108 Although this definition meets with problems in many areas of medicalpractice in that what were once regarded as CAM are now provided as part of conventional medicalservice it works reasonably well in perinatal depression as CAMs are not generally provided inperinatal services

Complementary and alternative medicine is widely used by pregnant women in the Western worldparticularly those who are highly educated and have high incomes109 often to reduce stress and improvemood however their use remains controversial110 Controversy extends beyond the definition of CAM tothe nature of the effects of CAM and to the quality of CAM research CAM is also widely used by thegeneral public particularly women111112 many of whom do not report its use to their doctors It is oftenused to promote wellness in the positive holistic sense as well as in the management of symptoms anddisease CAM has been offered to women with the aim of treating both antenatal depression63113ndash115

and PND63116 alone or in combination

The CAM interventions most commonly explored in these studies include aromatherapy massagehypnosis and other forms of relaxation therapy herbal medicine mindfulness and meditation acupunctureand general traditional Chinese medicine Ayurvedic medicine and homeopathy Acupuncture is a popularform of treatment for depression outside the perinatal period and there is evidence that its effectivenessis equivalent to that of antidepressants117 and that side effects are rare Acupuncture in the context ofantenatal depression was examined by a Cochrane review118 that reported inconclusive evidence

Mindndashbody therapies have also been used to treat depression in general and in the perinatal periodspecifically116119 and for many there is some evidence of effectiveness120 Mindfulness has received specificattention in the context of perinatal depression121 and is supported by an evidence base showing that it iseffective in depression in general122

Yoga and tai chiqi gong are practised both alone and as a component of Ayurvedic and traditionalChinese medicine and are used by pregnant women to improve their health110119 The health effects ofthese traditional medical approaches are held to extend beyond physical fitness suppleness and strengthand they overlap with those of simple physical activity which has also been investigated as an interventionto reduce depressive symptoms in pregnant women123

Summary

In summary the prevention of PND is an important and somewhat neglected area in the UK in terms ofthe potential impact on women and their infants and families Within the NHS effort is currently directedtowards treating identified depression in perinatal women particularly postnatally A range ofpsychological educational pharmacological social support and CAM interventions have been explored tominimise the development of and the intensity duration and frequency of depressive symptoms The nextchapter defines the decision problem

BACKGROUND

Chapter 2 Definition of the decision problem

Decision problem

The focus of this report is the prevention of PND and optimisation of the mental health of pregnant andpostnatal women and consequently the health of their infants

The population comprised all pregnant women (universal) pregnant women or subgroups whose risk ofdeveloping PND was significantly higher than average because they had one or more social risk factor(selective) and pregnant women at high risk of developing PND on the basis of psychological risk factorsabove-average scores on psychological measures or other indications of a predisposition to PND or diagnoseddepression (indicated) The population also included all postnatal women in their first 6 postnatal weeks(universal) postnatal women or subgroups whose risk of developing PND was significantly higher than averagebecause they had one or more social risk factor (selective) and postnatal women at high risk of developingPND on the basis of psychological risk factors above-average scores on psychological measures or otherindications of a predisposition to PND (indicated) but not postnatal women diagnosed with depression

All interventions suitable for pregnant women and women in the first 6 postnatal weeks were includedAll usual care and enhanced usual-care control and active comparisons were considered In the review ofboth the quantitative and the qualitative research literature all outcomes were considered

Overall aim and objectives of assessment

The overall aim of the report was to evaluate the clinical effectiveness cost-effectiveness acceptability andsafety of antenatal and postnatal interventions to prevent PND The purpose of the study was to applyrigorous methods of systematic reviewing of quantitative and qualitative studies evidence synthesis anddecision-analytic modelling to evaluate the preventive impact on women and their infants and families

The objectives of the review were as follows

1 to determine the clinical effectiveness of antenatal interventions and postnatal interventions to preventPND (systematic review of quantitative research)

a to identify moderators and mediators of the effectiveness of preventive interventionsb to undertake a meta-analysis of available evidence [including a network meta-analysis (NMA)

as appropriate]

2 to provide a detailed service user and service provider perspective on the uptake acceptability andpotential harms of antenatal and postnatal interventions (systematic review of qualitative research)

a to examine the main service models for prevention of PND in relation to the underlying programmetheory and mechanisms with a focus on group- and individual-based approaches (realist synthesis)

3 to undertake an economic analysis including a systematic review of economic evaluations and theidentification of other evidence needed to populate an economic model

4 to determine the potential value of collecting further information on all or some of the inputparameters (expected value of information analysis)

Service user involvementThe Nottingham Expert Patient (EP) committee is a group of women who have experienced the distressingeffects of severe PND Three of the women in the group were admitted to a mother and baby unit and allreceived community psychiatric care The EP committee established in 2009 has acted as the patientsrsquolsquovoicersquo advising the East Midlands Perinatal Mental Health Clinical Network Board on how to develop localservices to meet the needs of women who experience mental health problems in pregnancy and afterchildbirth The EP committee has joined the newly formed National Perinatal Mental Health ClinicalReference Group to ensure that the experiences and views of patients inform and influence the planningand delivery of the specialised service

The EP committee were pleased to be invited to contribute to this review to be involved in thedevelopment of the research proposal and to provide patient and public involvement (PPI) advicethroughout the research The EP committee reviewed the draft research proposal and provided detailedfeedback to the principal investigator The EP committee has maintained involvement through contact withthe principal investigator (JM) ad-hoc meetings having an EP committee member sit on the ExpertClinicalMethodological Group and providing input into this report

Service user feedback on the draft proposalThe EP committee was initially somewhat sceptical that interventions could prevent PND Early detectionand treatment of PND was considered more of a priority than prevention The importance of educatinghealth professionals in the detection of and impact of PND was also highlighted Further discussion andconsideration led to collective acknowledgement that all members of the EP committee had experiencedthe most severe PND which may not have been preventable It was agreed that prevention or at least areduction in severity of moderate or mild PND may be possible and worth investigating

Service user feedback on the proposal and ongoing reviewThe EP committee questioned the meaning of PND especially with regard to the term lsquodepressionrsquo as formany of the women anxiety was the major symptom The research team decided to include maternalanxiety or stress as a secondary outcome with depression as the primary outcome

It was suggested that both infanticide (although rare) and the decision to terminate a pregnancy(if PND had been experienced in a previous pregnancy) should be considered as outcomes Maternalsuicide (no longer the most common cause of maternal death)23 was another potentially preventableoutcome It was agreed to cover these outcomes in the background section of this report Family outcomeswere also emphasised as the entire EP committee reported the impact of their PND on their children andfamily members Of particular note was the impact of their PND on partners who also may becomedepressed or anxious

The group discussed the distinction between prevention and treatment The question was posed lsquoWhen isan intervention considered treatment and when is it preventionrsquo One EP committee member had been onantidepressant medication before conceiving (although symptom free) because she experienced PND withher first child This medication was increased at the end of the first trimester when she developedsymptoms of anxiety This also calls into question the term postnatal depression as many women alsobecome ill in the antenatal period There was some debate around EPDS scores in the literature and thecut-off point for including studies as prevention studies It was decided that trials in which includedwomen had a raised EPDS but no diagnosis of PND would be classed as prevention studies

DEFINITION OF THE DECISION PROBLEM

Service user feedback on acceptability of interventions to preventpostnatal depressionGiven their relatively extreme experiences of PND the EP committeersquos view on potential interventions toprevent PND was very open When faced with a life-changing and potentially life-threatening illnessthey felt the choice of intervention was likely to be focused on proven effectiveness

Medication during pregnancy was perceived to be acceptable to women who have experienced PND in aprevious pregnancy especially severe PND However they felt that preventive medication was probablyundesirable for those women in their first pregnancy who are asymptomatic but deemed lsquoat riskrsquo Othernon-pharmacological interventions such as those being investigated in this review were considered morelikely to be acceptable to the majority of pregnant women

Overall the acceptability of interventions to prevent PND was perceived to be influenced by many factorsnot least whether or not a woman has a history of PND The potential for prevention or lessening theseverity of PND was viewed by the EP committee as a very encouraging and exciting prospect

Chapter 3 Review methods

Overview of review methods

This chapter details the methods used to identify RCTs systematic and other reviews and qualitativestudies suitable for inclusion in the review Figure 1 illustrates the four phases of the review including thedata extraction analysis and interpretation phases

Methods for reviewing and assessing clinical effectiveness

Search strategies for identification of studiesThe review of effectiveness of interventions to prevent PND constituted the central platform for this reportThe objectives of the individual RCTs and the data available from them determined what NMAs werefeasible The analysis of effectiveness determined the subsequent qualitative synthesis and economicanalyses The leading candidate interventions demonstrated in terms of potential effectiveness becamethe focus for the realist synthesis This filtered approach recognised that it would not be feasible toconduct rich interpretive explorations across the wide heterogeneity of possible interventions andtherefore interpretive resources were focused where they were most likely to yield insights on current andfuture interventions

Search strategy for randomised controlled trials and systematic reviewsSearch activities were as follows

1 searches of electronic databases2 searches of the internet3 searches of specific websites4 citation searches5 reference lists of relevant studies6 hand searches of relevant journals7 scrutiny of references listed in reviews of the prevention of PND8 suggestions from experts and those working in the field

Searches of electronic databasesA comprehensive search of 12 electronic bibliographic databases was undertaken to identify systematicallyclinical effectiveness literature comparing different interventions to prevent PND The literature searchstrategy is presented in Appendix 1 The list of electronic bibliographic databases searched for publishedand unpublished clinical effectiveness research evidence is presented here

l The Cochrane Library including the Cochrane Systematic Reviews Database Cochrane Controlled TrialsRegister Database of Abstracts of Reviews of Effects (DARE) Health Technology Assessment (HTA) andNHS Economic Evaluation Database (NHS EED) 1991 searched on 28 November 2012

l MEDLINE (via Ovid) 1946ndashweek 3 November 2012 searched on 30 November 2012l PreMEDLINE (via Ovid) 4 December 2012 searched on 5 December 2012l EMBASE (via Ovid) 1974ndash4 December 2012 searched on 5 December 2012l Cumulative Index to Nursing and Allied Health Literature (CINAHL via EBSCOhost) 1982 searched on

11 December 2012l PsycINFO (via Ovid) 1806ndashweek 4 November 2012 searched on 5 December 2012l Science Citation Index (via ISI Web of Science) 1899 searched on 5 December 2012l Social Science Citation Index (via ISI Web of Science) 1956 searched on 5 December 2012

ndash7

Service user consultation

lsquofo

calrsquo

5ndash7

ndash7

FIGURE1

ofreview

methodsKey

IPIindicated

interven

quality-ad

justed

life-ye

PIselective

interven

IDieRtem

interven

tiondescriptionan

dreplicationU

niversalp

interven

hisisan

Accessarticle1

24distributedin

cewiththeCreativeCommonsAttribution

NonCommercial

(CCBY-N

hichpermitsothersto

distributerem

tbuild

uponthiswork

non-commerciallya

ndlicen

setheirderivativeworksondifferent

sprovided

theoriginal

isproperly

citedan

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isnon-commercialS

ttpcrea

commonsorglicensesby-nc30

REVIEW METHODS

l Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest) 1987 searched on 19 December 2012l Allied and Complementary Medicine Database (AMED) (via Ovid) 1985ndashDecember 2012 searched on

5 December 2012l Conference Proceedings Citation IndexndashScience (CPCI-S) (via ISI Web of Science) 1990 searched on

5 December 2012l Midwives Information and Resource Service (MIDIRS) Reference Database 1991 searched on 24 July 2013

Further searches for grey literature were conducted from January to March 2013 on additional resourcesA list of the additional resources is presented in Appendix 1

Search strategy search termsThe search strategy was developed using an iterative approach The search used a combination ofthesaurus and free-text terms for postnatal and antenatal depression combined with terms for preventionor risk factors or generic terms for interventions The search comprised four facets

l Facet 1 comprised terms for the population (pregnant and postnatal women)l Facet 2 comprised terms for preventionl Facet 3 comprised terms for known risk factors for PNDl Facet 4 comprised generic terms for interventions

Facet 1 was combined separately with facets 2 3 and 4 The major search refinement was to reduce thenumber of search terms in facet 1 then extra terms were added for facets 2 3 and 4 In addition thesearches were combined with search filters for specific study designs when appropriate All searches wereperformed by an information specialist (AC) from November to December 2012 Copies of The CochraneLibrary and all the other search strategies are presented in Appendix 1

The search strategy was used to search the Cochrane Central Register of Controlled Trials (CENTRAL) andthen to search other databases not indexed by Clinical Trials CENTRAL runs sensitive strategies onMEDLINE and EMBASE to identify relevant published RCTs therefore MEDLINE and EMBASE were notsearched retrospectively Records were retrieved through planned manual searching of a journal orconference proceedings to identify all reports of RCTs and controlled clinical trials125 The search was runwith a systematic reviews filter to find Cochrane and other systematic reviews The number of RCT andsystematic review results obtained for the various databases searched is presented in Appendix 2

Citation searches reference lists relevant journals and clinical expertsReference tracking of all included and relevant studies was performed and reference lists of relevantreviews and systematic reviews were scrutinised to identify additional relevant studies not retrieved by theelectronic search to identify further potentially eligible RCTs Searching of key journals selected followingconsultation with clinical experts was conducted using electronic table of contents alerts from January toJuly 2013 for 33 journals presented in Appendix 3 Clinical advisors were also contacted about furtherpotentially relevant RCTs

Search outcome summary for the randomised controlled trialsSearch result citations were imported and merged into Reference Manager version 12126 (ThomsonResearchSoft San Francisco CA USA) and duplicates were removed by Reference Manager or deletedmanually (by JM and AC)

Review protocol

The population intervention comparators outcomes study designs (PICOS) process was used to breakdown the research question into concepts and search terms Recognising that systems of care differinternationally rather than concentrating solely on UK-based RCTs we were deliberately inclusive in oursearch to capture RCTs of all interventions irrespective of their health-care context The research protocolis registered on PROSPERO (registration number CRD42012003273)

Inclusion and exclusion criteria for quantitative studies

PopulationThe population included women of all ages who were either pregnant or had given birth in the previous6 weeks The population was separated according to level of risk of PND into three levels universalselective or indicated as follows

l Universal all women in a defined population not identified on the basis of increased risk of PNDl Selective women or subgroups of the population whose risk of developing PND was significantly higher

than average because they had one or more social risk factors such as general vulnerability aged lessthan 18 years at risk of violence ethnic minority human immunodeficiency virus (HIV) positive living indeprivation or financial hardship or poverty or single socially disadvantaged or unsupported

l Indicated women at high risk of developing PND on the basis of psychological risk factors above-average scores on psychological measures or other indications of a predisposition to PND but who didnot meet diagnostic criteria for PND at that time such as antenatal depression a raised symptomdepression score and a history of PND or history of major depression

The population dimension for the PICOS framework is presented in Box 2

BOX 2 Population dimension of the PICOS framework for quantitative review

Included

Pregnant women (universal)

Postnatal women with a live baby born within the previous 6 weeks (universal)

Vulnerable pregnant or postnatal women who were aged less than 18 years at risk of violence an ethnic minority HIV

positive living in deprivation financial hardship or poverty or single socially disadvantaged or unsupported (selective)

Pregnant or postnatal women with a raised score on the antenatal risk questionnaire Beck Depression

Inventory Center for Epidemiologic Studies Depression scale the Cooper predictive index depression symptom

checklist EPDS HADS Hamilton Depression Rating Scale Health during pregnancy questionnaire a past history

of PND or major depression (indicated)

Pregnant women with a diagnosis of depression using Research Diagnostic Criteria or DSM-IV criteria (indicated)

Excluded

Postnatal women with a diagnosis of PND

Pregnant women with comorbid psychiatric disorders

Postnatal women with major medical problems

DSM-IV Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition

REVIEW METHODS

InterventionsThe preventive interventions were also separated into three levels of preventive intervention according tothe population for which the intervention was intended

l Universal preventive interventions interventions available for all women in a defined population notidentified on the basis of increased risk of PND

l Selective preventive interventions interventions offered to women or subgroups of the populationwhose risk of developing PND was significantly higher than average because they had one or moresocial risk factors

l Indicated preventive interventions interventions offered to women at high risk of developing PND onthe basis of psychological risk factors above-average scores on psychological measures or otherindications of a predisposition to PND but who did not meet diagnostic criteria for PND at that time

Seven main classes of interventions were also categorised as presented in Box 3

BOX 3 Intervention dimension of the PICOS framework for quantitative review

Included

Pharmacological agents or supplements prescribed antidepressants calcium dietary supplements

hormone therapy thyroid therapy

Psychological the breadth of psychological interventions and approaches which comprise components of a

psychotherapeutic approach

Social support home visits telephone-based peer support doula support social support

Educational educational information booklets and classes

Organisation of maternity care alternative forms of contact with care providers primary care strategies

CAM or other music acupuncture tai chi yoga pregnancy massage aromatherapy exercise and

herbal medicine

Midwifery-led interventions different approaches to antenatal care CenteringPregnancy team midwife

care caseload midwifery

Excluded

Treatment trials for women with PND

Interventions initiated preconceptually

Interventions initiated more than 6 weeks postnatally

ComparatorsAll comparison arms for all eligible studies in all countries were included whether usual care enhancedusual care or an active comparison group

OutcomesThe main outcome was a validated measure of symptoms of maternal depression or a diagnostic measureof depression from 6 weeks to 12 months postnatally Other maternal outcomes of anxiety and well-beingwere included Binary categorical or continuous outcomes were included whether as a single measure orassessed at more than one postbaseline treatment time point The outcomes dimension is presented inBox 4

Study designsThe study designs dimension is presented in Box 5

BOX 4 Outcome dimension of the PICOS framework for quantitative review

Included

Depression symptoms measured on a validated self-completed instrument

Depression diagnosis

Anxiety symptoms

Diagnostic measure of anxiety

Birth outcomes

Infant outcomes

Family outcomes

Excluded

No measure of PND reported in the results

Outcome measurements more than 12 months postnatally

Outcome measurements less than 6 weeks postnatally

Physiological measurement

Unvalidated measures of depression

REVIEW METHODS

BOX 5 Study design dimension of the PICOS framework for quantitative review

Included

Economic evaluations alongside RCTs

Systematic reviews of the prevention of PND

Excluded

Before-and-after studies

Casendashcontrol studies

Cohort studies

Commentary or clinical overviews

Cross-sectional surveys

Description of a study

Non-randomised control groups

Non-systematic reviews

Not a PND prevention trial

Ongoing RCTs

Protocols for a RCT

Reviews not about prevention of PND

Secondary analysis of data from a RCT

Studies reported in non-English language

Systematic reviews not about prevention of PND

Search strategy and outcome summary for the qualitativestudies

Electronic databasesThe search for the clinical effectiveness evidence was run with a qualitative filter to identify qualitativestudies The list of electronic bibliographic databases searched is presented in Appendix 1 The search wasrun again with a mixed-methods filter (devised with AB) to find papers that used quantitative andqualitative methodology The numbers of qualitative studies and mixed-methods studies retrieved for thevarious databases searched are presented in Appendix 4

Study selection

Study selection criteria and procedures for the quantitative reviewTwo reviewers (JM and PS) independently screened the titles and abstracts to identify papers for possibleinclusion If no abstract was available the full paper was retrieved for scrutiny Full papers for RCTs wereobtained if the abstract showed that the study fulfilled the inclusion criteria or it was unclear from theabstract whether or not the inclusion criteria were fulfilled All full papers retrieved were independentlyreviewed by two reviewers Papers were not excluded on quality at this selection stage The full papers hadto fulfil the inclusion criteria presented in Tables 2ndash5 Where there was no consensus following discussionabout inclusion at the full-paper stage a third reviewer or clinical expert (CLD HS or SS-B) was consultedThe reasons for exclusion are presented in Appendix 5

Study quality assessment checklists and procedures for the randomisedcontrolled trials

Risk-of-bias assessmentThe quality of each paper was assessed independently by two reviewers (JM and PS) using the CochraneCollaborationrsquos tool for assessing risk of bias in randomised trials126 Any disagreements about risk of biaswere resolved by a third reviewer The risks assessed were

l risk of selection bias (random sequence generation and allocation concealment)l risk of performance bias (blinding of participants and personnel)l risk of detection bias (blinding of outcome assessors)l risk of attrition bias (incomplete outcome data)l risk of reporting bias (selective reporting of the outcome subgroups or analysis)l risk of other sources of bias (any important concerns about other possible sources of bias such as

funding source adequacy of statistical methods used type of analysis baseline between-groupimbalance in important prognostic factors)

The risks were assessed as low risk of bias high risk of bias or unclear risk of bias For each assessed riskthe reviewers provided a statement description or direct quotation to support their judgement A summaryassessment of risk was made across all the risks to inform the interpretation of plausible bias andsummary risk of bias is presented in Chapter 4 the overview of results for quantitative andqualitative studies

Data extraction for randomised controlled trialsData from the full papers were entered on to a specially designed pre-piloted and tailored data extractionform to summarise the intervention The primary aim of the study was documented (PND preventionantenatal well-being birth outcomes general health general psychological well-being infant outcomes orfamily outcomes) The intervention and comparison arms were described The data extraction formindicating the main RCT characteristics is presented in Appendix 6

REVIEW METHODS

Outcomes were recorded as maternal neonatal and family outcomes using mean [standard deviation (SD)]values when available and numbers and proportions of participants in specific outcome categories Thequality of the extracted data was checked (JM and PS)

Potential moderatorsPotential moderators are variables describing population characteristics for which the intervention mayhave a different effect for different values of the moderator variable127 These were documented whenthere was some basis for believing that the maternal population characteristics might have a moderatingeffect on the outcomes for example maternal age parity being a sole parent history of mental healthproblems and history of PND Baseline depression scores were recorded to estimate the population meandepression score for women who entered the studies

Potential mediatorsPotential mediators are variables that could help explain the process by which an intervention waseffective127 These were documented such as the timing of the intervention the provider the number ofsessions offered and whether the intervention was individual based or group based

Data synthesis of randomised controlled trialsA large number of RCTs and systematic reviews were eligible for inclusion according to our broad inclusioncharacteristics We conducted a narrative description of the studies according to the level of preventiveintervention (universal selective or indicated) class of intervention and the context within which the RCTswere undertaken

Meta-analysis of randomised controlled trials

Methods of evidence synthesisThe extracted data and quality assessment variables were presented for each study in structured tablesand as a narrative description Both conventional RCTs in which individual women were randomised tointerventions and cluster RCTs (CRCTs) were eligible for inclusion Estimates of treatment effect andstandard error of treatment effects from CRCTs were included in the analyses after allowing for thecluster design

The reference treatment for comparative purposes and for estimating intervention effects was defined asusual care Usual care in the UK Australia Canada France Norway and the USA was assumed to besufficiently similar to be interchangeable and was collectively defined as lsquousual carersquo for the purpose ofthe analysis

The evidence was synthesised using a NMA128 A NMA (also known as a mixed-treatment comparison or amultiple treatment comparison) is an extension of a standard (pairwise) meta-analysis It allows evidencefrom RCTs comparing different interventions to be combined to provide an internally consistent set ofintervention effects while respecting the randomisation used in individual studies The NMA enables asimultaneous comparison of all evaluated interventions in a single coherent analysis thus all interventionscan be compared with one another including comparisons not evaluated within individual studies Theonly requirement is that each study must be linked to at least one other study through having at least oneintervention in common The analysis preserves the within-study randomised treatment comparison of eachstudy and assumes that there is consistency across evidence As with standard pairwise meta-analysestreatment effects are assumed to be exchangeable across studies In addition it is assumed that treatmenteffects are transitive such that if the effect of intervention 2 relative to intervention 1 is d21 and the effectof intervention 3 relative to intervention 1 is d31 then the effect of intervention 3 relative to intervention 2is d32= d31 ndash d21 this allows a synthesis of direct and indirect evidence about intervention effects and asimultaneous comparison between interventions Evidence from RCTs presenting data at any assessmenttime up to 12 months were considered relevant to the decision problem

Methods for the estimation of efficacy

Statistical model for Edinburgh Postnatal Depression Scale threshold scoreThe number of women who had an EPDS score greater than a specified threshold was available fromseveral studies at four different postnatal stages depending on the study (ie 6 weeks 3 months6 months and 12 months) Most studies used one threshold although the thresholds varied across studies(ie threshold score of 10 11 12 and 13) One study129 reported the number of women who had an EPDSscore at two thresholds (ie 10 and 13)

The EPDS threshold scores were regarded as being ordered categorical data with categories 0ndash9 10 1112 13 and 14 or more We assumed an underlying proportional odds model such that

logP(Yle jjx)

1minusP(Yle jjx)

= logit(P(Yle jjx)) = α j + βx j = 1hellip jminus1 x = 0 1 (1)

where αj is the cumulative log-odds for the control intervention (x= 0) and β is the log-odds ratio for theexperimental intervention (x= 1) relative to the control intervention The model assumes that thecumulative log-odds ratios are independent of the threshold so that the effect of treatment does notdepend on the threshold Although this may be a strong assumption it cannot be assessed in studies thatuse only one threshold which are all but one study

Studies were classified as follows

l RCTs randomising women to interventions and reporting data using one thresholdl RCTs randomising women to interventions and reporting data using two thresholdsl CRCTs

Randomised controlled trials randomising women to interventions andreporting data using one thresholdFor RCTs randomising women to interventions and reporting data using one threshold we let rik be thenumber of women with a response greater than the threshold for each arm out of nik women for arm k instudy i We assumed that the data follow a binomial likelihood such that

riksimBinomial(pik nik) (2)

where pik is the probability that a women has a response greater than the threshold in arm k of study iThe pik values are transformed to the real line using a logit link function such that

logit(pik) = microi + δi bkIfkne1g (3)

lfug =1 if u is true0 otherwise

microi is the study-specific baseline log-odds of having a response greater than the threshold in the controlintervention of the study and δibk is the study-specific log-odds ratios of having a response greater than thethreshold in the intervention group compared with the control intervention b

REVIEW METHODS

Randomised controlled trials randomising women to interventions andreporting data using two thresholdsFor RCTs randomising women to interventions and reporting data using two thresholds we fitted aproportional odds model using the freely available software package R (The R Foundation for StatisticalComputing Vienna Austria) using the lsquopolrrsquo function within the MASS package and obtained the sampleestimate of the log-odds ratio yibk and its standard error Vibk for intervention k relative to intervention bin study i We assumed that the sample log-odds ratios arose from a normal likelihood such that

yi bksimN(δi bk Vi bk) (5)

Cluster randomised controlled trialsFor two-arm CRCTs (which reported data using one threshold) the sample estimate of the log-odds ratioyibk and its adjusted standard error Vibk for intervention k relative to intervention b in study i wereextracted and assumed to have arisen from a normal likelihood such that

For three-arm CRCTs (which reported data using one threshold) the two intervention effects are correlatedbecause they are both estimated relative to the same control The likelihood function for study i wasdefined to be bivariate normal such that

yi b2yi b3

δi b2δi b3

Vi b2 se2i 1

se2i 1 Vi b3

where yibk and Vibk are as defined before and se2i1 is the variance of the control intervention log-odds

The population standard errors of the log-odds ratios and the population standard error of the controlintervention in a three-arm cluster randomised trial were assumed to be known and equal to thesample estimates

For a random (intervention)-effects model we assumed that the study-specific log-odds ratios arose from acommon population distribution such that

δi bksimN(d1kminusd1b τ2) (8)

where d1k is the population log-odds ratios for intervention k relative to the reference intervention(ie usual care) and τ is the between-study SD We assumed a homogenous variance model in which thebetween-study SD was assumed to be common to all treatment effects For multiarm trials theseunivariate normal distributions are replaced by a multivariate normal distribution to account for correlationbetween treatment effects within a multiarm study

Parameters were estimated using Markov chain Monte Carlo simulation conducted using the freelyavailable software package WinBUGS 143 (MRC Biostatistics Unit Cambridge UK)130

The model was completed by giving the parameters prior distributions

l Vague prior distributions for the trial-specific baselines microisimN(01000)l Vague prior distributions for the treatment effects relative to reference treatment d1tsimN(01000)

Weakly informative prior distribution for the between-study SD of treatment effects τsimHN(0 0322)[in addition as a sensitivity analysis the model was also run using the conventional vague prior distributionτsimU(02)]

Vague prior distributions were used for trial-specific baseline and treatment effect parameters Howevera weakly informative prior distribution was used for the between-study SD because there were insufficientstudies with which to estimate it from the sample data alone this prior distribution was chosen to ensurethat a priori 95 of the study-specific odds ratios were within a factor of 2 from the median odds ratiofor each treatment comparison

Convergence of the Markov chains to their stationary distributions was assessed using the GelmanndashRubinstatistic131 The chains converged within 25000 iterations a burn-in of 30000 iterations was usedWe retained a further 10000 iterations of the Markov chain with which to estimate parameters

Results are presented as odds ratios [and 95 credible intervals (CrIs)] the between-study SD (and its95 CrI) and rankograms (ie the probability of treatment rankings) CrIs provide an x interval such thatthere is a x probability that the true parameter lies within the interval Rankograms provide the probabilitiesof each treatment being ranked as the best second best and so on through to the lowest-ranked treatmentThe between-study SD provides a measure of heterogeneity in treatment effects between studies on thelog-odds scale a between-study SD less than 05 is indicative of mild heterogeneity of between 05 and 1 isindicative of moderate heterogeneity and of greater than 1 is indicative of extreme heterogeneity

Statistical model for Edinburgh Postnatal Depression Scale mean scoresThe analysis of the EPDS score data was conducted in two stages (1) a treatment-effects model in whichthe effect of each intervention was estimated relative to usual care and (2) a baseline (ie usual-care)model in which the absolute response to usual care was estimated The treatment-effects model providesestimates of relative treatment effects which are used to make inferences about the relative effects ofinterventions The estimates of treatment effects relative to usual care were combined with the baselinemodel to provide estimates of absolute responses for each intervention these estimates were used asinputs to the economic model

Treatment-effects modelIn general each study provided data for each intervention in each study at baseline and at least oneon-treatment assessment time We excluded the baseline data from the treatment-effects model theremaining data are longitudinal (ie repeated measures) and are correlated between times

We began by supposing that we have observations yij= (xij Sij) for i= 1 2 I and j= 1 2 Jfor women in study i receiving intervention j that is we suppose that the sample mean EPDS scores forwomen in study i receiving treatment j at times t can be denoted by the vector xij= (xij1 xijT)T and thatthe sample mean variancendashcovariance matrix Sij is

Si j =

S2i j1 Si j1Si j2r12Si

⋯ Si j1Si j Tminus1r1 Tminus1 SiSi j1Si jT r1TSi

Si j1Si j2r12SiS2i j2

⋮ ⋮ ⋱ ⋮ ⋮Si j1Si j Tminus1r1 Tminus1 Si

Si jTminus1Si j 2rTminus1 2Si⋯ S2

i jTminus1 Si jTminus1Si j T rTminus1 T Si

Si j1Si jT r1TSiSi jT Si j2rT2Si

⋯ Si jTSi j Tminus1rT Tminus1 SiS2i jT

1CCCCA (9)

where the diagonal elements are the variances of the sample means at each time the off-diagonalelements are the covariances between sample means at different times and the rijSi are the sampleestimates of the within-study correlation coefficients which depend on study si

REVIEW METHODS

Although the woman-specific EPDS scores are discrete in the range 0ndash30 and the underlying distributionof EPDS scores is unlikely to be normal we appeal to the central limit theorem which states that as thesample size approaches infinity for any underlying distribution with finite mean and variance then thedistribution of the sample mean is normal Therefore we assume that the likelihood for the samplesmeans for women in study i receiving treatment j is

x i jjθsimN(v i j si j) (10)

where vij= (vij1 vijT)T represents the study-specific population mean vector of EPDS scores for treatmentj in study i

Published papers provided no information on the correlation between sample means at different timesTherefore we began by assuming that the rijSi is zero We also assumed that the population standarderrors σ i jt= ffiffiffiffiffi

ni jtp were known and equal to the sample standard errors sijt where σijt are the population SDs of

an individual observation for women in study i receiving treatment j at time t

The model for the treatment effects follows that for a NMA of repeated measures as presented by Dakinet al132 We estimate the treatment effects separately for each time such that

vi jt = microit + δi jt (11)

where microit is the population mean EPDS score for the baseline treatment (which is allowed to vary betweenstudies) in study i at time t and δijt is the population mean effect of treatment j in study i at time t

We used an unconstrained baseline model in which the effect of the baseline treatment in each study isfixed at each time thereby preserving the randomisation within each study We assumed that the effectsof treatment j in study i at time t arose from a normal distribution such that

δi jtsimN(dai j bi tminusdai 1 bi t

τ2) (12)

where aik indicates the treatment used in the kth arm of study i We assumed a homogeneous variancemodel in which the between-study SD was assumed to be common to all treatment effects and also acrosstimes For multiarm trials these univariate normal distributions are replaced by a multivariate normaldistribution to account for correlation between treatment effects within a multiarm study

Parameters were estimated using Markov chain Monte Carlo simulation conduction using WinBUGS 143130

l Vague prior distributions for the trial-specific baselines μisimN(01000)l Vague prior distributions for the treatment effects relative to reference treatment d1tsimN(01000)l A weakly informative prior distribution for the between-study SD of treatment effects τsimHN(02)

Vague prior distributions were used for trial-specific baseline and treatment effect parameters However aweakly informative prior distribution was used for the between-study SD because there were insufficientstudies with which to estimate it from the sample data alone this prior distribution has median 095(95 CrI 004 to 317) and was chosen to ensure that a priori 95 of the study-specific differencesbetween interventions in mean EPDS scores were within a range plusmn 31 for each treatment comparison

Convergence of the Markov chains to their stationary distributions was assessed using the GelmanndashRubinstatistic131 The chains converged within 25000 iterations therefore a burn-in of 30000 iterations wasused We retained a further 10000 iterations of the Markov chain to estimate parameters

Results are presented as differences between intervention in mean EPDS scores and 95 CrIs thebetween-study SD (and its 95 CrI) and rankograms (ie the probability of treatment rankings) at eachtime Crls provide an x interval such that there is a x probability that the true parameter lies within theinterval Rankograms provide the probabilities of each treatment being ranked the best second bestthrough to the lowest-ranked treatment The between-study SD provides a measure of heterogeneity intreatment effects between studies for continuous outcome measures the extent to which the between-study SD indicates mild moderate or extreme heterogeneity depends on the scale of measurement andthe variation within study

Baseline modelIn general studies in which the control intervention was usual care provided data at baseline and at leastone on-treatment assessment time Therefore the data are longitudinal (ie repeated measures) and arecorrelated between times

We began by supposing that we have observations yi= (xiSi) for i= 1 2 I for women in study i thatis we suppose that the sample mean EPDS scores for women in study i receiving usual care at times t canbe denoted by the vector xi= (x1i xiT)T and that the sample mean variancendashcovariance matrix Si is

S2i1 Si1Si2r12Si

⋯ Si1Si Tminus1r1 Tminus1 SiSi1SiT r1TSi

Si1Si2r12SiS2i2 ⋯ Si2Si Tminus1r2 Tminus1 Si

Si2SiT r2TSi

⋮ ⋮ ⋱ ⋮ ⋮Si1Si Tminus1r1 Tminus1 Si

SiTminus1Si 2rTminus1 2Si⋯ S2

iTminus1 SiTminus1Si T rTminus1 T Si

Si1SiT r1TSiSiTSi2rT2Si

⋯ SiTSi Tminus1rT Tminus1 SiS2iT

1CCCCA (13)

where the diagonal elements are the variances of the sample means at each time the off-diagonalelements are the covariances between sample means at different times and the rijSi are the sampleestimates of the within-study correlation coefficients which depend on study si In practice not all womenprovide data at each time and the covariances depend on the number of women who provide data ateach time as well as the number of women who provide data at both times Therefore the covariancebetween sample means within a study at times t and trsquo is

nttrsquo

ntnsi1rsquo si2rsquo r12si (14)

Although the woman-specific EPDS scores are discrete in the range 0ndash30 and the underlying distributionof EPDS scores is unlikely to be normal we appeal to the central limit theorem which states that as thesample size approaches infinity for any underlying distribution with finite mean and variance then thedistribution of the sample mean is normal Therefore we assume that the likelihood for the samplesmeans for women in study i is

x ijθsimN(v i Si) (15)

where vi= (vi1 viT)T represents the study-specific population mean vector of EPDS scores for women instudy i receiving usual care at times t Studies do not provide data at all times so that the number of timeswith data Ti in study i is such that 1le Tile T

Published papers provided no information on the correlation between sample means at different timesHowever using individual woman-level data from the PoNDER (PostNatal Depression Economic evaluationand Randomised controlled trial) we obtained estimates of the correlation coefficients between sample

REVIEW METHODS

EPDS scores at baseline 6 months and 12 months to be rb6m= 0345 rb12m= 0369 and r6m12m= 0721In the absence of any additional external evidence we made the assumptions as follows

rb6w = rb3m = rb6m = r6w3m = r6w6m = 0345 (16)

rb12m = r6w12m = 0369 (17)

r3m6m = r6m12m = r6m12m = 0721 (18)

The model for the baseline effects follows that presented by Wei and Higgins133 We letυisimMVN(Ximicro XiΩXT

i ) where Xi is a Ti times T design matrix defining which of the T times are included in thestudy micro is a T times 1 vector of underlying mean EPDS scores across studies and Ω is a T times T matrixrepresenting the between study covariance matrix for all T times Thus the studies are linked through theparameters that characterise the distribution of the random effects

All analyses were conducted in WinBUGS 143130 The model was completed by giving the parametersprior distributions

l Vague prior distributions for the treatment effects relative to the reference treatment d1tsimN(01000)l Weakly informative prior distributions for the between-study SD of treatment effects τsimHN(02)l Weakly informative prior distributions for the correlation coefficients U(ndash11)

Vague prior distributions were used for treatment effect parameters However a weakly informative priordistribution was used for the between-study SD because there were insufficient studies with which toestimate it from the sample data alone this prior distribution has a median of 095 (95 CrI 004 to 317)and was chosen to ensure that a priori 95 of the study-specific differences in means lie within a rangeplusmn 31 for each treatment comparison

Convergence of the Markov chains to their stationary distributions was assessed using the GelmanndashRubinstatistic131 The chains converged within 10000 iterations so a burn-in of 10000 iterations was usedWe retained a further 10000 iterations of the Markov chain to estimate parameters after thinning the chainsby retaining every 10th iteration to account for correlation between successive iterations of the Markov chain

Results are presented as means (and 95 CrIs) and the between-study SD (and its 95 CrI) at each time

The mean EPDS scores and the covariance matrix were extracted and were coupled with the treatment-effectsmodel to generate absolute EPDS scores for each treatment as inputs to the economic model Riley134 showedthat in the context of multivariate meta-analyses ignoring the within-study correlation can have substantialimpact on parameter estimates and their correlation expect when the within-study variation is small relative tothe between-study variation Morrell et al61 provided information about usual care cognitivendashbehaviouralapproach (CBA)-based intervention and a person-centred approach (PCA)-based intervention at baseline6 months and 12 months and was used to estimate the within-study correlation coefficients

Methods for reviewing and assessing qualitative studies

Study selection criteria and procedures for the effectiveness reviewA two-stage sifting process for inclusion of studies (title and abstract then full paper sift) was undertaken Titlesand abstracts of the qualitative studies were scrutinised by one assessor (AS) using the inclusion and exclusioncriteria No papers were excluded on the basis of quality at this stage Full papers were obtained for potentiallyincluded studies and for where the abstract provided too little information One-fifth of the total citationsidentified by electronic database searching (n= 2313) were checked for inclusion or exclusion by AB (n= 427)

Inclusion and exclusion criteria for qualitative studiesThe PICOS process was used to clarify the inclusion and exclusion criteria (Box 6)

Population

ComparatorsAll comparators were considered whether they were usual care other controls or specificalternative comparators

OutcomesAll outcome measures were considered All types of data including case studies interview data andobservations were considered

Study designsNo study designs were excluded from the qualitative review (Box 7)

BOX 6 Population dimension of the PICOS framework for qualitative studies

Included

Studies of populations of antenatal women and postnatal women at any point postnatally (but with qualitative

data concerning the first postnatal year) and health-care practitioners involved in delivering preventive

interventions for PND were relevant

Excluded

Studies of pregnant or postnatal women with diagnosed PND or other comorbid psychiatric disorders or major

medical problems

BOX 7 Study design dimension of the PICOS framework for the qualitative studies

Included

l Qualitative studies concerning acceptability to pregnant women and service providers potential harm and

adverse effects were extractedl Studies reporting qualitative research qualitative data elicited via a survey or a mixed-methods study

including qualitative data on the perspectives and attitudes of either (1) those who had received preventive

interventions for PND regardless of modality in order to examine issues of acceptability or (2) from

women who had not experienced PND regarding PSSSs that they believed helped them to avoid the

condition in order to identify promising components of any candidate interventionl Qualitative data embedded in trial reports or in accompanying process evaluations to inform an

understanding of how issues of acceptability were likely to affect the clinical effectiveness of current and

potential interventionsl Qualitative data either from separately conceived research or embedded within quantitative study reports

reporting the acceptability of interventions to health-care practitioners

PSSSs personal and social support strategies

REVIEW METHODS

Study quality assessment checklists and procedures for qualitative studiesStudies meeting the inclusion criteria were evaluated by two reviewers (AS and AB) using the CERQual(Confidence in the Evidence from Reviews of Qualitative research) approach135 which aims to assess howmuch certainty could be placed in the qualitative research evidence and were rated as lsquovery lowrsquo lsquolowrsquolsquomoderatersquo or lsquohighrsquo A summary assessment was made for each study based on the methodologicalquality of each included study and the coherence of the review findings (the extent to which a clearpattern was identifiable across the individual study data) Coherence was assessed by examining whetheror not the review findings were consistent across multiple contexts and incorporated explanations forvariation across individual studies Coherence was strengthened when individual studies contributing to thefindings were drawn from a wide range of settings

The methodological quality of individual studies was appraised using an abbreviated version of the CriticalAppraisal Skills Programme (CASP) quality assessment tool for qualitative studies136 Two reviewers (AS andAB) independently applied the set of quality criteria to each included study

Review findings were subsequently graded as lsquohighrsquo lsquomoderatersquo lsquolowrsquo or lsquovery lowrsquo according to the CASPassessment the number and richness of the data in the studies the consistency of the data within thestudies across study settings and populations and the relevance of the findings to the review question

Data extraction strategy for qualitative studiesData extraction from included studies was undertaken by AS using a data extraction tool adapted andtailored for the qualitative review A 20 sample of data extractions were checked by AB When datafor included studies were missing reviewers attempted to contact the authors at their last knowne-mail address

Selective extraction of findings137 was undertaken when the data were pertaining to an optimalintervention to be delivered antenatally or postnatally to prevent PND A framework for extraction wasdeveloped to elicit data extraction elements related directly to the review question The data extractionelements for the data extraction for the studies are presented in Appendix 6 The level of extractedevidence included information on characteristics of the intervention identified in the results and discussionsections and author comments and interpretation

Data synthesis for qualitative studiesQualitative meta-synthesis was undertaken by highlighting womenrsquos and service providersrsquo issues aroundthe acceptability of interventions and elucidating evidence around regarding personal and social supportstrategies (PSSSs) applied by women using the data extraction framework and thematic synthesis toaggregate the findings138 Evidence about interventions from women and service providers and evidenceabout PSSSs are presented separately (see Appendix 7)

Synthesis drawing upon realist approaches

Identification of key potential CLUSTERsTo exploit the potential of realist synthesis approaches requires rich conceptual and contextual dataReporting limitations and the varied emphases of published reports make it unlikely that all relevant dataare included in a single report of a study However the scale and expense of a RCT increases the likelihoodthat multiple research reports have been produced relating to the study of interest Such reports mayinclude supplementary qualitative work process evaluations student projects pilot studies feasibilitystudies and follow-up studies All such papers may help us to understand the study context mechanismsand outcomes Therefore a key task is to move from analysis of a single study report to a detailedexamination of a cluster of related papers Such forensic examination looks not only for directly relatedlsquosibling studiesrsquo but also for tangentially related lsquokinshiprsquo papers (ie papers that may represent replicationof an existing programme in a different context thus allowing for comparison and contrast)

Finally syntheses analyses and theoretical papers may locate the study within a wider context of exemplarsor case studies thereby expanding the potential for comparison Selection of clusters is necessarily limitedby the resources available for analysis In-depth analysis as typically performed for realist synthesis typicallyprecludes the comprehensive and exhaustive approaches prescribed by systematic review methodsIn selecting focal study clusters the team considered both the likely success of the programme and theavailability of sibling andor kinship study reports At this stage the Preparing for Parenthood cluster wasexcluded as even though it possessed several companion reports the trial did not demonstratepotential effectiveness

Searching for CLUSTER documentsSearching for documents to populate a study cluster has until recently been viewed as essentially anunsystematic and arbitrary procedure Conceptually it draws upon the long-established retrieval practicesoutlined in Batesrsquo seminal paper139 on lsquoberry pickingrsquo including lsquobackward chainingrsquo (following up citedreferences) and lsquoforward chainingrsquo (following up cited articles) Recent years have revealed a prodigiouspotential yield from supplementary documents For example a review by Jagosh et al140 revealed severalclusters with an average of 12 reports per cluster We used systematic methods previously developed byone of the authors of our study (AB) for implementing cluster to become CLUSTER searching for which afull published description of the CLUSTER methods (Citations Lead authors Unpublished materials Scholarsearches Theories Early examples Related projects) is openly available141 In essence the research teamundertook persistent pursuit of study links contextual links and theoretical links from the source study orstudies to other related reports which then themselves initiated a further cause for searching CLUSTERsearching is reliant on relatively rapid judgements on potential links between a referring document and itsreferent141 When papers shared a study identifier or acronym (eg PoNDER) or a RCT identifying numbersuch connections were easy to establish However more typically a sibling relationship between papersrelies on similarities in authorship study context and sponsoring institution However further checksinvolve pursuing cross-citation and co-citation so that a network of studies could be constructed

Synthesis and construction of a theoretical modelFor the synthesis stage we developed a rapid realist review approach provisionally labelled as lsquobest-fitrealist synthesisrsquo This involves

1 identification of a provisional lsquobest-fitrsquo conceptual framework as a starting point for data analysis2 population of the conceptual framework with lsquoifndashthenrsquo statements from the identified articles3 construction of pathways or chains from lsquoifndashthenrsquo statements to surface potential mechanisms by which

outcomes might be achieved4 identification of existing theory underpinning individual mechanisms5 development of a programme theory to explain how PND prevention programmes may work6 testing of the programme theory with contextual data from included studies

Identification of provisional lsquobest fitrsquo conceptual frameworkGiven the prominence of group care approaches among the candidate interventions (eg CenteringPregnancyor IPT) the research team decided to focus initial analytical attempts on the group-care model and then toseek to highlight similarities and differences with behavioural interventions delivered on an individual basiseither via face to face or via telephone A search was conducted on Google Scholar (Google Inc MountainView CA USA) harnessing its extensive full-text searching functionality using the terms lsquogroup carersquo ORlsquogroup visitsrsquo AND lsquohealth educationrsquo AND lsquomodelrsquo OR lsquoframeworkrsquo

Population of the conceptual frameworkIn examining CLUSTER documents the research team sought to identify mechanisms by which outcomeswere achieved in a particular context Mechanisms were operationalised by construction of a series oflsquoifndashthenrsquo statements based on causal relationships advanced by the RCT or hypothesised explanationsproposed by either the qualitative research or derived from the lsquoDiscussionrsquo sections of the associatedstudy reports

REVIEW METHODS

Construction of pathways or chains from lsquoifndashthenrsquo statementslsquoIfndashthenrsquo statements were subsequently constructed into complete pathways or partial chains to form anembryonic basis for a theoretical model that attempted to explain how the intervention works for differentpopulations in different contexts from first action through to ultimate outcome Given the heterogeneityof the interventions present in the initial clusters it is unsurprising to note the presence of differentmechanisms (eg between group- and individual-based approaches) and yet common success factorsfor example the establishment of lsquotrustrsquo whether this be between a woman and a health-care providerbetween a woman and other members in her group or between peers This modelling process providedthe facility to explain both generalisable mechanisms and specific areas of variance

Identification of existing theory underpinning individual mechanismsExamination of mechanisms by which the interventions sought to meet the various needs of the pregnantwomen identified several key concepts In several instances these concepts were explicitly linked withinthe study to specific theory or an implicit connection was readily identifiable (eg by using terminologyassociated with a theory)

Development of a programme theoryBased on the conceptual framework and starting from the premises involved in the group-based modelthe research team constructed a programme theory to explain how such a model might work inpreventing PND This overarching programme theory was then examined in more detail to identify whereindividual-based approaches were unable to meet the same programme requirements and eitherattempted to substitute for them (eg in substituting the resources of the individual peer supporter for thecollective resources of facilitator plus group) or offered features not possible within the constraints of thegroup approach (eg in targeting and making application of strategies to the specific needs of the individual)

Data from included studies quantitative and qualitative were used to examine the evidence in support ofthe programme theory Realist synthesis also accommodates the bringing to bear of a wider evidence baseIn this review more proximate evidence was first accessed identified via a CLUSTER searching approach141

and then expanded where necessary to a wider set of theoretical and empirical papers For examplelsquodirectrsquo qualitative data related to the experience of group-based interventions was used to identify thefeatures of such approaches and this was then supplemented by theoretical understandings of the basisunderpinning the interventions142 and by middle-range theory examining mechanisms for PND143 In thisway the explanatory power of the review was broadened beyond the tight focus prescribed by theinclusion criteria

The supporting data may be limited and may be at a level of abstraction that makes it difficult to identifythe exact mechanism by which cause achieves effect As a consequence synthesis is to a certain extent aninterpretive process which may require the reviewer to identify hypothetical intermediate links in a chain144

by which for example training leads to self-efficacy A further challenge of this method relates to relianceon the detail and quality of reporting while it is legitimate for the reviewer to generate potentialexplanations by which a particular outcome is affected more typically these connections are advanced inthe published literature As a consequence certain explanations may be well rehearsed but poorlysubstantiated whereas others may be novel and consequently unsupported A key stage is therefore thesubsequent validation of the lsquoifndashthenrsquo statements such that they are supported by empirical data or atthe very least they are internally consistent with a range of published data sources To a certain extent theprocess is analogous with brainstorming processes in which idea generation is deliberately divorced fromsubsequent validation In summary a complete explanation is initially privileged over a high-quality onewith the realisation that a poorly constructed study may perversely yield valuable explanatory insightsValidation of lsquoifndashthenrsquo statements therefore follows as an important supplemental stage

Integrating quantitative and qualitative findings

Methodological work to date has been unable to establish the superiority of conducting the qualitativeand quantitative synthesis in parallel or of conducting quantitative followed by qualitative qualitativefollowed by quantitative or some more iterative approach Our choice of method of combining data hasbeen determined by the needs of this particular review in which the quantitative data are the main focusand the qualitative data are used for their explanatory potential Having initially intended to use methodssimilar to those described by Noyes et al145 to explore an effectiveness review in the light of supportingqualitative research data further examination revealed significant heterogeneity across the types ofbehavioural intervention used within the included studies We therefore decided to expand the explanatorypotential of our study by drawing upon the methods of realist synthesis

Typically realist synthesis explores variation around a single programme type intended to achievepredefined outcomes with much of the variation relating to the population for whom the interventionworks) Early examination revealed that most interventions to be included in the review gravitated primarilyto either group- or individual-based approaches and we therefore decided to start by examining theprogramme theory for group-based approaches and then to re-examine this in the light of individual-basedapproaches As mentioned previously realist synthesis embraces the widest possible range of data sourcesIt therefore becomes a method by which quantitative and qualitative data might potentially be integratedFor example an hypothesis generated by a qualitative report may be substantiated by a trial that formallyestablishes the mechanism of cause and effect Alternatively the qualitative report may enable the reviewto help explain how a particular outcome might be achieved It may also specify aspects of an interventionconsidered important by women that may map to specific components either present in a currentintervention or mooted for inclusion in a future intervention yet to be studied within a trial

REVIEW METHODS

Chapter 4 Overview of results for quantitative andqualitative studies

Literature search for the quantitative review

The electronic searches identified 3072 references following removal of duplicates 2064 remainedA total of 180 additional records were identified from other sources Following removal of duplicatesthere were 2244 records to be screened of which 1910 were excluded at titleabstract level The full textof the remaining 256 records was examined following which 122 (representing 86 unique studies) wereincluded in the review and 134 were excluded The 122 included papers reported 80 conventional RCTs inwhich individual women were randomised to interventions and six CRCTs61146ndash150 The 86 RCTs werereported in multiple publications one study61 included two levels of analysis that were reported in differentpublications151152 Throughout this review these 86 RCTs are cited according to the first author of theircorresponding original publications

The search of ongoing trials in Clinical Trialsgov Current Controlled Trials and UK Clinical ResearchNetwork Portfolio databases (carried out in September 2013) retrieved 47 potentially relevant recordsHowever none of these met the criteria for inclusion in the review

A flow diagram outlining the process of identifying relevant literature and the 86 included RCTs alongwith reasons for exclusion of full-text articles is provided in Figure 2

Quantitative review study characteristicsAn overview of the 86 included RCTs is presented here61121123129146ndash150153ndash229

Yield of systematic reviewsTwenty-three reviews were included (ie Austin et al230 Bennett et al231 Cuijpers et al68 Dale et al232

Dennis and Creedy233 Dennis234 Dennis118 Dennis235 Dennis and Kingston236 Dennis et al237 Dennis238

Dodd and Crowther239 Fontein-Kuipers et al240 Howard et al241 Jans et al242 Lawrie et al243 Leis et al244

Lumley et al245 Marc et al246 Miller et al247 Sado et al248 Shaw et al249 and Sockol et al250) of whichone provided an additional included study not identified in the searches191 The included reviews aresummarised in Appendix 8

Quantitative review study characteristicsSome studies are reported in multiple references for example Armstrong et al 1999164251252 Brugha et al2000188253254 Chabrol et al 2002158255256 Cooper et al 2009153257 Dennis et al 2009205258 Gamble et al2005221259260 Harrison-Hohner et al 2001208261 Ickovics et al 2011222262 Lumley et al 2006147263

MacArthur et al 2002146264 Makrides et al 2010211265 Morrell et al 2000199266 Morrell et al 200961151152

Petrou et al 2006174267 Reid et al 2002200268 Richter et al 2014203269 Rotheram-Borus et al 2011226270

Sen 2006191271 Stamp et al 1995195272 Wisner et al 2001215273 Wisner et al 2004216274 and Wolmanet al 1993204275276 Henceforth studies are referred to by the first identifying reference only

Records identified throughdatabase searching

(n = 3072)

Additional records identifiedthrough other sources

(n = 180)

Records after duplicates removed(n = 2244)

Records screened at titleabstract(n = 2244)

Excluded records at titleabstract(n = 1910)

Full-text articles assessed foreligibility(n = 256)

Articles (n = 122) representing 86unique RCTs included in

quantitative review

Studies included in quantitativesynthesis (meta-analysis)

(n = 35)

Identified reviews(n = 78)

Excluded reviews(n = 55)

bull Commentary or clinical overview n = 2bull No measure of PND reported n = 2bull Non-systematic review n = 29bull Outcome measurement before 6 weeks postnatally n = 6 bull PND treatment trial n = 1bull Protocol for or description of study n = 1bull Systematic review not about prevention of PND n = 7bull Review not about prevention of PND n = 7

Excluded full-text articles(n = 134)

(reasons for exclusions)

bull Commentary or clinical overview n = 15bull Intervention initiated after 6 weeks postnatally n = 18bull No measure of PND reported n = 15bull Non-randomised control group n = 8bull Not a PND prevention trial n = 11bull Outcome measurements after 12 postnatal months n = 7bull Outcome measurement before 6 weeks postnatally n = 31bull PND treatment trial n = 8bull Protocol for or description of study n = 11bull Secondary analysis of data from a RCT n = 5bull Study reported in non-English language n = 5

Included reviews(n = 23)

bull Cochrane review n = 11bull Systematic review n = 2bull Systematic review and meta-analysis n = 3bull Review n = 7

FIGURE 2 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart of studiesincluded in the quantitative review

OVERVIEW OF RESULTS FOR QUANTITATIVE AND QUALITATIVE STUDIES

Level of preventive interventionThe 86 RCTs one reporting both a universal preventive intervention level of analysis and an indicatedpreventive intervention level of analysis61151 comprised

l 37 trials reporting a universal preventive intervention61123129146147150153ndash157180ndash187197ndash200207ndash212217ndash220225ndash228

l 20 trials reporting a selective preventive intervention149158ndash163188ndash192201ndash204213221ndash223

l 30 trials reporting an indicated preventive intervention61121148164ndash179193ndash196205206214ndash216224229

Study locationIn total 15 of the included RCTs were undertaken in the UK61146149150174177188191199ndash201206213219224 31 in theUSA121160161163166ndash173178ndash181187190192197198202208210212214ndash216222227229 18 in Australia123147159164165182184185189195196211217218220221223225 five in South Africa153203204209226 three in the China154157162 two in Canada186205

two in Hong Kong156175 two in the Republic of China (Taiwan)183193 and one each in France158 Germany176

Hungary155 Japan228 Mexico194 the Netherlands207 Norway129 and Pakistan148

ParticipantsA total of 66418 participants were randomised across the 86 trials with the individual trial sample sizesranging from 25 to 18555 participants The mean number of participants was 7723 (SD 2210) The mean(SD) age of participants was 2716 years (SD 406 years)

Intervention classSeven intervention types were identified across the 86 RCTs these were

1 psychological (n= 30)61121148153ndash179

2 educational (n= 17)180ndash196

3 social support (n= 11)149197ndash206

4 pharmacological agents or supplements (n= 10)207ndash216

5 midwifery-led interventions (n= 9)146217ndash224

6 organisation of maternity care (n= 5)147150225ndash227

7 CAM and other (n= 4)123129228229

Outcome assessmentThe studies varied in their duration and assessment times 6ndash8 weeks 10ndash12 weeks 3 or 4 months5 months 6 months 7 months and 12 months postnatally

Following the description of the overall study quality the RCTs are described fully according to the level ofpreventive intervention in Chapters 5ndash7

Quality of quantitative studies

Overall risk of bias of randomised controlled trials

Selection biasOf all the 86 RCTs 64 (744) reported an adequate method for random sequence generation(low risk of bias) 16 (190) were unclear about the allocation method (unclear risk of bias) and six (70)had used a non-random process (high risk of bias) The greatest level of risk was associated with allocationconcealment Furthermore 50 RCTs (581) reported adequate treatment allocation concealment(low risk of bias) 27 (314) were unclear (unclear risk of bias) and nine (105) were at high risk of bias

Performance biasThe nature of most of the interventions made blinding of participants and caregivers not possible but it isunlikely that the lack of blinding could not have affected the results Therefore 73 RCTs (849) wererated as being at low risk of performance bias for the assessment of blinding for participants and staff

12 (140) were rated as being at unclear risk of bias and one RCT (12) was rated as at high risk ofbias for failing to report blinding status of the women and study personnel In 61 RCTs (71) outcomeassessors were reported to be blinded (low risk of bias) in 24 (280) it was not clear if the outcomeassessors were blinded (unclear risk of bias) and in one RCT the risk of bias was rated as high

Attrition biasThe risk of attrition bias was assessed as low for 51 (593) RCTs and unclear for 27 RCTs (314)eight (93) RCTs were assessed as being at high risk for selective outcome andor analysis bias

Reporting bias and other biasThe risk of reporting bias was assessed as low in 74 RCTs (86) unclear in eight RCTs (93) and high infour RCTs (47)

The risk of other bias (eg funding source or inappropriate analysis) was judged to be low for 54 RCTs(628) unclear for 28 (326) and high for four (47)

Overall the risks of bias were rated as higher for universal preventive intervention studies than for theselective and indicated preventive interventions this was most notable for selection bias and attrition biasThe judgements about each risk of bias domain are presented in Tables 1ndash3 for each included studyaccording to the level of preventive intervention (universal selective or indicated) and summarised inFigure 3 for all included studies

Quality of systematic and other reviewsNo quality assessment was undertaken for the systematic reviews

Literature search for the qualitative review

The electronic searches identified 2131 records after removal of duplicates and a further 20 records thatwere from other sources Overall 2151 records were screened by title and abstract and 1991 wereexcluded The remaining 56 records (representing 44 unique studies) were included and the full textexamined A flow diagram outlining the identification of relevant included qualitative studies and reasonsfor exclusion of full-text articles is provided in Figure 4

Qualitative studies level of preventive interventionAmong the 21 studies (27 citations)

l Fourteen were studies of a universal preventive intervention Twelve studies reported qualitative dataon the perspectives and attitudes of those who had received universal preventive interventions forPND277ndash289 (of these two also reported perspectives and attitudes of service providers on universalpreventive interventions287288 and two studies reported only on the perspectives and attitudes of serviceproviders to preventive interventions)290291

l Four studies presented data from those who had received a selective preventive intervention292ndash298

(with one study additionally presenting data relating to an indicated population)296ndash298 Of these one studyalso reported perspectives and attitudes of service providers on selective preventive interventions296ndash298

l Three studies presented data from those who had received an indicated preventiveintervention253256299300 One study with a separate citation301 additionally reported on the perspectivesof and attitudes of service providers on indicated preventive interventions

These data are synthesised in Chapters 5ndash7 The remaining 29 (23 studies) citations about PSSSs thatwomen believed helped prevent PND are synthesised in Chapter 8 the realist synthesis and are presentedseparately (see Appendix 7)

1Riskofbiasforincluded

universalpreve

interven

tionRCTssummaryjudgmen

chrisk-of-biasitem

Firstau

thorye

reference

number

Selectionbias

Perform

Detectionbias

Attritionbias

ortingbias

sequen

eration

cation

concealmen

dingof

participan

dingof

outcome

assessors

mplete

outcomedata

Selectivereportingof

theoutcome

subgroups

alysis

Fundingso

uacyof

statisticalm

ethodsusedtyp

alysis

PP)baseline

imbalan

importan

aracteristics

Christie

Unclear

Feinbe

0Unclear

Unclear

Fujita

Unclear

Gjerdinge

Unclear

Harrison

Unclear

Hayes20

Unclear

nett20

Unclear

Kieffer20

Kozinsky

Unclear

Lawrie

Lloren

Unclear

Lumley

Unclear

MacArthu

continued

universalpreve

interven

chrisk-of-biasitem

(continued

Firstau

thorye

reference

number

Selectionbias

Perform

Detectionbias

Attritionbias

ortingbias

sequen

eration

cation

concealmen

dingof

participan

dingof

outcome

assessors

mplete

outcomedata

theoutcome

subgroups

alysis

Fundingso

uacyof

statisticalm

ethodsusedtyp

alysis

PP)baseline

imbalan

importan

aracteristics

Makrid

Unclear

Matthey20

4Unclear

Unclear

Milgrom20

Unclear

hber20

2Unclear

Unclear

Morrell

Norman

Unclear

Priest20

Unclear

Reid20

Rotheram

-Borus

Unclear

Selkirk

7Unclear

Unclear

Shields19

Unclear

oslashyga

Unclear

nstrom

Unclear

Keyhigh

riskof

biasIDiden

tification

intentionto

treatlowlow

riskof

biasPPpe

rprotocolun

clearun

clearriskof

selectivepreve

interven

chrisk-of-biasitem

Firstau

thorye

reference

number

Selectionbias

Perform

Detectionbias

Attritionbias

ortingbias

sequen

eration

cation

concealmen

dingof

participan

dingof

outcome

assessors

mplete

outcomedata

theoutcome

subgroups

alysis

Fundingso

uacyof

statisticalm

ethodsusedtyp

alysis

PP)baseline

imbalan

importan

aracteristics

Barnes20

9Unclear

Unclear

Buist19

9Unclear

Unclear

brol20

8Unclear

Unclear

ples20

Harris20

Unclear

vics20

Logsdo

Unclear

Phipps20

Richter20

Unclear

Silverstein

Small20

Unclear

Wolman

Unclear

Zlotnick20

Unclear

Keyhigh

riskof

biasIDiden

tification

intentionto

treatlowlow

riskof

biasPPpe

rprotocolun

clearun

clearriskof

indicated

interven

tionRCTssummaryjudgem

aboutea

chrisk-of-biasitem

Firstau

thorye

reference

number

Selectionbias

Perform

Detectionbias

Attritionbias

ortingbias

sequen

eration

cation

concealmen

dingof

participan

dingof

outcome

assessors

mplete

outcomedata

theoutcomesu

bgroups

alysis

Fundingso

urcead

equacyof

statisticalm

ethodsusedtype

alysis

baseline

imbalan

importan

aracteristics

strong

Austin

Unclear

Crockett20

6Unclear

Unclear

Ginsburg

Unclear

Gorman

9Unclear

Unclear

Grote20

Unclear

Harris20

Unclear

Lara20

Unclear

9Unclear

Unclear

Marks20

Unclear

2Unclear

Unclear

Morrell

Mozurkewich

Unclear

Petrou

Firstau

thorye

reference

number

Selectionbias

Perform

Detectionbias

Attritionbias

ortingbias

sequen

eration

cation

concealmen

dingof

participan

dingof

outcome

assessors

mplete

outcomedata

theoutcomesu

bgroups

alysis

Fundingso

urcead

equacyof

statisticalm

ethodsusedtype

alysis

baseline

imbalan

importan

aracteristics

Tiwari20

Vieten

Unclear

ster20

Unclear

Wilson

Unclear

Zlotnick20

8Unclear

Unclear

Zlotnick20

Unclear

Keyhigh

riskof

biasIDiden

tification

intentionto

treatlowlow

riskof

biasPPpe

rprotocolun

clearun

clearriskof

FIGURE3

Risk-of-biasgraphforallincluded

RCTsau

thorsrsquojudgem

aboutea

chrisk-of-biasitem

intentionto

plicab

protoco

Records screened by title and abstract(n = 2151)

Full-text articles and abstracts excluded(n = 105)

Reasons for exclusionbull Women with a diagnosis of PND PTSD or psychosis andor not a preventive intervention n = 43bull No qualitative data n = 20bull No datano relevant qualitative data n = 11bull Qualitative data from health professionals but not about an intervention n = 9bull About screeningcare n = 8bull About stressful events during the postnatal year n = 4bull Systematic review n = 1bull Literature review n = 2bull Not in English language n = 3bull Not within 1 year postnatal n = 1bull About treatment for PND n = 1bull About fathersrsquo perceptions only n = 1bull Feasibility study n = 1

Excluded by title and abstract(n = 1991)

Full-text articles and abstracts(citations) included inqualitative syntheses

(n = 55)(relating to 42 studies)

27 citations relating topreventive interventions

29 citations relating to PSSSswomen believed helped

prevent PND

(n = 2131)

(n = 20)

FIGURE 4 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart of studiesincluded in the qualitative reviewKey PTSD post-traumatic stress disorder

Qualitative review study characteristics

Study locationOf the included studies two were undertaken in the UK253254287 seven in the USA283284286291ndash298 one inSweden277 one in Ireland278279 four in Australia280288289300 three in Canada281285290299301 and onein China282

ParticipantsThe studies contained qualitative data from 940 service users (when reported) and from 29 serviceproviders (when reported) Service provider data came from four clinicians296ndash298 three nurses288 twocertified nurse-midwives and two medical assistants293ndash295 three physicians290 four certified nurse midwivesfive health centre staff and five administrators284 from support workers midwives and health visitors287 andfrom peer volunteers301 The age range of the women was reported in eight studies Age ranged from13 to 45 years Ethnicity was reported in 13 studies280282ndash286290292ndash298300 For further details of participantcharacteristics see Appendix 9

Intervention classA total of 19 qualitative studies corresponded to the seven intervention classes which were identifiedpreviously across the RCTs These were

1 psychological (n= 3 six reports)253254282296ndash298

2 educational (n= 0)3 social support (n= 3 four reports)281287299301

4 pharmacological agents or supplements (n= 0)5 midwifery-led interventions (n= 8 11 reports)277283ndash285289ndash295

6 organisation of maternity care (n= 2)288300

7 CAM and other (n= 3 four reports)278ndash280286

Qualitative review study characteristics personal and social supportstrategy studiesA total of 23 studies (n= 29 citations) reported qualitative data on perspectives and attitudes of women whohad not experienced PND regarding PSSSs that they believe helped them to prevent the condition7302ndash325

This included five citations from three intervention studies which included PSSS evidence286292296ndash298

Study locationTen studies were conducted in the UK304306ndash315319321322324 seven studies were conducted in theUSA286292296ndash298302303318320 one in Switzerland316 one in Canada317 one in Norway323 one in India325 one inChina305 and one in multiple centres7

ParticipantsThe total number of reported participants contributing qualitative evidence was 801 (one study did notprovide the number of participants who contributed to qualitative findings)7 Fifteen studies provided datafrom participants who were part of the general population in the country of study whereas the remainingstudies examined evidence from minority groups within the country of study The minority groups eitherwere a culturally different group based within the country of study (n= 5)304306ndash311314318 or were a selectivegroup (n= 3)292296ndash298315 For details of participant characteristics see Appendix 9

Quality of the qualitative intervention studiesAll studies met the requirement to report either qualitative research or qualitative data within mixed-methodsstudies indicated in Table 4 All included studies also adequately described the context and aims of thestudy Few (29) demonstrated evidence of researcher reflexivity (ie awareness of the researcherrsquoscontribution to the construction of meanings throughout the research process and an acknowledgement ofthe impossibility of remaining lsquooutsidersquo onersquos subject matter while conducting research) among those whichdid these descriptions were brief A number of studies illustrated that reflexivity in the research process hadbeen incorporated such as making changes to the interview guide as necessary and responding toparticipantsrsquo wishes All 21 studies provided adequate descriptions of recruitment methods just over half(n= 13) provided adequate descriptions of data collection methods although such descriptions tended tobe brief The study methods used involved interview methods in nine studies supplemented by other methodssuch as focus groups and observation in three studies Qualitative data came from open-ended questions aspart of a questionnaire in three studies Two studies used focus groups and one study used online messagesTwelve studies provided an adequate description of data analysis methods and 13 studies providedsufficiently in-depth detailed and rich data The absence of detail in the remaining studies may have been inpart because of limitations imposed by journal reporting requirements

Certainty of the review findings intervention studiesThe CERQual approach137 was used to assess the certainty of the review findings graded as lsquovery lowrsquolsquolowrsquo lsquomoderatersquo or lsquohighrsquo A summary assessment was based on the CASP quality assessment finding136

the number and richness of the study data the consistency of the data across study settings andpopulations and the relevance of the finding to the review question There were 37 findings in womenrsquosevidence nine were assessed as of moderate certainty 25 as low and three as of very low certainty Forservice providersrsquo evidence there were 25 findings one finding was assessed as being of moderatecertainty 18 as of low certainty and six as of very low certainty No findings were assessed as high certainty

Overview of main findings from qualitative intervention studies (all levels)

PsychologicalWomen reported that IPT served to promote the development of relationships with other group memberswhich had a normalising effect282ndash285 It facilitated gaining support from family members Women alsoreported that they appreciated the support of the midwife as part of the intervention Participants reportedlearning useful and applicable practical strategies282 IPT facilitated the gaining of knowledge and theactive participation of women in their own health care specifically in realistic information about motherhoodand in the empowerment to ask for help

TABLE 4 Qualitative studies quality assessment of the studies of universal preventive interventions

QuestionYessomewhat(n= 21 studies)

1 Is the study qualitative researchor provide qualitative data 2121

2 Is the study context and aims clearly described 2121

3 Is there evidence of researcher reflexivity 621

4 Are the sampling methods clearly described and appropriate for the research question 2121

5 Are the methods of data collection clearly described and appropriate to the research question 1321

6 Is the method of analysis clearly described and appropriate to the research question 1221

7 Are the claims made supported by sufficient evidence That is did the data provide sufficientdepth detail and richness

This table is adapted from the CASP checklist for qualitative studies136 (URL wwwcasp-uknet under Creative Commons licence)

EducationalThe Preparing for Parenthood intervention was aimed at improving womenrsquos knowledge and activeparticipation in their own health care253254 specifically gaining information about sensitive subjects suchas PND Although appearing to want information about PND women who attended the Preparationof Parentedhood intervention were reluctant to ask for information because of the fear of stigmaOther women appeared to avoid information about PND authors interpreted this as a belief that lack ofknowledge could operate as a protective factor Although most women reported benefits of the groupenvironment a few did not want to join because of privacy concerns Most participants valued theopportunity provided for their partner to join the group and were interested in the partnerinvolvement session

Social supportThe qualitative review demonstrated that both women and service providers felt the support group andsupport intervention adequately provided emotional and informational support reassurance and validationParticipants of the support worker intervention287 reported that the intervention would have been morebeneficial if it were more intensive Concerns articulated by service providers included worries about theirown ability to deal with unpredictable situations and womenrsquos overdependence on the service287288

Midwifery-led interventionsPeer support partner support and support from health professionals were particularly helpful aspects ofthe CenteringPregnancy intervention277283285289ndash294 Specifically a supportive environment and theopportunity to share experiences were appreciated However some women reported a dislike for thegroup environment and the inclusion of partners because of concerns regarding privacy277 Some partnersalso felt uncomfortable with their own inclusion for similar reasons277 Women felt the health professionalswere able to pay more attention to their own concerns and offer them more solutions285 although the skillof the midwife was an important factor in the success of the intervention277 Service providers felt theintervention promoted better communication between providers and users and between health providersThey were able to develop better relationships with the intervention recipients and the enhancedcommunication served to facilitate information exchange290 Education and information about pregnancyand the postnatal period were valued283284293294 However the evidence indicated283289 that some womenwanted more and more intensive education on issues relating to labour birth and parenting particularlyabout the early weeks of parenting

Organisation of maternity careThe support women received from the health professionals delivering the service was felt to behelpful288300 although a lack of understanding of the role of the maternal and child health nurse created apotential barrier to accessing the service288 Women reported that they felt able to rely on the serviceparticularly if they needed the service urgently300 However concerns included feeling intimidated by thethought of referral to the specialist perinatal and infant mental health service300 worries about stigmaassociated with using the service288 and concerns about being ready to be discharged300

Complementary and alternative medicine or other interventionWomen reported that the CAM interventions provided peer support specifically by the sharing ofexperiences and birth stories and the facilitation of family support278ndash280286 They reported the practicaluse of strategies learned during the intervention278279286 However some difficulty in being able to applylearned techniques in practice was expressed286 together with a concern that the use of the learnedstrategies could result in unexpected emotional responses278279 The interventions facilitated preparation forbirth both emotionally278ndash280 and physically280

Tables 5ndash12 provide a synthesis of the qualitative evidence across all types of intervention

TABLE 5 Synthesis of findings across all intervention studies what helped

Meta-theme Subtheme Mechanism (with examples)Evidencesource CASPa

Certainty inCERQual137

Support Peer support Peer support providing reassurancenormalisation of experiences emotionalsupport practical advice and informationaladvice Achieved through reading aboutpeer experiences281 sharing experiences277283

and through the development of friendshipand relationships and forming a connectionwith others280

Moderate(times 6)low

Moderate

Family support Practical and emotional support from thefamily facilitated by educating familymembers through provision formenpartners to join the group to besupported283 and partners beingencouraged to be actively involved inintervention289 through family joining thegroup and participants teaching theirpartner or mother the song learned in thegroup278279

Moderate

Educating the intervention recipients aboutlsquodoing the monthrsquo served to facilitatedevelopment of a relationship with themother-in-law leading to her providingpractical support282

Moderate Moderate

Health professionalsupport

Health professionals leading theintervention were seen as having concernfor participants providing emotional andpractical support Specifically discussionswith nurses288 support workers287 or socialsupport from the midwife throughtelephone follow-up282 were reported asbeing helpful

Moderate(times 3)low (times 2)

Moderate

Partner support Partnersrsquo support in applying techniqueslearned through the intervention whichwent on to facilitate better communicationbetween the partners286289

Highlow Low

Empowerment Educationactiveparticipation inown health care

Participants empowered by being allowedto weigh themselves283 providing educationand information280282284

Moderate Moderate

Learning practicalstrategiesskillsknowledge

Learning practical strategies such assinging278279 problem-solving skillsmindndashbody exercises and techniques286 tobe applied during pregnancy or in thepostpartum period These included theability to calm the infant278279 the gainingof information about sensitive subjects suchas PND282 and realistic information aboutmotherhood thus helping participantsaccept the reality of early motherhood282

Moderatehighmoderate

Moderate

Self-esteem Yoga provided emotional preparation forbirth280

Moderate Low

Interventions promoted abilities in dealingwith offers of support and asking forsupport and developing a goodrelationship with mother-in-law to beempowered to ask for help282

Moderate Low

continued

TABLE 6 Synthesis of findings across all intervention studies what did not help

An intervention for the prevention of PND was unhelpful when it resulted in aperception of

Evidencesource CASP

Lack of support as a result of partners feeling uncomfortable with discussions and thusdisengaging283

Moderate Moderate

Inability to implement learned strategies without the support of the group286 High Moderate

Difficult to raise questions with partners present at group intervention84283 Moderate Moderate

An unexpected emotional response because of the application of the strategies learnedin the group (singing) resulting in a lsquoprofoundrsquo emotional response85279

Moderate Low

Feeling rushed by health professionals during the intervention90 Moderate Low

Lack of privacy during the intervention90 Moderate Low

Lack of consideration for workload specific to a service in a military setting90 Moderate Low

Midwife being too controlling and not asking about the wishes of the group84 Moderate Low

Service was not family centred and older children were not welcome at the service90 Moderate Low

Service providers were scrimping and cost-saving on care (women were asked to delivertheir own samples to the laboratory)90

Moderate Low

Not being able to implement strategies because of forgetfulness3 High Low

Format of the sessions was not ideal because a 2-hour session was too long96 Low Low

A long interval between first and second group meetings84 Moderate Moderate

Group format was disliked84 Moderate Low

TABLE 5 Synthesis of findings across all intervention studies what helped (continued )

Time outrelaxationsocialisation

ndash Reduction of stress and anxiety andcountering isolation by the provision ofsocialisation in a group278279 or via aone-to-one intervention287

Moderatemoderatelow

Physicalpreparationrecovery

ndash Yoga practice as part of the groupintervention promoted preparation for birthand quicker physical recovery from birth280

Moderate Low

Reducedwaiting times

ndash A group rather than individual formatresulted in reduced waiting times289

Low Very low

Continuity ofcare

ndash Group intervention promoted continuity ofcare277

Moderate Low

Connectingwith the baby

ndash Yoga aspect of group interventionpromoted connection with unborn baby280

Moderate Low

Safe space ndash Group intervention provided a safe space280 Moderate Low

a Multiple ratings indicate that the results have been synthesised from two or more studiesNoteCertainty is based on quality of individual studies rated as lsquovery lowrsquo lsquolowrsquo lsquomoderatersquo or lsquohighrsquo

TABLE 7 Synthesis of findings across all intervention studies service delivery

An intervention for prevention of PND should have includedEvidencesource CASP

Education specifically about the early weeks of parenting289 Low Very low

More intensive intervention more visits and longer visits287 Low Very low

Something different from the mainstream (CAM)280 Moderate Low

Structure to the group aspect280 Moderate Low

More drinksrefreshments283 Moderate Low

TABLE 8 Synthesis of findings across all intervention studies service delivery barriers to participation

Barriers to participation includedEvidencesource CASPa

Poor access to the service including practical difficulties in getting to appointmentsand physical limitations (bleeding) which hindered attendance283

Moderate Low

Unhelpful front-desk staff long waits and lsquobrush-offsrsquo283 Moderate Low

Not understanding role of the service provider288 Moderate Low

Not associating the depression with pregnancypostpartum period286288 Moderatehigh Moderate

Perceived stigma related to the admission of not being able to cope286288 Moderatehigh Moderate

Being unable to see use of strategies learned during pregnancy for the postpartum period286 High Low

Being unable to find the time to implement strategies learned286 High Low

a Multiple ratings indicate that the results have been synthesised from a number of studies

TABLE 9 Synthesis of findings across all intervention studies health-care professionalsrsquo views on what helped

Things helpful for the intervention recipientsEvidencesource CASPa

Peer support through sharing experiences providing reassurance normalisation ofexperiences emotional support practical support and informational advice287290291

Moderatemoderatelow

Moderate

Education group environment provided more opportunity for teaching284291 Moderate Low

Womenrsquos active participation in their own health care (empowerment) the groupenvironment allowed more time to be allocated to this284290

Moderate Low

Better communication between provider and user facilitating information exchange inthe group setting290

Moderate Low

Health professional developed better relationships with service users in the group setting290 Moderate Low

Provision of richer care provided in a group setting290291 Moderate Low

Womenrsquos enthusiasm about a group setting served to increase participation284 Moderate Low

Group setting allowed more women to be seen in same amount of time therebyaddressing waiting time issues284

Moderate Low

Sensitivity to the women and a subtle and non-threatening manner in approach to issues288 Moderate Low

Things helpful for the health professionals delivering the intervention

Group setting resulted in more efficient use of time290 Moderate Low

Health professionals found delivering the group intervention enjoyable satisfying anda rewarding experience290291

Moderate Low

Delivering an innovative (group) intervention brought recognition to the site (health centre)284 Moderate Low

TABLE 10 Synthesis of findings across all intervention studies health-care professionalsrsquo views on what did not help

Things that health professionals thought did not help prevent PNDEvidencesource CASPa

Restricting service to selective groups through staff and provider bias for example onlyfor teens291

Moderate Low

Difficulties in funding the service284291 Moderate Low

Difficulties in facilitating access to the service because of work conflicts for serviceproviders and transportation difficulties for women attending groups and also forsupport workers travelling to womenrsquos homes to deliver the one-to-one intervention287291

Moderatelow Low

Womenrsquos resistance to the intervention or discontinuation of the intervention because ofparticipantsrsquo resistance to a group format291 or the individual support worker visit wasanxiety inducing287

Moderatelow Low

Group interventions result in provider having less opportunity for one-to-one care284 Moderate Low

Inability to address deeply personal issues in group setting Service providers felt thatdeeper issues were not appropriate to be discussed in a group setting284

Moderate Low

Scheduling difficulties as while one provider was doing group care the other had to dealwith everything else284

Moderate Low

Potential for participants to become dependent on the intervention287 Low Very low

Potential conflicts or threats to provider roles287 Low Very low

Potential for invasion of participant privacy287 Low Very low

Being unable to deal with unpredictable situations or those for which they wereunqualified Anxieties about their own abilities skills and helpfulness287

Low Very low

TABLE 11 Synthesis of findings across all intervention studies health-care professionalsrsquo views on service delivery

Health professionalsrsquo thought an intervention for prevention of PNDshould include

Evidencesource CASP

Certainty inCERQual

Closer integration with other service providers (primary care team)287 Low Very low

Target vulnerable groups287 Low Very low

TABLE 12 Qualitative studies quality assessment of PSSSs

1 Is the study qualitative researchor does it provide qualitative data 2323

2 Is the study context and are the aims clearly described 2323

7 Are the claims made supported by sufficient evidence ie did the data provide sufficient depthdetail and richness

This table is adapted from CASP checklist for qualitative studies136 (URL wwwcasp-uknet under Creative Commons licence)

Quality of the qualitative personal and social support strategy studiesAs shown in Table 12 all included studies reported either qualitative research or qualitative data withinmixed-methods studies All included studies adequately described the context and aims of the studySixteen of the 23 studies demonstrated evidence of researcher reflexivity As in the intervention studiesfew PSSS studies made explicit reference to researcher reflexivity and in those which did descriptions wereoften brief Most studies adequately described recruitment methods (n= 21) and data collection methods(n= 21) although such descriptions tended to be brief Eighteen studies used interview methods fourused focus groups and one study used an online survey Eighteen of 23 of studies provided an adequatedescription of data analysis methods and 20 of the 23 studies provided sufficiently in-depth detailed andrich data

Certainty of the review findings personal and social support strategy studiesThe CERQual approach137 was applied to assess the certainty of the review findings graded as lowmoderate or high In each case a summary assessment was made of the CASP quality assessment findingthe number of studies contributing to the finding the consistency of study setting and the populationThe PSSS data yielded 19 findings one assessed as high certainty 11 assessed as moderate certainty andseven assessed as low certainty

The findings were used to inform the realist synthesis and are presented in Chapter 8

Qualitative studies further analysis by level of preventive interventionuniversal selective and indicatedFurther quantitative and qualitative results are presented in Chapter 5 (37 universal preventive interventionstrials 14 qualitative studies) Chapter 6 (20 selective preventive interventions trials four qualitative studies)and Chapter 7 (30 indicated preventive interventions trials three qualitative studies) One study presentedtwo levels of intervention and analysis61

Chapter 5 Results for universal preventiveintervention studies

Characteristics of randomised controlled trials of universalpreventive interventions

There were 37 RCTs included in the universal preventive interventionsgroup61123129146147150153ndash157180ndash187197ndash200207ndash212217ndash220225ndash228266287 in the seven intervention classes defined as

7 CAM or other (n= 3)123129228

The results are presented in this order for the RCTs of universal preventive interventions There was limitedreplication of interventions across the trials The 37 universal preventive intervention trials are describedfirst by their intervention context mechanisms and measured outcomes within the seven classes

Description of qualitative studies of universal preventive interventionsThere were 14 studies relating to 15 citations reporting qualitative data on universal preventiveinterventions for PND277ndash291 Twelve studies relating to 13 citations reported the perspectives and attitudesof women who had received an intervention277ndash289 Four studies reported perspectives and attitudes ofservice providers of universal preventive interventions286287290291

The qualitative studies related to five of the seven intervention classes

1 psychological (n= 1)282

2 social support (n= 2)281287

3 midwifery-led interventions (n= 7)277283ndash285289ndash291

5 CAM or other (n= 3)278ndash280286

For ease of reference the universal preventive interventions have been given short-version descriptive labels(Table 13)

TABLE 13 Universal preventive interventions short-version descriptive labels

First author yearreference number

Short-versiondescriptive label Fuller description

Gunn 1998225 Early contact with careprovider

A postnatal check-up with a GP 1 week after hospital discharge

Harrison-Hohner2001208261

Calcium 2000mg of elemental calcium per day during pregnancy

Hodnett 2002197 Support in labour Continuous labour support by a specially trained nurse

Lumley 2006147263 Primary care- andcommunity-basedstrategies

Complex multifaceted primary care- and community-basedstrategies

MacArthur 2002146

2003264Midwifery redesignedpostnatal care

Redesigned midwifery-led community postnatal care

Makrides 2010211265 DHA 800mg of DHA in DHA-rich fish oil capsules in pregnancy

Matthey 2004184 Baby play A session focused on the importance of play with a baby withvideotapes and discussion on how parents can play with infants

Matthey 2004184 Education on preparingfor parenting

A session focusing on postpartum psychosocial issues related tobecoming first-time parents

Mokhber 2011212 Selenium 100 microg of selenium as selenium yeast daily during pregnancy

Morrell 2000199266

2002287Social support Up to 10 home visits in the first postnatal month by a community

postnatal support worker

Morrell 200961151152326 CBT-based intervention HV training in the assessment of postnatal women with CBAsessions for eligible women

Morrell 200961151152326 PCA-based intervention HV training in the assessment of postnatal women combined withPCA sessions for eligible women

Norman 2010123 Exercise An 8-week lsquoMother and Babyrsquo programme of specialised exerciseprovided by a physical therapist combined with parenting education

Norman 2010123 Educational information An 8-week lsquoMother and Babyrsquo programme with parentingeducation

Sealy 2009186 Booklet on PND An educational pamphlet lsquoWhy is everyone happy but mersquo mailedat 4-weeks postpartum that explained the symptoms of PPD andidentified local services for PPD

Shields 1997219 Midwife-managed care A new programme of midwife-managed care (MidwiferyDevelopment Unit)

Songoslashygard 2012129 Exercise A 12-week exercise programme of aerobic and strengtheningexercises during pregnancy a weekly physiotherapy-led groupsession and home exercises encouraged twice a week

Waldenstrom 2000220 Midwifery team care Team midwife care eight midwives who provided antenatal andintrapartum care and follow-up visits to the postnatal ward

Key DHA docosahexaenoic acid HV health visitor PPD postpartum depression

RESULTS FOR UNIVERSAL PREVENTIVE INTERVENTION STUDIES

Universal preventive interventions psychological interventions

Characteristics and main outcomes of randomised controlled trials ofuniversal preventive interventions of psychological interventionsOf the 37 universal preventive interventions six studies evaluated a psychological intervention61153ndash157

including promotion of parentndashinfant interaction153 psychoeducation155 IPT154157 CBT-basedinterventions61157 and PCA Comparators included usual care in specific countries61153154156157 andeducational information155 Three studies provided the intervention using a group format154ndash156 whereastwo involved individual sessions61153 and one combined both group and individual sessions157 Two trialsprovided interventions in the home setting61153 whereas in the other four trials the intervention wasprovided in the antenatal setting154ndash157 Three trials provided the intervention in the antenatal periodonly155ndash157 whereas one trial initiated the intervention postnatally61 and two trials provided the interventionacross the perinatal period both during pregnancy and following childbirth153154 The interventions wereprovided by different health-care providers including community workers153 midwives154 health visitors155

psychologists156 and obstetricians157 with the number of intervention contacts ranging from two154 to 16153

and with the duration of contact ranging from 1 to 2 hours

A summary of the characteristics and main outcomes is provided in Table 14 In the psychologicalintervention trials PND was assessed using various measures including the EPDS61153154156157 GeneralHealth Questionnaire154 Leverton Questionnaire155 the Short Form questionnaire-36 items (SF-36) mentalcomponent summary (MCS)328 the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM)151

the PHQ-9157 and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders(SCID)157 The StatendashTrait Anxiety Inventory (STAI) was the only anxiety outcome reported151 and the PerceivedStress Scale (PSS) the only stress outcome156 Family outcomes included the Dyadic Adjustment Scale61 theParenting Stress Index (PSI)151 the Relationship Efficacy Measure156 the Satisfaction with InterpersonalRelationships Scale154 and motherndashinfant interaction (maternal sensitivity and intrusiveness)153 The three infantoutcomes reported were the Ainsworth Strange Situation Assessment of Infant Attachment153 the BehaviourScreening Questionnaire61 and the Checklist for Autism in Toddlers61 General health and other outcomesincluded the Short Form questionnaire-12 items (SF-12) the SF-36 physical component summary (PCS) theShort-Form questionnaire-6 Dimensions (SF-6D)61 and the Subjective Happiness Scale156

Description and findings from qualitative studies of universal preventiveinterventions of psychological interventionsA description of the qualitative study evaluating a psychological intervention is provided in Table 15

SupportThe qualitative study of a psychological intervention was IPT based and was conducted in China282

Data from participants demonstrated that the intervention promoted the development of relationships andconnection with other group members normalised their experience282 helped them to harness supportfrom family members282 and educated them about the Chinese cultural ritual known as lsquodoing the monthrsquo(which they had felt was unscientific and out of date) and how it could help them to develop a betterrelationship and elicit support from their mother-in-law282 Women appreciated the social support theyreceived from the midwife through a telephone follow-up282

Learning practical strategiesParticipants learned useful and applicable practical strategies as part of the intervention282 gainingknowledge and skills to cope with the postpartum period282

Educationactive participation in own health careThe intervention promoted knowledge gain and active participation in their own health care282 Specificallyparticipants reported that they were able to gain realistic information about motherhood that it helpedthem to accept the reality of early motherhood282 and that they felt empowered to ask for help282

TABLE 14 Universal preventive interventions characteristics and main outcomes of RCTs of psychologicalinterventions

Interventionsummary

First authoryear referencenumber Country

Total numberof womenrandomised Place Timing

Type ofsession Provider

CBT-basedintervention

Mao 2012157 China 204 Antenatalsetting

Antenatal Individuallyand group

Obstetrician

CBT-basedintervention andPCA-basedintervention

Morrell200961151152326

UK 2241 Homevisits

Postnatal Individually Health visitor

IPT-basedintervention

Gao 2010154

2012327China 194 Antenatal

settingAntenataland postnatal

Group Midwife

Comparisongroup(s)

Number ofcontacts

Durationof contact(minutes)

Depressionoutcomes

Otheroutcomes Main findings

Overallrisk ofbias

Usual care inChina

4 90 EPDS meanscore (Chineseversion) PHQ-9score (Chineseversion) SCID

ndash On completion of theprogram IG reportedsignificantly lower meanPHQ-9 and EPDS scoresthan CG157

Unclear

The mean EPDS score at6 weeks postnatally was lowerin the intervention group(mean 645 SD 109) than inthe control group (mean 923SD 291) (t= 195 p= 004)

Fewer participants from theIG were diagnosed ashaving PND using theSCID for DSM-IV157

Usual care inthe UK

1 ndash EPDS score 12or more SF-12MCS scoreCORE-OMscore

STAI DASPSI BSQCHATSF-12 PCSSF-6D

At 6 months among all ofthe women who hadreturned both a 6-week anda 6-month questionnaire164 in CG scored 12 ormore on the EPDS versus117 in IG Absolutedifference was 47(95 CI 07 to 86)(p= 0003)61

Mean EPDS score was 64(SD 52) in CG and 55(SD 47) in IG Differencewas statistically significant(p= 0001)61

Usual care inChina

2 90 EPDS score13 or more(Chineseversion) GHQscore 4 ormore

SWIRS (devisedby first author)

Women receiving thechildbirth psychoeducationprogramme had significantlybetter psychologicalwell-being (t = ndash333p= 0001) fewer depressivesymptoms (t= ndash376p= 0000) and betterinterpersonal relationships(t= 325 p= 0001) at6 weeks postpartumcompared with those whoreceived only routinechildbirth education152

continued

TABLE 14 Universal preventive interventions characteristics and main outcomes of RCTs of psychologicalinterventions (continued )

Interventionsummary

Leung 2012156 China(HongKong)

156 Antenatalsetting

Antenatal Group Psychologist

Promotingparentndashinfantinteraction

Cooper 2009153 SouthAfrica

449 Homevisits

Antenataland postnatal

Individually Communityworker (Lay)

Psychoeducationalintervention

Kozinsky2012155

Hungary 1762 Antenatalsetting

Antenatal Group Hungarianhealthvisitors

Key ASSA Ainsworth Strange Situation Assessment of Infant Attachment BSQ Behaviour Screening QuestionnaireCG control group CHAT Checklist for Autism in Toddlers CI confidence interval DAS Dyadic Adjustment Scaledf degrees of freedom GHQ General Health Questionnaire high high risk of bias IG intervention group low low risk ofbias OR odds ratio REM Relationship Efficacy Measure SHS Subjective Happiness Scale SWIRS Satisfaction withInterpersonal Relationships Scale unclear unclear risk of biasEffect statistically significant at a conventional p-value of plt 005

Comparisongroup(s)

Number ofcontacts

Depressionoutcomes

Overallrisk ofbias

Usual care inHong Kong

2 or more ndash EPDS score 13or more

PSS(four-items)REM SHS

Intention-to-treat analysisshowed IG had significantlylower perceived stress andgreater happiness than CGimmediately after theintervention (in pregnancy)Effects not sustained atpostnatal follow-up156

Usual care inSouth Africa

16 60 EPDS meanscore SCID(DSM-IV)

Motherndashinfantinteractionmaternalsensitivity andintrusivenessASSA

At 6 months and 12 monthspostnatally the SCID indicatednon-statistically significantdifferences in depression in theintervention and control group(χ2= 085 df= 1 p= 036 at6 months χ2= 116 df= 1p= 021 at 12 months)

Unclear

With regard to maternaldepressive symptoms (thecontinuous EPDS) the meanscores for those in the IGwere lower at bothassessments than werethose for the CG but thebenefit of treatment wassignificant only at6 months (z= 205p= 0041 at 6 monthsz= 024 p= 0813 at12 months)153

Educationalinformation

4 180 LevertonQuestionnairescore

ndash Leverton scores appeared toindicate a reduction in therisk of depression in theintervention group (OR= 069)The risk was reduced byaround 18 among womenwho were depressed inpregnancy and 05in women not depressed inpregnancy

At 6 weeks postnatally theprevalence of depression was127 in the intervention groupand 175 in the control group(χ2 plt001 OR 068) Levertonscores were 943 (plusmn2168) vs1012 (plusmn3632) in theintervention and control groupsrespectively

15Qualitativestudyofuniversalp

interven

tionsdescriptionofstudyev

aluatingapsych

ological

interven

Firstau

quality

grading

Country

Interven

tiondetails

Delivered

antenatal

postnatal

individual

Numbers

ingroup

Number

sessions

Durationof

session(m

inutes)

Facilitatorservice

provider

IPT-oriented

Second

ndashteaching

hospita

postna

individu

Twoclasses

postna

follow-up

teleph

onecall

90Midwife

notrepo

Universal preventive interventions educational interventions

Characteristics and main outcomes of randomised controlled trials ofuniversal preventive interventions of educational interventionsEight included studies evaluated an educational intervention for the universal prevention of PND none ofwhich were conducted in the UK180182ndash187 Two main types of educational interventions were identifiededucation on preparing for parenting180181184185187 and various advisory booklets on PND182183186

Comparisons were made with usual care in specific countries180ndash184186 and educational information185

Four trials provided the educational intervention via group format180181184187 while the remaining four trialsinvolved individual sessions182183185186 Only one trial provided the intervention in the home setting186

Four trials provided the intervention in the antenatal period only181182185187 whereas two trials initiated theintervention postnatally183186 and two trials provided the intervention across the perinatal period bothduring pregnancy and following childbirth180184 The interventions were provided by psychologists180181184185

midwives182 and nurses183186 The number of contacts ranged from two to eight and the duration of contactranged from 30 minutes to 4 hours

A summary of the characteristics and main outcomes is provided in Table 16 No qualitative studies werefound for educational interventions as a universal preventive intervention

Universal preventive interventions social support

Characteristics and main outcomes of randomised controlled trials ofuniversal preventive interventions of social supportOf the 37 RCTs of universal preventive interventions four (11) evaluated a social supportintervention197ndash200 two of which were conducted in the UK199200 Several types of social support wereidentified including support in labour197 and self-help support200 Comparisons were made with usual carein specific countries197199200 and educational information198 One intervention involved a group session200

two studies involved individual sessions197199 and one involved both group and individual sessions198

One study took place in the home setting199 None of the studies were undertaken in the antenatal periodonly two were in the postnatal period only199200 two were in a combination of both antenatal andpostnatal periods198 and one was at the stage of labour197 As with other types of included interventionsthese were provided by different health-care providers community workers198 midwives200 nurses197

and support workers198 The number of contacts ranged from one to 14 but duration of contact(10ndash378 minutes) was reported in only one study199

A summary of the characteristics and main outcomes is provided in Table 17

Description and findings from qualitative studies of universal preventiveinterventions of social supportOf the two qualitative studies of social support included in the universal preventive interventions categoryone was conducted in the UK287 and one in Canada281 One intervention was an online discussion group281

and the other a postnatal support worker intervention287 Further details are provided in Table 18

Findings from qualitative studies of universal preventive interventions ofsocial support

SupportParticipants reported that helpful aspects of the intervention were emotional and informational supportthe development of relationships with peers281287 reassurance and validation (appraisal support)normalisation of their feelings practical advice281 and practical support287

TABLE 16 Universal preventive interventions characteristics and main outcomes of RCTs of educationalinterventions

Interventionsummary

Booklet on PND Hayes 2001182

2004329Australia 188 Antenatal

settingAntenatal Individually Midwife

Booklet on PND Ho 2009183 Taiwan 200 Primary care Postnatal Individually Postpartumward nurse

Booklet on PNDand availableservices

Sealy 2009186 Canada 256 Home visits Postnatal Individually Nurse

Education onpreparing forparenting

Feinberg2008180

USA 169 Antenatalsetting

Antenatalandpostnatal

Group Psychologist

Gjerdingen2002181

Matthey2004184

Australia 268 Antenatalsetting

Group Psychologist

Comparisongroup(s)

Numberofcontacts

Depressionoutcomes

Risk ofbias

Usual care inAustralia

1 ndash POMS NSSQ Significant and steadyreduction in scores (overalland on the subscales) wasobserved over time for bothgroups that showedsignificant improvement insymptoms of depression Nodifference when comparingIG vs CG182

Unclear

Usual care inTaiwan

1 ndash EPDS score10 or more(Chineseversion)

ndash No significant difference forIG vs CG at 6 weeks(χ2= 190 df= 1 p= 017)and 3 months postpartum(χ2= 102 df= 1 p= 031)183

Usual care inCanada

1 ndash EPDS score12 or more

The Parkyntool

Women in IG had EPDSscores significantly lowerthan women in CG IG 414CG 501 t= 2180df= 254 p= 0030186

Usual care inthe USA

8 ndash CES-D (subsetof 7 items)

ndash Intent-to-treat analysesindicated significant programeffects on coparentalsupport maternal depressionand anxiety distress in theparentndashchild relationshipand several indicators ofinfant regulation180

Unclear

Results indicate a significantintervention effect onmaternal depressionand anxiety180

2 30 SF-36 5-itemmental healthscale

Partnersatisfactionand caringSF-365-items

No significant groupdifferences on postpartumhealth or work outcomes181

7 120 CES-D DIS(DSM-IV)EPDS POMS

SOS CSEI No significant effects wereobtained for either measureof caseness at 6 monthspostpartum184

Unclear

Findings point strongly todifferential effects of anintervention dependent uponthe womanrsquos level ofself-esteem184

continued

TABLE 16 Universal preventive interventions characteristics and main outcomes of RCTs of educationalinterventions (continued )

Interventionsummary

Milgrom2011185

Australia 143 Telephone Antenatal Individually Psychologist

Shapiro 2005187 USA 38 Antenatalsetting

Key BDI Beck Depression Inventory CES-D Center for Epidemiologic Studies Depression scale CG control groupCSEI Coopersmithrsquos Self-Esteem Inventory DASS Depression Anxiety Stress Scale-short form DIS Diagnostic InterviewSchedule df degrees of freedom DSM-IV Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition highhigh risk of bias IG intervention group low low risk of bias NSSQ Norbeck Social Support Questionnaire POMS Profileof Mood States RAC Risk Assessment Checklist SCL Symptom Checklist SOS Significant Others Scale unclear unclearrisk of biasEffect statistically significant at a conventional p-value of plt 005

Comparisongroup(s)

Numberofcontacts

Depressionoutcomes

Risk ofbias

8 ndash BDI DASSscore EPDSscore 13 ormore

RAC Significantly fewer casesscoring above threshold formild to severe depressionanxiety symptoms postnatallyvs routine care185

Unclear

IG reported significantlylower levels of depression(BDI-II) post-treatment thanparticipants in routine care(F186= 782 plt 001 Cohenrsquosd= 06)185

2 420 SCL score (dataextracted usingdigitisingsoftware)

MaritalAdjustmentTest

In general intervention waseffective compared to CG forwife and husband maritalquality for wife and husbandpostpartum depression187

The major change inpostpartum depression wasfrom 3 months to 1 year CGincreased and IG decreasedt(32)= 213 plt 005187

TABLE 17 Universal preventive interventions characteristics and main outcomes of RCTs of social support

Interventionsummary

First authoryearreferencenumber Country

Totalnumberof womenrandomised Place Timing

Self-helpsupport

Reid2002200268

UK 1004 Primarycare

Postnatal Group Midwifegroupfacilitator

Social support Kieffer 2013198 USA 278 Antenatalsetting

Individuallyand group

Communityhealth worker

Social support Morrell2000199266287

UK 623 Home visits Postnatal Individually Postnatalsupportworker

Support inlabour

Hodnett2002197

Canada 6915 Labourward

Labour Individually Nurse

Key CES-D Center for Epidemiologic Studies Depression scale CG control group CI confidence interval DUFSS DukeFunctional Social Support Scale high high risk of bias IG intervention group LAS Labor Agentry Scale low low riskof bias LSQ Labour Support Questionnaire MOMs Mothers on the Move SSQ6 Social Support Questionnaireunclear unclear risk of biasEffect statistically significant at a conventional p-value of plt 005

Comparisongroup(s)

Number ofcontacts

Depressionoutcomes

Overallrisk ofbias

Usual care inthe UK

2 or more ndash EPDS score12 or more

ndash There were no significantdifferences in EPDS scoresbetween the control andtrial arms at 3 and6 months nor were theredifferences in the SF-36and the SSQ6 scores

14 ndash CES-D score16 or more

ndash IG less likely than CG to beat risk for depression atfollow-up198

From baseline topostpartum the meanCES-D score of the MOMsgroup decreased145 points more than themean CES-D score ofthe CG although thisdifference in overallchange scores was notsignificant (95 CI ndash326037 p= 012)198

Usual care inthe UK

10 Range10ndash378

EPDS score12 or more

BreastfeedingSF-36 DUFSSresource usecosts

At 6 weeks no significantimprovement in health statusamong the women in the IG

Caesareandelivery LASLSQ

No significant differences inwomenrsquos perceived controlduring childbirth or indepression measured at6ndash8 weeks postpartum A totalof 245 women in IG (87)had evidence of postpartumdepression vs 277 women(101) in CG (p=008)

Unclear

18Qualitativestudiesofuniversalpreve

interven

tionsdescriptionofstudiesev

aluatingsocial

support

Firstau

yearreference

number

Quality

Grading

Country

Interven

tiondetails

Delivered

antenatalpostnatal

Groupindividual

Number

ingroup

Number

sessions

Duration

ofsession

Facilitatorservice

providers

Onlinediscussion

ortgrou

pOnlineforum

Postna

Virtua

lgroup

(onlineforum)

Morrell

Postna

talsup

worker

interven

evisits

Postna

Individu

10sessions

ortworkers

traine

level2

fortherole

KeyNAno

plicab

leNVQNationa

lVocationa

lification

I would just like to say the support worker who came to help me was fantastic I had twins bycaesarean so I couldnrsquot move around too good She sent me off to bed and when Irsquod get up the housewould be straight ironing done babies bathed and my 3-year-old amused J was brilliant I think thesupport worker is good and hope you can carry it on

Participant287

Providers of the support worker intervention reported that it provided women with emotionalinformational and appraisal support287 However one concern about the interventions was whether or notwomen would become overdependent on the additional support287

Service deliveryParticipants287 reported that the intervention would be more beneficial if it were more intensive forexample if visits were longer andor more frequent Midwives raised concern about the support workerrsquosrole threatening their own role Service providers were concerned that the intervention represented aninvasion of the womenrsquos privacy287 and were worried that they would be unable to deal with unpredictablesituations which they were not qualified to address In the study the authors suggested that serviceproviders wanted closer integration with other service providers such as the primary care team and thatthe intervention should be targeted at vulnerable groups287

Universal preventive interventions pharmacological agentsor supplements

Characteristics and main outcomes of randomised controlled trials of universalpreventive intervention of pharmacological agents or supplementsOf the six trials that evaluated a specific supplement or drug for the universal prevention of PND nonewere conducted in the UK207ndash212 Several types of pharmacological agents or supplements were identifiedincluding docosahexaenoic acid (DHA) at different doses207210211 calcium208 norethisterone ethanate209 andselenium212 All six studies compared the interventions with usual care in specific countries207ndash212 All sixstudies involved individual sessions207ndash212 Three studies took place in the antenatal period208211212 and twoin the postnatal period209210 one combined both antenatal and postnatal periods207 Included interventionswere all delivered by the provider A summary of the characteristics and main outcomes is provided inTable 19 No qualitative studies were identified of pharmacological agents or supplements aimed at auniversal population

Universal preventive interventions midwifery-ledinterventions

Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of midwifery-led interventionsOf the five studies146217ndash220 evaluating midwifery-led interventions for the universal prevention of PND twowere conducted in the UK146219 Several types of midwifery-led interventions were identified includingmidwifery redesigned postnatal care146 midwife-led debriefing or counselling after childbirth217218

midwife-managed care219 and team midwife care220 Comparisons were made with usual care in specificcountries146217ndash220 All six trials involved individual sessions146217ndash220 None of the trials provided theintervention only antenatally three initiated the intervention postnatally146217264 and two trials initiated theintervention during the pregnancy and continued it postnatally219220 The provision of the midwifery carevaried in the number of contacts with duration ranging from 15 minutes to 1 hour A summary of thecharacteristics and main outcomes is provided in Table 20

TABLE 19 Universal preventive interventions characteristics and main outcomes of RCTs of pharmacological agentsor supplements

Interventionsummary

Calcium Harrison-Hohner2001208261

Antenatal Individually Prescriber

DHA Doornbos2009207

TheNetherlands

Individually Prescriber

DHA 200mgday Llorente 2003210 USA 89 Postnatalsetting

Postnatal Individually Prescriber

DHA 800mg Makrides2010211265

Norethisteroneethanate 200mgadministeredintramuscularly

Lawrie 1998209 SouthAfrica

180 Postnatalsetting

Selenium Mokhber 2011212 Iran 166 Antenatalsetting

Key BDI Beck Depression Inventory BSID Bayley Scales of Infant Development CG control group CI confidence intervalhigh high risk of bias low low risk of bias MADRS MontgomeryndashAringsberg Depression Rating Scale OOS Obstetric OptimalityScore SCID-CV Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders clinician versionunclear unclear risk of biasEffect statistically significant at a conventional p-value of plt 005

Comparisongroup

Number ofcontacts

Depressionoutcomes Other outcomes Main findings

Overallrisk ofbias

2 or more EPDS score14 or more

Norbeckrsquos modifiedSarasonrsquos LifeEvents Survey

There was a trend among293 women who scored 14on more on the 6-week EPDStowards less depressionin the intervention groupAt 12 weeks postnatally theintervention group were lessdepressed (p= 004)

The authors suggested thatcalcium supplementationcould have had a preventiveeffect at one centre but noeffect at another and thatthese outcomes were difficultto explain

Usual carein theNetherlands

2 or more EPDS score12 or more(Dutch version)

OOS IG did not differ in mean EPDSscores or changes in EPDSscores nor in incidence orseverity of postpartum blues

2 or more BDI EPDS meanscore SCID-CV

Plasmaphospholipid DHAacid content

After 4 months no differencebetween groups in eitherself-rating or diagnosticmeasures of depression

Unclear

BSID The percentage of womenwith high levels of depressivesymptoms during the first6 months postpartum did notdiffer for IG vs CG (967 vs1119 adjusted relative risk085 95 CI 070 to 102p= 009)

1 EPDS score12 or moreMADRS

Breastfeedingvaginal bleedingsomatic complaints

Mean depression scoressignificantly higher in IGvs CG at 6 weekspostpartum (mean MADRSscore 83 vs 49p= 00111 mean EPDSscore 106 vs 75p= 00022)209

Usual care inIran

2 or more EPDS score 13 ormore (Iranianversion)

ndash Mean EPDS score in seleniumgroup significantly lower thanin CG (plt 005)

Unclear

TABLE 20 Universal preventive interventions characteristics and main outcomes of RCTs of midwifery-ledinterventions

Interventionsummary

Midwife-leddebriefing orcounselling afterchildbirth

Priest 2003217

Henderson1998330

Australia 1745 Postnatalsetting

Postnatal Individually Midwife

Selkirk 2006218 Australia 149 Postnatalsetting

Midwife-managed care

Shields 1997219 UK 1299 Antenatalsetting

Individually Midwife

Comparisongroup

Number ofcontacts

Depressionoutcomes

Risk ofbias

1 Range15ndash60

EPDS score13 or moreSCID SADs

IoE Scale(revised)(psychologicaltrauma)

No significant differences forCG vs IG in scores on IoEScale or EPDS at 2 6 or12 months postpartum or inthe proportions of womenwho met diagnostic criteria fora stress disorder (intervention06 vs control 08p= 058) or major or minordepression [intervention178 vs control 182relative risk 099 (95 CI087 to 111)] during thepostpartum year Nodifferences in median time toonset of depression[intervention 6 (interquartilerange 4ndash9) weeks vs control43ndash8 weeks p= 084] orduration of depression(intervention 2412ndash46 weeks vscontrol 2210ndash52 weeksp= 098)

Unclear

1 Range30ndash60

EPDS meanscore SCL-90

STAI IESDAS FADPSI IIS POBS

No significant differencesfor IG vs CG on measuresof personal informationdepression anxietytrauma perception of thebirth or parenting stressat any assessment pointspostpartum218

Usual care inthe UK

2 or more ndash EPDS meanscore (question10 on self-harmwas excluded)

Infant feeding EPDS has not beenvalidated as a 9-itemscale It was not possibleto give a lsquotruersquo measure ofpoint prevalence of PND219

Unclear

The mean scores for womenin the MDU were lower thanthose for the traditional caregroup (81 SD 49 vs 90SD 49) 167 of women inthe MDU vs 232 womenin usual care had an EPDSscore 13 or more (95 CIndash121 to ndash09)

continued

TABLE 20 Universal preventive interventions characteristics and main outcomes of RCTs of midwifery-ledinterventions (continued )

Interventionsummary

Midwifery-redesignedpostnatal care

MacArthur2002146 2003264

UK 2064 Postnatalsetting

Team midwifecare

Waldenstrom2000220

Key CI confidence interval DAS Dyadic Adjustment Scale FAD Family Assessment Device high high risk of biasIES Impact of Events Scale IoE Impact of Events scale IIS Intrapartum Intervention Scale low low risk of biasMDU Midwifery Development Unit POBS Perception of Birth Scale SADs Schedule for Affective Disorders SCL-90Symptom Checklist-90 SD standard deviation unclear unclear risk of biasEffect statistically significant at a conventional p-value of plt 005

Comparisongroup

Number ofcontacts

Depressionoutcomes

Risk ofbias

Usual care inthe UK

2 or more ndash EPDS score13 or moreSF-36 MCS

SF-36 PCS Womenrsquos mentalhealth measures weresignificantly better in theIG (MCS 303 [95 CI153ndash452] EPDS ndash192[ndash255 to ndash129] EPDS13+ odds ratio 057[043ndash076]) than incontrols but the physicalhealth score didnot differ146

ndash Team midwife careassociated with increasedsatisfaction Differencesbetween groups mostnoticeable for intrapartumcare and least noticeablefor postpartum care Nodifferences for teammidwife care vs standardcare in medicalinterventions or inwomenrsquos emotionalwell-being 2 months afterthe birth220

Unclear

Description and findings from qualitative studies of universal preventiveinterventions of midwifery-led interventionsSeven qualitative reports were identified of womenrsquos experiences of midwifery-ledinterventions277283ndash285289ndash291 All seven reports related to the CenteringPregnancy initiative (Table 21)

Findings from the qualitative studies of universal preventive interventions ofmidwifery-led interventions

Peer supportSeveral respondents in the seven studies277283ndash285289ndash291 reported gaining support particularly in theCenteringPregnancy intervention Service providers were positive about their experience and thought theintervention facilitated peer support290291 In addition the women felt that they had benefited from asupportive environment and from sharing experiences277283289

I really enjoyed having others who were at the same stage of pregnancy as me to talk to and comparefeelings and symptoms

Participant289

Women talked about building relationships with peers283289 receiving reassurance and normalisation oftheir experiences during the pregnancy during birth and postnatally289 Women also valued the emotionalinformational and appraisal support received from peers289 One woman did not find the groupenvironment helpful

It wasnrsquot a good idea in the beginning of the pregnancy I would not want the pregnancy be open tothe public

Participant277

PartnersRespondents felt that their partners needed and appreciated the support from the intervention283289

It was good for the husbands They all came and it was nice [that] they were included my husbandliked it because before he had to wait in the waiting room and now he was involved

Participant283

Some women felt more of the intervention focus should be on partners277 although one womanwas ambivalent277283

I think itrsquos good if they can come but when they were present there were things you did not want toask in front of others I did not want to raise questions in front of them

Participant277

Authorsrsquo interpretations277283 revealed either that partners had difficulty contributing to the group becauseof shyness277 or that women felt that partners were uncomfortable with intimate discussions283

Service providersrsquo skillsParticipants found the midwivesrsquo support and group skills in running the intervention helpful277285289

because they were able to pay attention to womenrsquos concerns and offer women solutions277285 althoughsome midwives required more training to lead groups

I was disappointed that the midwife did not ask about the wishes of the groupParticipant277

interven

aluatingmidwifery-ledinterven

quality

grading

Firstau

yearreference

number

Country

Setting

Delivered

antenatal

postnatal

individual

Number

ingroup

Number

sessions

Duration

ofsession

(hours)

Facilitatorservice

providers

gPregn

ersson

Second

arycare

antena

talclinic

postna

individu

al6ndash

Midwives

gPregn

nedy20

Second

arycare

airforceba

USNavyho

postna

talreu

12ndash16

ofpreg

individu

al8ndash

2Midwivesnurse

gPregn

Second

arycare

antena

talclinic

postna

individu

al4ndash

Certifiednu

midwives

gPregn

Second

arycare

antena

talclinic

postna

individu

al8ndash

2Family

physician

andape

rinatal

educator

gPregn

Second

arycare

antena

talclinic

postna

individu

al8ndash

2Family

physician

andape

rinatal

educator

gPregn

Australia

Second

arycare

antena

talclinic

commun

centres

postna

individu

al8ndash

Midwivesstud

midwivessocial

workers

gPregn

er-Smith

Second

arycare

antena

talclinic

commun

centresndashmultisite

postna

individu

al8ndash

notrepo

Participants felt midwives should focus more on their partners277 Others appreciated the midwifersquos skillsknowledge warmth providing suggestions for group discussion and allowing unstructured discussion277 Serviceproviders felt the intervention improved communication between them and participants which promoted abetter relationship and facilitated information exchange290 Service providers said they enjoyed delivering theintervention and found it a satisfying and rewarding experience in that it provided richer care to women290291

Active participationeducationAnother important theme related to how participants might actively participate in their own health careincluding the provision of education and the gaining of information and knowledge283ndash285289 Severalrespondents said that they valued receiving education and information about pregnancy and the postnatalperiod283284 The women felt empowered by being allowed to undertake certain health monitoring tasks suchas weighing themselves and taking their own blood pressure283 In two studies283289 the women wanted moreand more intensive education on issues relating to labour birth and parenting and the early weeks of parenting

At the time we were given ample information I was very well informed for my birth Moreinformation about coping with a newborn would be helpful

Participant289

Group settingService providers in two studies reported that compared with individual care the group environmentprovided more opportunity for teaching and enhanced education284291 Providers across studies felt that theintervention encouraged women to be active participants in their own health care284290 They reported thatwomen were enthusiastic about the group setting and this enthusiasm served to increase participation284

Service delivery and barriers to participationPractical aspects relating to how the service is delivered has important implications regarding interventionup-take Participants reported the format reduced waiting times285289 and promoted continuity of care277

In a study in a US military setting283 participants found lsquofront-desk staffrsquo unhelpful

You would have to wait for a really long time on the phone or for them to call back And then it feltlike they just brushed you off

Participant283

They complained about the lack of child care and consideration for children283 Participants reported theyfelt they had few assessments and that they experienced lsquoscrimping and cost savingrsquo as they were asked toundertake tasks such as taking samples to the laboratory They felt they would not have had to undertakethese activities if their care been delivered in a civilian setting283

Suggested improvementsWays suggested to improve the service were to reduce the period of time between first and second groupmeetings277 to reduce the 2-hour session289 to address the rushed feeling283 to improve the lack ofprivacy277283 to address the lack of healthy snacks283 and to add individual appointments

As a first-time mom you need more reassurance to talk with a caregiver Or perhaps have an opentime where you can go in ndash perhaps before or after to talk with them

Participant283

Service providers reported the group intervention helped to address waiting time issues in one study284 andsuggested that the intervention was a more efficient use of time290

I canrsquot impart everything Irsquove learned from 20 years of delivering babies in five 7-minute visits but I can get more of that across in all their 2-hour groups

Participant290

The intervention was still restricted to groups such as teenagers because of provider bias291 There weredifficulties gaining funding to keep the intervention running284291 and attendance difficulties because oftransport or work conflict issues Some women were resistant to the group format291 which serviceproviders felt did not allow lsquodeeper issuesrsquo to be addressed284 Service providers reported concerns that thegroup intervention took a provider away from one-to-one care284 and that they experienced difficultieswith scheduling

There is no system for scheduling While one provider does the group the other provider getsdumped on

Participant284

Universal preventive interventions organisation of maternity care

Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of organisation of maternity careOf the five studies147150225ndash227 evaluating the organisation of maternity care for the universal prevention ofPND only one was conducted in the UK150 Several types of organisation of maternity care interventionswere identified including planned health visitor visits150 early contact with care provider225 primary careand community care strategies147 programmes for HIV alcohol and mental health226 and early contact withcare provider227 Comparisons were made with usual care in specific countries147225ndash227 All five studiesinvolved individual contacts147150225ndash227

None of the studies were undertaken in only the antenatal period three in only the postnatal period150225227

and two used a combination of both antenatal and postnatal periods226227 The interventions were providedby different health-care providers including health visitors150 GPs225 primary care nurses communitydevelopment workers147 community health workers peer mentors226 paediatric house officer or nursepractitioners227 The number of contacts varied greatly A summary of the characteristics and main outcomesis provided in Table 22

Description and findings from qualitative studies of universal preventiveinterventions of organisation of maternity careOne qualitative study288 reported womenrsquos experiences of interventions aimed at a universal populationinvolving the organisation of maternity care (Table 23)

Findings from qualitative studies of universal preventive interventions of organisationof maternity care

SupportWomen found the service providerrsquos support helpful288 and appreciated the infant welfare sisterrsquos concernexpressed for them and the baby They also talked about the nurse as maternal figure for themselves

Shersquos a supplement to my own mother Shersquos easy to talk to I depend on her Shersquos not just there totake care of the baby but for the mothers too She started a group for us new mothers

Participant288

However this positive effect may have become a barrier to effective service use in situations in whichwomen reported that they did not understand the role of the maternal and child health nurse288 Onewoman reported

I never thought I had a right to talk about emotional problems as I was never told what the role ofthe nurse covers

Participant288

TABLE 22 Universal preventive interventions characteristics and main outcomes of RCTs of organisation ofmaternity care

Interventionsummary

Totalnumber ofwomenrandomised Place Timing

Early contact withcare provider

Gunn 1998225 Australia 475 Primarycare

Postnatal Individually GP

Serwint 1991227 USA 251 Postnatalsetting

Postnatal Individually Paediatrichouse officeror nursepractitioner

Primary care andcommunity carestrategies

Lumley2006147263

Australia 18555 Primarycare

Individually Primary carenurse andcommunitydevelopmentworker

Program for HIValcohol mentalhealth

Rotheram-Borus2011226 le Roux2013270

SouthAfrica

Individually Communityhealth worker(peer mentors)

Comparisongroup

Number ofcontacts

Durationof contact

Depressionoutcomes

Risk ofbias

BreastfeedingSF-36

No significant differencesbetween groups in EPDSand SF-36 scores numberof problems breastfeedingrates or satisfaction withgeneral practitioner careIG less likely to attend fortheir check-up (764 vs884 p= 0001)225

1 ndash CES-D Maternalknowledgeuse of services

No differences for IG vs CGfor emergency roomutilisation percentage whoreceived immunisations by90 days of age maternalknowledge of infant carematernal anxiety orpostpartum depression

SF-36 PCS There were no differences inmean scores for the MCS orEPDS There were nodifferences in the proportionof women scoring 13 or moreon the EPDS There were alsono differences in the meanPCS scores

Unclear

The combination ofprimary care andcommunity basedstrategies did not reducethe symptoms ofdepression or improve thephysical health of womenat 6 months postnatally

11 ndash EPDS score14 or moreGHQ

ndash PIP is a model forcountries facing significantreductions in HIV fundingwhose families facemultiple health risksHealthcare maternaldepression social supportand of motherssecuring the child grantwere similar acrossconditions270

continued

TABLE 22 Universal preventive interventions characteristics and main outcomes of RCTs of organisation ofmaternity care (continued )

Interventionsummary

Six plannedhealth visitorvisits

Christie 2011150 UK 295 Homevisits

Key CES-D Center for Epidemiologic Studies Depression scale CI confidence interval GHQ General Health Questionnairehigh high risk of bias low low risk of bias OR odds ratio PES Parenting Expectations Survey PIP Philani InterventionProgramme unclear unclear risk of biasEffect statistically significant at a conventional p-value of plt 005

Comparisongroup

Number ofcontacts

Durationof contact

Depressionoutcomes

Risk ofbias

Health visitorsingle visit

6 ndash EPDS PSI rolerestrictionattachmentself-efficacyPES babynurturebreastfeedinguse of servicessatisfaction

There were no differences inoutcomes for the interventiongroup compared with thecontrol group apart from theEPDS score which was higher(indicating more symptoms ofdepression) in the interventiongroup at 8 weeks postnatallyCompared with the controlgroup women in theintervention group reportedhigher levels of satisfactionand lower use of emergencyservices up to 8 weekspostnatally

Unclear

interven

aluatingorgan

isationofmaternitycare

Firstau

yearreferen

cenumber

Country

Interven

tiondetails

quality

grading

Delivered

antenatalpostnatal

Groupindividual

Number

ingroup

Number

sessions

Duration

ofsession

Facilitatorservice

providers

Scott19

8Australia

Materna

dchild

health

nurses

Second

arycare

materna

health

centres

Postna

Individu

Multip

lecontact

Nurses

KeyNAno

plicab

Service delivery and barriers to participationWomen reported that they did not understand that depression was associated with the baby andtherefore did not talk to the nurse about their feelings or they were worried about stigma if theyapproached the nurse for emotional support288

Universal preventive interventions complementary and alternativemedicine or other

Characteristics and main outcomes of randomised controlled trials of universalpreventive interventions of complementary and alternative medicine or otherNone of the three studies123129228 evaluating the CAMs for the universal prevention of PND wereconducted in the UK Several types of CAMs interventions were identified including baby massage228 andexercise123129 Comparisons were made with usual care in specific countries129228 and educationalinformation123 All three studies involved individual sessions One was undertaken in the antenatal periodonly129 and two in the postnatal period only123228 The provider of these interventions was a massageinstructor228 or physical therapist123129 The number of contacts varied and the length of contact was1 hour in two studies123129 A summary of the characteristics and main outcomes is provided in Table 24

Description and findings of qualitative studies of universal preventiveinterventions of complementary and alternative medicine or otherThree qualitative studies278ndash280286288 reported womenrsquos experiences of interventions aimed at a universalpopulation involving the CAMs or other intervention (Table 25)

SupportSupport was an important theme in studies of a group mindndashbody exercise (MBE) intervention286 a singinglullabies group intervention278279 and a yoga and discussion group280 In two studies278ndash280 the benefit ofpeer support was reported by participants especially the sharing of experiences and birth stories and in thedevelopment of connections with their fellow group members

(when I was giving birth) I thought of all the women in the lullaby project having their babies

it just connected me and I didnrsquot feel so nervous Participant278279

Women who took part in the MBE techniques reported that when partners supported them in applyingthe MBE techniques this facilitated communication between them and their partners286 Participantsreported that family support was also facilitated by teaching the songs learned in the lullabyintervention278279 The study author reported that participants found it difficult to apply MBE techniqueslearned during the intervention without group support286

TABLE 24 Universal preventive interventions characteristics and main outcomes of RCTs of CAM or other

Interventionsummary

Baby massage Fujita 2006228 Japan 57 Postnatalsetting

Postnatal Individually Massageinstructor

Exercise Norman 2010123 Australia 161 Postnatalsetting

Postnatal Group Physicaltherapist

Exercise Songoslashygard2012129

Norway 855 Antenatalsetting

Antenatal Group Physiotherapist

Key high high risk of bias low low risk of bias PABS Positive Affect Balance Scale POMS Profile of Mood Statesunclear unclear risk of biasEffect statistically significant at a conventional p-value of plt 005

Comparisongroup

Number ofcontacts

Depressionoutcomes

Risk ofbias

Usual care inJapan

2 or more ndash POMS(Japaneseversion)

Salivarycortisol

Significant differences inthe POMS score seen indepression and vigorbetween two groups at3 months No significantdifferences in the salivarycortisol levels 3 monthsafter delivery scores hadimproved more positively indepression and vigor in IGvs CG (D t= ndash257p= 02 V t= 239p= 02)228

8 60 EPDS score13 or more

PABS There was a reduction in meanEPDS score in the Mother andBaby Program interventiongroup at 8 weeks comparedwith the education-only groupmaintained for 4 weeks

Unclear

Usual care inNorway

12 60 EPDS score10 or moreEPDS score13 or more

ndash 14379 (37) women inIG and 17 of 340 (50) inCG had an EPDS score of10 or more (p= 046) and4379 (12) women in IGand 8340 (24) in CGhad an EPDS score of13 or more (p= 025)129

Unclear

interven

aluatingCAM

orother

quality

grading

Firstau

reference

number

Country

Setting

Delivered

antenatalpostnatal

Groupindividual

Number

ingroup

Number

sessions

Duration

ofsession

(minutes)

Facilitatorservice

providers

lullabies

Carolan

Second

arycare

antena

talclinic

atally

45Musicians

ddiscussion

0Australia

Second

arycare

commun

feministno

vernmen

enrsquoshe

centre

atallyan

Midwife

teache

Mindndash

exercise

techniqu

Migl20

Second

arycare

atally

5weekly

sessions

notrepo

Learning practical strategiesBeneficial aspects of the interventions were reported by participants as the practical use of strategieslearned during the intervention278279286 Participants reported that they served to prevent panic attackscombat physical symptoms of stress and could be used in combination with existing strategies286

Participants in one study286 reported that they valued techniques that were easy to use in any setting andfor a short period and being able to take the specific parts of the intervention they needed

[MBE was] something new and easy to use in almost any setting and for period a short period of time Participant286

However in one study278279 it was reported that the use of the learned strategies could result inunexpected emotional responses

I was told yoursquore going to get blue so I was expecting that I didnrsquot expect [what happened] At first Irsquod start crying was when I was singing that song I was crying at the time It was so strong

Participant278279

In one study286 the authors reported that the women found it difficult to allocate time to use the practicalstrategies learned forgot to implement the strategies or were resistant to using techniques because ofstigma in that they felt certain MBE techniques were not accepted by wider society One woman reportedthat she could not see the value in the use of the techniques during the postpartum period286

Empowerment (self-esteem)Women in two interventions reported that the intervention facilitated preparation for birth278ndash280 This was bothemotionally through stress reduction and confidence building278ndash280 and physically through yoga techniques280

Results from network meta-analysis for universal preventiveinterventions for Edinburgh Postnatal Depression Scalethreshold score

A NMA is an extension of a standard meta-analysis that enables a simultaneous comparison of allevaluated interventions in a single coherent analysis In this way all interventions can be compared withone another including comparisons not evaluated within individual studies The only requirement is thateach study must be linked to at least one other study through having at least one intervention in common

Among the trials excluded because they could not be connected to the main network (see Appendix 10Table of universal preventive intervention studies omitted from network meta-analysis) three were conducted inSouth Africa153209226 three in China154156157 one in Japan228 one in the Republic of China (Taiwan)183 and onein Hungary155 Three of these trials were at high risk of bias155183228 and two were of uncertain risk of bias153157

Among the other excluded trials three had no usual-care comparator150185198 Six trials did not report anEPDS score180ndash182187227329 and in two the EPDS score was unusable200268 Two trials of social support oneconducted in the UK200 and one in the USA198 were at low risk of bias and found no evidence of an effectThere were five studies at high risk of bias181187207218227 In all of the other studies the risk of bias wasunclear Three of these studies did not have negative results150180185 A US trial of education on preparingfor parenting found lsquoa [statistically] significant intervention effect on maternal depression and anxietyrsquo180

using a subset of seven items from the Center for Epidemiologic Studies Depression (CES-D) scaleAn Australian trial of education on preparing for parenting found lsquoparticipants in the intervention reportedsignificantly lower levels of depression [Beck Depression Inventory (BDI-II)] post-treatment than participantsin routine carersquo185 A UK-based trial of six planned health visitor visits150 found that the lsquointervention had noimpact on most outcomes however it was associated with an increased EPDS score at eight weeks (beforeaccounting for outliers) but not at seven monthsrsquo

Results for universal preventive interventions for Edinburgh PostnatalDepression Scale threshold score at 6 weeks postnatallyData were available from five studies presenting the EPDS threshold score at 6 weeks postnatally197208211219220

The results for the five universal preventive intervention trials presenting an EPDS threshold score arecombined here A NMA compared the effects of support in labour197 midwife-managed care219 DHA211

calcium208 and team midwife care220 relative to usual care on EPDS threshold Figure 5 presents the networkof evidence There were five intervention effects (relative to usual care) to estimate from five studies

Figure 6 presents the odds ratios of each intervention relative to usual care and Figure 7 presents theprobabilities of treatment rankings The total residual deviance was 1004 which is compared with thetotal number of data points 10 included in the analysis This implies a good fit of the model to the dataThe between-study SD was estimated to be 026 (95 CrI 001 to 072) which implies mild heterogeneityof intervention effects between studies

For all interventions except midwifery team care the odds ratio was less than 1 suggesting a beneficialeffect compared with usual care However none of the comparisons were statistically significant at aconventional 5 level (see Figure 6) The interventions with the highest probabilities of being the bestwere midwife-managed care and calcium (probability 043 and 036 respectively)

Midwifery team care was associated with an increased odds ratio compared with usual care(139 95 CrI 065 to 301) and had a 74 chance of being the least effective among the six interventions(see Figure 7)

Harrison-Hohner 2001 208

Hodnett 2002 197

Makrides 2010 211

Shields 1997 219

Waldenstrom 2000 220

Usual care

Calcium

Support in labour

Midwifery team care

FIGURE 5 Universal preventive interventions EPDS threshold score at 6 weeks postnatally network of evidence

005 018 063 225 800

Midwifery team care

Calcium

Support in labour

Midwifery team care

Calcium

Support in labour

Calcium

Support in labour

066 (030 to 140)

139 (065 to 301)

070 (029 to 164)

087 (041 to 183)

085 (040 to 174)

212 (074 to 639)

106 (033 to 325)

131 (046 to 383)

129 (045 to 381)

050 (015 to 152)

063 (022 to 178)

061 (021 to 175)

124 (042 to 391)

122 (041 to 381)

098 (034 to 283)

vs DHA

vs calcium

vs midwifery team care

vs midwife-managed care

vs usual care

Treatment comparison OR (95 CrI)

FIGURE 6 Universal preventive interventions EPDS threshold score at 6 weeks postnatally odds ratios for alltreatment comparisons Key OR odds ratio

wife-m

wifery

Calciu

Support

FIGURE 7 Universal preventive interventions EPDS threshold score at 6 weeks postnatally probability of treatmentrankings (ranks 1ndash6)

Results for universal preventive interventions for Edinburgh Postnatal DepressionScale threshold score at 3 months postnatallyA NMA was used to compare the effects of calcium208 booklet on PND186 exercise129 and early contactwith care provider225 relative to usual care on EPDS threshold Data were available from four studiescomparing five interventions Figure 8 presents the network of evidence There were four interventioneffects to estimate from four studies129186208225

Figure 9 presents the odds ratios of each intervention relative to usual care and Figure 10 presents theprobabilities of treatment rankings The total residual deviance was 704 which is compared with the totalnumber of data points seven included in the analysis This implies a good fit of the model to the dataThe between-study SD was estimated to be 023 (95 CrI 000 to 074) which implies mild heterogeneitybetween studies in intervention effects

The odds ratios of calcium a booklet on PND and exercise were less than 1 suggesting a beneficial effectcompared with usual care Early contact with care provider had an odds ratio greater than 1 suggestinga worsening effect (see Figure 9) However only the effect of calcium was statistically significant at aconventional 5 level The interventions with the highest probabilities of being the best were calcium andbooklet on PND (probability 048 and 045 respectively)

Results for universal preventive interventions for Edinburgh PostnatalDepression Scale threshold score at 6 months postnatallyA NMA was used to compare the effects of DHA211 CBT-based intervention61 PCA-based intervention61

primary care and community care strategies147 and early contact with care provider225 relative to usual careon EPDS threshold Data were available from four studies comparing six interventions Figure 11 presentsthe network of evidence There were five intervention effects to estimate from four studies61147211225

Figure 12 presents the odds ratios of each intervention relative to usual care and Figure 13 presents theprobabilities of treatment rankings The total residual deviance was 704 which is compared with the totalnumber of data points seven included in the analysis This implies a good fit of the model to the dataThe between-study SD was estimated to be 022 (95 CrI 000 to 071) which implies mild heterogeneityof intervention effects between studies

Gunn 1998 225

Sealy 2009 186

Songoslashygard 2012 129

Usual care

Early contact with care provider

Calcium

Booklet on PND

Exercise

FIGURE 8 Universal preventive interventions EPDS threshold score at 3 months postnatally network of evidence

005 022 100 447 2000

Calcium

Booklet on PND

Exercise

Booklet on PND

Exercise

032 (009 to 094)

034 (006 to 138)

130 (057 to 301)

071 (026 to 186)

106 (016 to 663)

419 (105 to 1812)

223 (051 to 1097)

391 (072 to 2425)

211 (035 to 1507)

054 (015 to 202)

vs early contact with care provider

vs booklet on PND

vs calcium

vs usual care

FIGURE 9 Universal preventive interventions EPDS threshold score at 3 months postnatally odds ratios for alltreatment comparisons Key OR odds ratio

025Pro

Calciu

Booklet

ith ca

FIGURE 10 Universal preventive interventions EPDS threshold score at 3 months postnatally probability oftreatment rankings (ranks 1ndash5)

Gunn 1998 225

Lumley 2006 147

Makrides 2010 211

Morrell 2009 61

Usual care

Primary care and community care strategies

CBT-based intervention

PCA-based intervention

FIGURE 11 Universal preventive interventions EPDS threshold score at 6 months postnatally network of evidenceDashed lines represent three-arm trials

005 018 063 225 800

DHACBT-based intervention

PCA-based interventionEarly contact with care provider

CBT-based interventionPCA-based intervention

Early contact with care providerPrimary care and community care strategies

085 (039 to 174)067 (030 to 146)069 (032 to 146)

089 (039 to 212)106 (052 to 221)

079 (027 to 234)

082 (029 to 236)106 (035 to 351)

125 (045 to 375)

104 (049 to 222)134 (041 to 452)160 (057 to 480)

129 (042 to 426)154 (053 to 458)

118 (037 to 365)vs early contact with care provider

vs PCA-based intervention

vs CBT-based intervention

vs DHA

vs usual care

FIGURE 12 Universal preventive interventions EPDS threshold score at 6 months postnatally odds ratios alltreatment comparisons Key OR odds ratio

For all interventions except primary care and community care strategies the odds ratio compared withusual care was less than 1 suggesting a beneficial effect However none of the comparisons werestatistically significant at a conventional 5 level (see Figure 12) The interventions with the highestprobabilities of being the best were CBT-based intervention and PCA-based intervention (probabilities 038and 029 respectively) (see Figure 13)

Results for universal preventive interventions for Edinburgh Postnatal DepressionScale threshold score at 12 months postnatallyA NMA was used to compare the effects of CBT-based intervention61 PCA-based intervention61 andmidwifery redesigned postnatal care146 relative to usual care on EPDS threshold Data were available fromtwo studies comparing four interventions Figure 14 presents the network of evidence There were threeintervention effects to estimate from two studies61146

CBT-bas

ct with

nd com

munity

tegies

025Pro

MacArthur 2002 146

Morrell 2009 61

Usual care

Midwifery redesigned postnatal care

Morrell 200961

All three interventions were associated with a beneficial effect although the results were statisticallyinconclusive (Figure 15) The probability of the intervention being the best was 043 032 and 025 formidwifery redesigned postnatal care146 CBT-based intervention61 and PCA-based intervention61

respectively (Figure 16)

005 018 063 225 800

057 (027 to 121)

058 (027 to 130)

061 (029 to 136)

103 (034 to 308)

107 (037 to 309)

105 (047 to 229)

vs midwifery redesigned postnatal care

vs usual care

wifery

CBT-bas

Summary of results from network meta-analysis for universal preventive interventionsfor Edinburgh Postnatal Depression Scale threshold scoreIn general the intervention effects were inconclusive although calcium was associated with a statisticallysignificant benefit relative to usual care at 3 months Intervention effects tended to vary over timeThe interventions most likely to be the best among those evaluable at each assessment were

l at 6 weeks postnatally midwife-managed care219 and calcium208 (the included studies were of unclearand high risk of bias respectively)

l at 3 months postnatally booklet on PND186 and calcium208 (the included studies were both at high riskof bias)

l at 6 months postnatally CBT-based intervention61 and PCA-based intervention61

l at 12 months postnatally midwifery redesigned postnatal care146 CBT-based intervention61 andPCA-based intervention61

However there was considerable uncertainty associated with the results and none of the probabilities ofbeing the best intervention exceeded 05

A weakly informative prior distribution was used for the between-study SD because there were insufficientstudies with which to estimate it from the sample data alone This prior distribution was chosen to ensurethat a priori 95 of the study-specific odds ratios were within a factor of 2 of the median odds ratiofor each treatment comparison The sensitivity analysis is presented for completeness in Appendix 11

Results from network meta-analysis for universal preventiveinterventions for Edinburgh Postnatal Depression Scalemean scores

A NMA was used to compare the effects of baby play184 booklet on PND186 calcium208 CBT-basedintervention61 early contact with care provider225 education on preparing for parenting184 educationalinformation123 exercise129 midwife-managed care219 midwifery redesigned postnatal care146 PCA-basedintervention61 primary care and community care strategies147 selenium212 and social support199 relative to usualcare on EPDS mean scores Data were available from 12 studies comparing 15 interventions so that therewere 14 intervention effects (relative to usual care) to estimate from 12 studies61123129146147184186199208212219225

Figure 17 presents the network of evidence

Figure 18 presents the differences in EPDS mean scores of each intervention relative to usual careThe between-study SD was estimated to be 081 (95 CrI 004 to 261) which implies moderateheterogeneity of intervention effects between studies

The interventions associated with the greatest reduction in EPDS mean score were selenium212

(ndash190 95 CrI ndash483 to 138 at 6ndash8 weeks) and midwifery redesigned postnatal care146 (ndash164 95 CrIndash407 to 107 at 3ndash4 months ndash143 95 CrI ndash400 to 136 at 12 months) None of the comparisonsagainst usual care were statistically significant at a conventional 5 level

Figures 19ndash22 present the probabilities of treatment rankings at 6ndash8 weeks 3ndash4 months 6ndash7 months and12 months respectively

The intervention with the highest probability of being the best at 6ndash8 weeks postnatally was selenium212

(probability 059) at 3ndash4 months postnatally the intervention with the highest probability of being the bestwas midwifery redesigned postnatal care (probability 055) while at 6ndash7 months postnatally CBT-basedintervention and PCA-based intervention were equally likely to be the best (probability 030 in each case)and at 12 months postnatally the highest probabilities were associated with midwifery redesignedpostnatal care146 and PCA-based intervention (probability 058 and 025 respectively)

Gunn 1998 225

Lumley 2006 147

MacArthur 2002 146

Mokhber 2011 212

Morrell 2000 199

Norman 2010 123 Sealy 2009 186

Shields 1997 219

Matthey 2004 184

Morrell 2009 61

Usual care

Calcium

Selenium

Social support

Educational information

Exercise

Booklet on PND

Education on preparing for parenting

Baby play

FIGURE 17 Universal preventive interventions EPDS mean scores network of evidence Dashed lines representthree-arm trials

ndash 500 ndash 250 000 250 500

6 ndash 8 weeks

3 ndash 4 months12 months

3 ndash 4 months

6 ndash 8 weeks

6 ndash 8 weeks6 ndash 7 months

3 ndash 4 months

3 ndash 4 months6 ndash 7 months

6 ndash 7 months

3 ndash 4 months

ndash 089 (ndash 349 to 184)

ndash 164 (ndash 407 to 107)ndash 143 (ndash 400 to 136)

ndash 073 (ndash 370 to 225) 048 (ndash 261 to 354)

068 (ndash 200 to 333)ndash 011 (ndash 278 to 264)

056 (ndash 245 to 343) 143 (ndash 166 to 442)

184 (ndash 205 to 566)

009 (ndash 246 to 270)

001 (ndash 241 to 267)Exercise

Booklet on PND

Social support

Baby play

Selenium

Calcium

Treatment comparison EPDS difference (95 CrI)

FIGURE 18 Universal preventive interventions EPDS mean scores mean differences of treatment comparisons vsusual care across all time points

wifery

Calciu

Booklet o

tional

ct with

FIGURE 20 Universal preventive interventions EPDS mean scores probability of treatment rankings at 3ndash4 monthspostnatally (ranks 1ndash7)

wife-m

Baby p

l support

tion o

g for p

FIGURE 19 Universal preventive interventions EPDS mean scores probability of treatment rankings at 6ndash8 weekspostnatally (ranks 1ndash6)

Summary of results from network meta-analysis for universal preventiveintervention studies for Edinburgh Postnatal Depression Scale mean scoresNot all studies provided information about intervention effects at each time making it difficult to drawinferences across all interventions at each time In general the intervention effects were inconclusive andthe CrIs were wide Intervention effects tended to vary over time The interventions most likely to be thebest among those evaluable at each assessment were

l 6ndash8 weeks postnatally selenium212 (the risk of bias for this study was unclear so the benefit of seleniumestimated in this NMA should be treated with some caution)

l 3 months postnatally midwifery redesigned postnatal care146

l 6 months postnatally CBT-based intervention61 and PCA-based intervention61

l 12 months postnatally midwifery redesigned postnatal care146 CBT-based intervention61 andPCA-based intervention61

Baby p

CBT-bas

l support

tion o

g for p

ct with

nd com

munity

tegies

wifery

CBT-bas

FIGURE 22 Universal preventive interventions EPDS mean scores probability of treatment rankings at 12 monthspostnatally (ranks 1ndash4)

Summary of results for universal preventive interventions forEdinburgh Postnatal Depression Scale threshold and EdinburghPostnatal Depression Scale mean scores

Overall summary of results for universal preventive interventions for EdinburghPostnatal Depression Scale threshold and Edinburgh Postnatal DepressionScale mean scoresTable 26 indicates the results of the NMAs for the EPDS threshold scores and EPDS mean scores at allassessment times The results indicate that the universal preventive intervention with the best-qualityevidence and the most enduring effect were midwifery redesigned postnatal care146 CBT-basedintervention61 and PCA-based intervention61

The qualitative data indicated that women appreciated the benefits from IPT the reassurance andnormalisation of social support and the support received from peers while taking part in midwifery-ledinterventions and group-based CAM interventions

TABLE 26 Universal preventive interventions NMAs overall summary of main effects of interventions relative tousual care

Time postnatally

EPDS mean score EPDS threshold score

Overallrisk ofbias

Difference in mean(95 CrI)

Probabilityof beingthe besta

Odds ratio(95 CrI)

6 weeks postnatally

Midwife-managed care219ndash089 (ndash349 to 184) 017 066 (030 to 140) 043b Unclear

Calcium208 NE NE 070 (029 to 164) 036b High

3 months postnatally

Midwifery redesignedpostnatal care146

ndash164 (ndash407 to 107) 055c NE NE Low

Calcium208ndash090 (ndash356 to 185) 019 032 (009 to 094) 048d High

Booklet on PND186ndash087 (ndash331 to 189) 015c 034 (006 to 138) 045d High

CBT-based intervention61ndash091 (ndash341 to 176) 030e 067 (030 to 146) 038b Low

PCA-based intervention61ndash090 (ndash332 to 174) 030e 069 (032 to 146) 029b Low

ndash143 (ndash400 to 136) 058f 057 (027 to 121) 043f Low

PCA-based intervention61ndash097 (ndash354 to 171) 025f 061 (029 to 136) 025f Low

CBT-based intervention61ndash078 (ndash341 to 191) 015f 058 (027 to 130) 032f Low

Key high high risk of bias low low risk of bias NE not evaluable unclear unclear risk of biasa Probability of being the best among interventions with evaluable data at each assessmentb Best among six interventionsc Best among seven interventionsd Best among five interventionse Best among eight interventionsf Best among four interventionsNotesFor difference in mean lt ndash075 or odds ratio lt 070Not evaluable data were data not available on this outcome measure for this intervention

Chapter 6 Results for selective preventiveintervention studies

Characteristics of randomised controlled trials of selectivepreventive interventions

There were 20 RCTs in the selective preventive interventions group in five of the seven intervention classesdefined as

l psychological (n= 6)158ndash163

l educational (n= 5)188ndash190192271

l social support (n= 5)149201ndash204

l pharmacological agents or supplements (n= 1)213

l midwifery-led interventions (n= 3)221ndash223

l organisation of maternity care (n= 0)l CAM or other (n= 0)

Results are presented in this order for the RCTs of selective preventive interventions There was limitedreplication of interventions across the trials The 20 selective preventive intervention trials are described bytheir intervention context mechanisms and measured outcomes within the seven classes The results of theNMAs are presented for the EPDS threshold score and EPDS mean scores followed by the findings ofthe qualitative data

Description of qualitative studies of selective preventive interventionsThe qualitative synthesis identified four studies in the selected preventive interventions group within threeof the seven intervention classes

2 educational (n= 1)253254

For ease of reference the selective preventive interventions have been given short-version descriptive labels(Table 27)

TABLE 27 Selective preventive interventions short-version descriptive labels

Short-version descriptivelabels Fuller description

Barnes 2009149 Peer support Home-Start UK volunteer visits

Brugha 2000188 Education on preparing forparenting

Preparing for Parenthood is a series of six structured 2-hour longantenatal classes These are preceded by an initial introductorymeeting with the woman and her partner The classes are designedto increase social support and problem-solving skills

Buist 1999189 Education on preparing forparenting

Ten classes in pregnancy and postpartum focusing on parentingand coping strategies Sessions covered physical preparing forparenting but focused on emotional issues and highlighted thereality of parenting Didactic teaching was combined with interactivegroup work films and experiential exercises

Chabrol 2002158 CBT-based intervention One cognitivendashbehavioural prevention session during hospitalisation

Gamble 2005221 Midwife-led debriefing orcounselling after childbirth

Face-to-face counselling within 72 hours of birth and again viatelephone at 4ndash6 weeks postpartum for women who report adistressing birth experience

Harris 2002213 Thyroxine 100 microg of thyroxine tablets daily in thyroid antibody-positive women

Sen 2006191 Education on preparing forparenting

A twin midwife advisor invitation to attend a series of educationsessions additional home visits and attendance at an antenatal twinclinic for women with twins

Small 2000223 Midwife-led debriefing orcounselling after childbirth

Midwife-led debriefing after operative childbirth before dischargefrom hospital

Zlotnick 2011163 IPT-based intervention An interpersonally based intervention for low-income pregnantwomen with intimate partner violence

RESULTS FOR SELECTIVE PREVENTIVE INTERVENTION STUDIES

Selective preventive interventions psychological interventions

Characteristics and main outcomes of randomised controlled trials ofselective preventive interventions of psychological interventionsOf the six included selective preventive intervention trials evaluating a psychological intervention158ndash163

none were conducted in the UK Three types of psychological interventions were evaluatedpsychoeducational therapy162 IPT160163 and CBT158159161 Comparisons were made with usual care inspecific countries158159161ndash163 and educational information160 One trial provided the intervention in a groupformat159 and five trials incorporated individual sessions158160ndash163 None of the interventions were providedin the home setting One trial provided the intervention in the antenatal period only160 whereas three trialsinitiated the intervention postnatally159161162 and two trials provided the intervention across the perinatalperiod from pregnancy to after childbirth158163 Interventions were provided by a variety of serviceproviders The number of contacts ranged from one to six (mean 43) and contact duration ranged from25 minutes to 2 hours

Description and findings from qualitative studies of selective preventiveinterventions of psychological interventionsThere was one US-based study reporting qualitative data on selective preventive interventions forPND296ndash298 The IPT intervention for teenagers promoted support from peers and clinicians and participantswere able to gain practical skills and felt empowered (Table 29)

Findings from qualitative studies of selective preventive interventions ofpsychological interventions support learning practical strategiesand empowermentParticipants reported that the intervention promoted the development of relationships and connection withother group members and that it was a normalising experience296ndash298 Service providers said gainingpractical skills was an important aspect of the intervention and that the intervention was beneficial whenthe group was supportive and when the group members could share experiences and give advice296ndash298

Clinicians raised the importance of supporting the women and the validation of the pregnancy as part ofan IPT intervention for teenagers296ndash298

That we honored the arrival of motherhood supported it as valid and no less valid even though theywere young and poor

Participant296ndash298

Helping them to think about whatrsquos next how to get the child care how to find a school for the childhow to negotiate with the difficult people in their lives to get what they need

Being able to self-advocate and establish personal boundaries was interpreted by the authors as twobenefits of IPT296ndash298

TABLE 28 Selective preventive interventions characteristics and outcomes of RCTs of psychologicalinterventions

Interventionsummary

Chabrol2002158255256

France 258 Antenatalsetting

Individually Psychologist

Hagan 2004159 Australia 199 Postnatalsetting

Postnatal Group Midwife

Silverstein2011161

USA 50 Postnatalsetting

Postnatal Individually Social worker

Comparisongroup

Number ofcontacts

Depressionoutcomes

Overallrisk ofbias

Usual care inFrance

1 60 BDI EPDSscore 11 ormore HDRSMINI SIGH-D

ndash Compared with the controlgroup women in theprevention group hadsignificant reductions in thefrequency of probabledepression (30plusmn 2 vs48plusmn 2) Recovery ratesbased on HDRS scores oflt 7 and BDI scores of lt 4were also significantlygreater in the treated groupthan in the control group158

The study suggests that thisprogramme for preventionand treatment of post-partum depression isreasonably well-acceptedand efficacious158

6 120 BDI DSM-IVEPDS median(interquartilerange) GHQSADs

ndash Fifty-four mothers (27) inthe trial were diagnosedwith minor or majordepression in the 12 monthsfollowing very pretermdelivery 29 (29) in theintervention group and 25(26) in the control group[relative risk 11 (95 CI080ndash15)]159

There were no differences inthe time of onset or theduration of the episodes ofdepression between thegroups159

Our intervention programdid not alter the prevalenceof depression in thesemothers159

4 25ndash60 QIDS ndash Forty-four per cent ofcontrol group mothersexperienced an episode ofmoderately severedepression symptoms overthe follow-up periodcompared to 24 of PSEmothers Control mothersexperienced an average119 symptomatic episodesover the 6 months offollow-up compared to052 among PSE mothers161

PSE appears feasible and maybe a promising strategy toprevent depression amongmothers of preterm infants161

continued

TABLE 28 Selective preventive interventions characteristics and outcomes of RCTs of psychologicalinterventions (continued )

Interventionsummary

Phipps 2013160 USA 106 Antenatalsetting

Antenatal Individually Psychologist

Zlotnick2011163

Individually Interventionist

Tam 2003162 China 516 Postnatalsetting

Postnatal Individually Nurse

Key CGI Clinical Global Impressions CI confidence interval CTS Conflict Tactics Scale DTS Davidson Trauma ScaleGHQ General Health Questionnaire HDRS Hamilton Depression Rating Scale high high risk of bias IPV Intimate PartnerViolence KID-SCID childhood version of the Structured Clinical Interview for Diagnostic and Statistical Manual of MentalDisorders LIFE Longitudinal Interval Follow-up Examination low low risk of bias MINI Mini International NeuropsychiatricInterview PSE Problem Solving Education PTSD post-traumatic stress disorder QIDS Quick Inventory of DepressiveSymptoms SADs Schedule for Affective Disorders SCIDNP Structured Clinical Interview for Diagnostic and StatisticalManual of Mental Disordersndash non-patient edition SIGH-D Structured Interview Guide for the 17-item version of theHamilton Depression Rating Scale unclear unclear risk of bias WHO-QOL World Health Organization Quality of Life scale

Comparisongroup

Number ofcontacts

Depressionoutcomes

Overallrisk ofbias

6 60 KID-SCID ndash The overall rate ofdepression in theintervention group (125)was lower than the controlgroup (25) with a hazardrate ratio of 044 (95confidence interval017ndash115) at 6 monthsafter delivery160

An intervention that isdelivered during theprenatal period has thepotential to reduce the riskfor postpartum depressionin primiparous adolescentmothers160

5 60 EPDS meanLIFE SCIDNP

DTS CriterionA of PTSDmodule ofSCID-NPCTS2

The intervention was notassociated with a reduction inmajor depressive episodesPTSD or IPV in pregnant orpostnatal women There wassome effect in loweringsymptoms of PTSD anddepression among pregnantwomen For women up to3 months postnatally there was alarger effect for PTSD symptoms

This study suggests someinitial support for ourintervention Largerrandomized trials areneeded to further examinethe intervention both duringand after pregnancy163

Usual care inChina

4 ndash CGI GHQHADS

WHO-QOL(Chineseversion)

There was no significantdifference in psychologicalmorbidity quality of life orclient satisfaction betweenthe counselling group andthe control group162

Unclear

29Qualitativestudyofselectivepreve

interven

tionsch

aracteristicsofstudiesev

aluatingpsych

ological

interven

Firstau

yearreferen

cenumber

Country

Interven

tiondetails

Delivered

antenatalpostnatal

Groupindividual

Number

ingroup

Number

sessions

Duration

ofsession

Facilitatorservice

providers

6ndash29

erateCASP

quality

IPT(n=14

curren

pressive

disorder)

inclusion

exclusioncrite

Second

carescho

olforpreg

parenting

Majority

antena

weekly

75minutes

Clinical

psycho

logist

andco-the

rapist

training

Selective preventive interventions educational interventions

Characteristics and main outcomes of randomised controlled trials ofselective preventive intervention of educational interventionsOf five included trials of a selective preventive intervention evaluating an educational intervention188ndash190192271

two were conducted in the UK188191 Two main types of interventions were identified education on preparingfor parenting188189192271 and a booklet on PND and social worker telephone call190 Comparisons were madewith usual care in specific countries188189192271 One study evaluated the effect of group sessions188

two studies evaluated the effect of individual sessions only190192 and two studies evaluated a combination ofindividual and group sessions189191 One trial provided the intervention in a home setting192 Three trialsprovided the intervention in the antenatal period only188189191 whereas one trial initiated the intervention inthe postnatal period190 and one trial provided the intervention across the antenatal and postnatal periods192

The interventions were provided by a variety of service providers with the number of contacts rangingfrom 1 to 25 (mean 96 contacts) and the duration varying between 1 and 2 hours A summary of thecharacteristics and main outcomes is provided in Table 30

Description and findings from qualitative studies of selective preventiveinterventions of educational interventionsOne qualitative study of an educational intervention was included in the indicated preventive interventionscategory253254 This study was linked to the trial of education on preparing for parenting188 Further detailsare provided in Table 31

Findings from the qualitative review

SupportData from participants of the group intervention demonstrated that the intervention promoted thedevelopment of relationships and connection with other group members and that it was a normalisingexperience253256 One participant refused to take part in the intervention and said the idea of being inroom full of people who did not know each other was lsquostrangersquo253254

Recipients reported that the intervention helped them to harness support from family members253254

Authorsrsquo interpretations indicated that participants valued the provision for their partner to join the groupand that they were most interested in the session that included partner involvement Participants found ithelpful having another person with them to hear information that was provided253254

Learning practical strategiesParticipants reported that they had learned useful practical strategies as part of the intervention253254

Specifically participants learned and were then able to apply the SODAS (situation optionsdisadvantages advantages solution) problem-solving system253254

Educationactive participation in own health careThe intervention promoted the gaining of knowledge and active participation in their own healthcare253254 Specifically the recipients reported that they were able to gain information about sensitivesubjects such as PND253254

Service delivery and barriers to participationAlthough the majority of service user perspectives on psychological interventions were positive a numberof suggestions for improvement were provided Authors of one study253254 reported participants wantedmore time for sharing of experiences The women reported that they wanted to keep groups intimate

And then when there were four of us there was more trust you could be honest it became like alittle family

Participant253254

TABLE 30 Selective preventive interventions characteristics and outcomes of RCTs of educationalinterventions

Interventionsummary

Booklet on PNDand social workercall

Howell 2012190 USA 540 Postnatalsetting

Brugha2000188254331

UK 209 Antenatalsetting

Antenatal Group Nurse andoccupationaltherapist

Buist 1999189 Australia 44 Antenatalsetting

Midwifepsychologistnurse

Sen 2006191271 UK 162 Antenatalsetting

Midwife

Comparisongroup

Number ofcontacts

Depressionoutcomes

Risk ofbias

1 ndash EPDS score10 or morePHQ-9

An intention-to-treatrepeated measures analysisfor up to 6 months offollow-up demonstratedthat mothers in theintervention group were lesslikely to screen positive fordepression versus enhancedusual care (odds ratio of067 95 CI 047ndash097number needed to treat16 95 CI 9ndash112)190

For black and Latina postnatalwomen the action orientedbehavioural educationalintervention was associatedwith fewer depressivesymptoms

Usual care inthe UK

6 120 EPDS score11 or moreGHQ-DSCAN

Assignment to the IG didnot significantly impact onPND [odds ratio for GHQ-Depression 122 (95 CI063 to 239) p= 055] oron risk factors fordepression188

Unclear

Attenders benefited nomore than non-attenders188

10 ndash BDI EPDSscore 13 ormore

STAI DAS SSS Postpartum nodifferences in depressionscores however anxietyless at 6 weeks in IG189

Unclear

Usual care inthe UK

6 90 EPDS score13 or moreHADS

HADS subscalefor anxietyPSI maritalrelationshipmotherndashinfantattachmentsocial support

Non significant differenceswere noted at 6 weeks(8 vs 20 p= 052)12 weeks (11 vs 22p= 020) and 26 weekspostnatal (9 vs 19p= 008) but not at52 weeks postnatal(18 vs 20 p= 068)191

Future provision of care fortwin pregnancy birth andparenting requires carefulconsideration Theintervention resulted inimproved psychologicalbenefit other thandepression191

continued

TABLE 30 Selective preventive interventions characteristics and outcomes of RCTs of educationalinterventions (continued )

Interventionsummary

Walkup2009192

USA 167 Homevisits

Individually Communitywomen

Key CI confidence interval DAS Dyadic Adjustment Scale GHQ General Health Questionnaire high high risk of biasHOME Home Observation for Measurement of the Environment ITSEA Infant Toddler Social Emotional Assessmentlow low risk of bias SCAN Schedule for Clinical Assessment in Neuropsychiatry SSS Sarason Social Support Scaleunclear unclear risk of bias

Comparisongroup

Number ofcontacts

Depressionoutcomes

Risk ofbias

25 60 CES-D PSI Parentingknowledgetest HOMEParentinvolvementITSEA SocialSupportself-reportmeasuresubstance use

No between-groupdifferences found formaternal involvementhome environment ormothersrsquo stress socialsupport depressionor substance use192

Unclear

Supports efficacy ofparaprofessional-deliveredFamily Spirit home-visitingintervention for youngAmerican Indian motherson maternal knowledgeand infant behavioroutcomes192

31Qualitativestudiesch

aluatinged

ucational

interven

Firstau

reference

number

Country

Interven

tiondetails

Delivered

antenatalpostnatal

Groupindividual

Numbers

ingroup

Number

ofsessions

Duration

ofsession

Facilitatorservice

providers

aringfor

parentho

odSecond

arycare

antena

talclinic

10ndash15

introd

uctory

meetin

gsixgrou

psessions

talreu

notrepo

Participants also reported that they would have liked written information such as handouts to be able tore-read them at a later point253254

The authors253254 also raised the point that when women were provided with information about theintervention they were told that only some women would be invited to take part At the same time theywere told the primary aim of the intervention was to reduce the likelihood of PND The authors concludedthat the selected women may have made the assumption that they were considered as of increasedvulnerability for PND but as it was never confirmed it may have left them with unresolved questions andanxieties This may have implications for how information about interventions is presented to women

A participant in one study253254 reported difficulties in accessing the service

I mean I wish I hadnrsquot missed the others you know what I mean to carry on really but just whatwith getting there as well and my bleeding ndash so like you know I was upset that I missed quite afew sessions

Participant253254

Other barriers were less visible and concerned how women approached the taboo subject of PND Theauthors of one study253254 reported that women appeared to want information about PND but wereresistant to ask for this information in fear that they would be thought of as lsquogoing madrsquo Other womenappeared to actively avoid information about PND when one woman was asked if she had found outabout PND from health professionals she replied

Well no not really I just didnrsquot want to know I think I thought if I didnrsquot know about it itwouldnrsquot happen

Participant253254

The authors concluded that some participants avoided information about PND as they believed a lack ofknowledge could operate as a protective factor When this information about PND was provided to themin the context of the intervention it appeared most were receptive to it

Selective preventive interventions social support interventions

Characteristics and main outcomes of randomised controlled trials ofselective preventive interventions of social supportOf the five included trials149201ndash204 evaluating social support interventions for the selective preventionof PND only two were conducted in the UK149201 Peer support was the main type of social supportintervention identified booklet on PND149201203 as well as support in labour204 and a booklet plus video202

One trial provided the intervention using a group format203 whereas the remaining four trials providedindividual sessions149201202204 Two trials provided the intervention in a home setting149201 One trialprovided the intervention in the antenatal period only202 and no trial initiated the intervention postnatallyThree trials provided the intervention in both the antenatal and postnatal time periods149201203 One trialprovided the intervention during labour204 As in the other included trials the interventions were providedby a variety of lay and professional service providers The number of contacts varied greatly with durationof contact (300 minutes) reported in only one trial204

No qualitative studies provided data on social support interventions

TABLE 32 Selective preventive interventions characteristics and outcomes of RCTs of social supportinterventions

Interventionsummary

Booklet plusvideo

Logsdon 2005202 USA 128 Antenatalsetting

Antenatal Individually Nurse

Peer mentorsliving with HIV

Richter 2014203

Rotheram2014269

SouthAfrica

262 Primarycare

Group Peer mentors

Peer support Barnes 2009149 UK 527 Homevisits

Individually Home-Startvolunteers

Peer support Cupples 2011201 UK 343 Homevisits

Individually Peer mentors

Comparisongroup

Number ofcontacts

Depressionoutcomes

Risk ofbias

1 ndash CES-D PSQ RSE No significant differencesfound in Center forEpidemiological Trials ofDepression instrumentscores among groups at6 weeks postpartum202

Unclear

No significant difference

Usual care inSouth Africafor womenwith HIV

Infant healthweight-for-agez-score health-care utilisationsocial supportHIVtransmission-relatedbehaviours

Compared to standard carewomen living with HIVEnhanced Intervention womenwere less likely to reportdepressed mood (OR= 255p= 0003)

Adherence to clinicintervention groups waslow yet there werebenefits for maternal andinfant health at 15 monthspost birth203

Significant difference

Usual care inthe UK

2 or more ndash EPDS score13 or moreSCID

PSI ICQ MSSI Volunteer support had noidentifiable impact on theemergence of maternaldepression from 2 to12 months or ondepression symptomswhen infants were12 months149

Unclear

Informal support initiatedfollowing screening fordisadvantage in pregnancydid not reduce thelikelihood of depressionfor mothers with infants149

Usual care inthe UK

2 or more ndash SF-36 BSID-II IG and CG did not differin BSID-II psychomotor(mean difference 16495 CI minus094 to 421) ormental (minus081 minus278 to116) scores nor SF-36physical functioning (minus54minus116 to 07) or mentalhealth (minus18 minus61 to26)201 scores

No benefit for infantdevelopment or maternalhealth at 1 year201

continued

TABLE 32 Selective preventive interventions characteristics and outcomes of RCTs of social supportinterventions (continued )

Interventionsummary

Support inlabour

Wolman 1993204

Trotter 1992276

Nikodem 1998275

SouthAfrica

189 Labourward

Labour Individually Supportivelabourcompaniondoula

Key BSID Bayley Scales of Infant Development CG control group CI confidence interval CSEI Coopersmithrsquos Self-EsteemInventory GHQ General Health Questionnaire HDRS Hamilton Depression Rating Scale high high risk of bias ICQ InfantCharacteristics Questionnaire IG intervention group low low risk of bias MSSI Maternal Social Support IndexPDI Pitt Depression Inventory PSQ Postpartum Support Questionnaire RSE Rosenberg Self-Esteem scaleSEM standard error of the mean unclear unclear risk of bias

Comparisongroup

Number ofcontacts

Depressionoutcomes

Risk ofbias

1 300 EPDS meanscore HDRSPDI

STAI CSEI The mean depressionscore of control groupmothers was 2327 (SEM128) and of supportedmothers 104 (SEM 077)(plt 0001)204

Unclear

The group receivingsupport attained higherself-esteem scores andlower postpartumdepression and anxietyratings 6 weeks afterdelivery204

According to the dataanalysis the presence of asupportive labourcompanion resulted in asignificant decrease indepression 3 months afterbirth t(61) = 218plt 005276

There were no differencesin postpartum depressionscores between twogroups at 1 year275

Mixed results

Selective preventive interventions pharmacological agentsor supplements

Characteristics and main outcomes of randomised controlled trials of selectivepreventive interventions of pharmacological agents or supplementsOnly one trial was identified that evaluated a pharmacological agent or supplement intervention for theprevention of PND213 This trial was conducted in the UK and evaluated the administration of thyroxine duringthe postnatal period The number of contacts involved was two or more but duration length of contact wasnot reported A summary of the characteristics and main outcomes is provided in Table 33

No qualitative studies provided data on studies of pharmacological agents or supplement interventions

Selective preventive interventions midwifery-led interventions

Characteristics and main outcomes of randomised controlled trials ofselective preventive interventions of midwifery-led interventionsOf the three trials221ndash223 included in the selective preventive interventions evaluating midwifery-ledinterventions none were conducted in the UK The types of midwifery-led interventions that were identifiedincluded midwife-led debriefing after childbirth221223 and CenteringPregnancy Plus222 Comparisons weremade with usual care in Australia221223 and the USA222 Two studies evaluated individual sessions221223 andone study was undertaken in the antenatal period only222 Midwives provided the interventions The numberof contacts varied and duration of contact ranged from 1 to 2 hours A summary of the characteristics andmain outcomes is provided in Table 34

Description and findings from qualitative studies of selective preventiveinterventions of midwifery-led interventionsTwo US-based studies292ndash295 included in the selective preventive interventions reported on midwifery-ledinterventions Details of these CenteringPregnancy interventions are presented in Table 35

SupportWomen reported gaining support of various kinds such as peer support as a particularly helpful aspect ofthe CenteringPregnancy intervention292ndash295 Women talked about building relationships with peers293ndash295

receiving reassurance and normalising their experiences of pregnancy birth and the postpartumperiod293ndash295 Women reported how they valued the emotional support informational support and practicaladvice they gained from peers293ndash295

Service providers were positive about their experience in delivering CenteringPregnancy They echoedservice user views suggesting that the intervention facilitated peer support293ndash295

Women in two studies felt the intervention encouraged family and partner support and increased familyawareness of difficulties in pregnancy292ndash295 Participants in one study felt health professionalsrsquo support washelpful292 Service providers reported the intervention facilitated improved communication between healthproviders such as between community mental health teams and obstetric providers293ndash295

lectivepreve

interven

tionsch

aracteristicsan

doutcomes

ofRCTs

ofpharmacological

tsorsupplemen

Interven

summary

Firstau

reference

number

Country

number

randomised

Timing

Typeof

session

Provider

Comparison

group(s)

Number

contacts

Duration

(minutes)

ression

outcomes

Mainfindings

Riskof

Thyroxine

Harris

Postna

setting

Postna

Individu

Prescriber

intheUK

ndashEPDSscore

ndashNoeviden

cethat

thyroxineha

yeffect

onoccurren

depression

Unclear

KeyGHQGen

Health

stionn

airehigh

riskof

biaslowlow

riskof

biasMADRS

eryndashAringsbergDep

ressionRa

tingScale

unclearun

clearriskof

TABLE 34 Selective preventive interventions characteristics and outcomes of RCTs of midwifery-led interventions

Interventionsummary

CenteringPregnancyPlus

Ickovics 2011222

Ickovics 2007262USA 1047 Antenatal

settingAntenatal Group Midwife

Midwife-leddebriefing afterchildbirth

Gamble2005221259260

Small 2000223 Australia 1041 Postnatalsetting

Key CI confidence interval DAS Dyadic Adjustment Scale high high risk of bias low low risk of bias MINI Mini InternationalNeuropsychiatric Interview MSSS Maternity Social Support Scale PTSD post-traumatic stress disorder RR relative riskSRS Social Relationship Scale unclear unclear risk of bias

Comparisongroup(s)

Number ofcontacts

Depressionoutcomes

Risk ofbias

10 120 CES-D PSS SRS socialsupportsubscale itemsseven SRSsocial conflictsubscale items

Using intention-to-treatmodels there were nosignificant differences inpsychosocial function yetwomen in the top tertile ofpsychosocial stress at studyentry did benefit fromintegrated group care222

Scores for high-stress women inthe CenteringPregnancy Plusarm were higher for self-esteemand lower for stress and socialconflict in the third trimesterand depression was lower at1 year postnatally

2 or more ndash EPDS score13 or moreDASS-21

MINI-PTSDMSSS

At 3-month follow-upintervention group womenreported decreased traumasymptoms low relative riskof depression low relativerisk of stress and lowfeelings of self-blame221

The midwifery-led interventionfor women following adistressing birth experience wasassociated with a reduction insymptoms of stress traumadepression and self-blame

Four women in the interventiongroup and 17 women in thecontrol group had an EPDSscore 12 or more at 3 monthspostnatally (RR 025 95 CI009 to 069)

SF-36 subscales More women allocated to IGscored as depressed 6 monthsafter birth than womenallocated to usual postpartumcare [81 (17) vs 65 (14)]although this difference wasnot significant (odds ratio 12495 CI 087 to 177)

35Qualitativestudiesofselectivepreve

interven

tionsdescriptionofstudiesofmidwifery-ledinterven

author

reference

number

Quality

Grading

Country

Interven

tiondetails

Delivered

antenatalpostnatal

Groupindividual

Number

sessions

Duration

ofsession

Facilitatorservice

providers

gPregn

Second

-based

commun

centre

postna

individu

10(the

andthen

fortnigh

Novick

294 29

gPregn

Second

ndashan

clinic

postna

individu

al8ndash

individu

8ndash10

Certifiednu

midwife

assistan

notrepo

Active participationeducationOne study highlighted how participants might actively participate in their own health care including theprovision of education and gaining information and knowledge293ndash295 Several respondents in one studyreported that they valued receiving education and information about pregnancy and the postnatalperiod293ndash295 Providers across several studies felt that the intervention encouraged women to be activeparticipants in their own health care293ndash295

Service delivery and barriers to participationService providers said that the group intervention was a more efficient use of their time293ndash295

The review showed that peer support was an important aspect of the intervention The intervention alsoappeared to promote and facilitate support from the womanrsquos family and partner Women found thesupport received from health professionals helpful Service providers felt that the intervention facilitatedimproved communication between health providers Women valued receiving education and informationabout pregnancy and the postnatal period Providers felt that the intervention encouraged activeparticipation by the women Service providers also felt that the intervention was an efficient use of timecompared with other models

Selective preventive interventions organisation ofmaternity care

No selective preventive intervention for PND was identified concerning the organisation of maternity careNo qualitative studies provided data on selective preventive interventions of organisation of maternity care

Selective preventive interventions complementary andalternative medicine or other interventions

No selective preventive intervention for PND was identified concerning CAMs or other interventionsNo qualitative studies provided data on selective preventive interventions of CAMs or other interventions

Results from network meta-analysis for selective preventiveinterventions for Edinburgh Postnatal Depression Scalethreshold score

Of the 20 selective preventive intervention trials nine were included in the NMA150160188190213215221223225

Among the 11 trials excluded because they could not be connected to the main network (see Appendix 10Table of selective preventive intervention studies omitted from network meta-analysis) two were conductedin South Africa203204269270275276 and one in China162 Three trials were excluded because they could not beconnected to the main network of evidence160190192

Five trials were excluded because of a lack of EPDS data159161201202222262 and three trials because there wasno usual-care comparator160190192

Three of the trials at low risk of bias found no benefit of CenteringPregnancy Plus for young ethnicminority women of low socioeconomic status222262 of CBT-based intervention for mothers following verypreterm delivery159 or of peer mentors for first-time mothers in socioeconomically deprived communities

Of the other three trials at low risk of bias one found that a CBT-based intervention was associated with areduction in depressive symptoms for women living in financial hardship161 one found that an IPT-basedintervention was associated with an overall lower rate of depression among primiparous adolescentmothers160 and one found that a booklet on PND and social worker call was associated with a reducedlikelihood of screening positive for depression among black and Latina mothers postpartum190

Results from network meta-analysis for selective preventive intervention forEdinburgh Postnatal Depression Scale threshold score at 6 weekspostnatallyA NMA was used to compare the effects of thyroxine213 a CBT-based intervention158 and midwife-leddebriefing following childbirth221 relative to usual care on EPDS threshold data Data were available fromthree trials comparing three interventions158213221 Figure 23 presents the network of evidence158213221

Harris 2002 213

Gamble 2005 221

Chabrol 2002 158

Usual care

Thyroxine

Midwife-led debriefing or counselling after childbirth

FIGURE 23 Selective preventive interventions EPDS threshold score at 6 weeks postnatally network of evidence

Figure 24 presents the odds ratios of each intervention relative to usual care and Figure 25 presents theprobabilities of treatment rankings The total residual deviance was 600 compared with the totalnumber of data points six included in the analysis This implies a good fit of the model to the dataThe between-study SD was estimated to be 021 (95 CrI 001 to 072) which implies mild heterogeneityof intervention effects between trials

008 025 078 240 739

Thyroxine

095 (033 to 257)

127 (056 to 305)

046 (018 to 110)

135 (037 to 539)

050 (013 to 188)

036 (010 to 119)

vs thyroxine

vs midwife-led debriefing or counselling after childbirth

vs usual care

FIGURE 24 Selective preventive interventions EPDS threshold score at 6 weeks postnatally odds ratios all treatmentcomparisons Key OR odds ratio

Cognitivendashbehavioural therapy-based intervention had the biggest effect relative to usual care (odds ratio046 95 CrI 018 to 110) although this was not statistically significant at a conventional 5 level(see Figure 24) CBT-based intervention had the highest probability of being the best (probability 084)(see Figure 25)

Results from network meta-analysis for selective preventive intervention forEdinburgh Postnatal Depression Scale threshold score at 3 monthspostnatallyA NMA was used to compare the effects of midwife-led debriefing after childbirth221 education onpreparing for parenting188 and thyroxine213 relative to usual care on EPDS threshold Data were availablefrom three trials comparing four interventions188213221 Figure 26 presents the network of evidenceThree treatment effects were estimated from three trials188213221

wife-le

riefing o

r counse

r child

CBT-bas

FIGURE 25 Selective preventive interventions EPDS threshold score at 6 weeks postnatally probability of treatmentrankings (ranks 1ndash4)

Brugha 2000 188

Gamble 2005 221

Harris 2002 213Usual care

Thyroxine

FIGURE 26 Selective preventive interventions EPDS threshold score at 3 months postnatally network of evidence

008 032 128 508 2009

Midwife-led debriefing or counselling afterchildbirthThyroxine

Thyroxine

018 (004 to 065)

143 (059 to 326)

083 (030 to 223)

803 (162 to 4227)

469 (087 to 2734)

058 (015 to 216)

vs thyroxine

vs usual care

FIGURE 27 Selective preventive interventions EPDS threshold score at 3 months postnatally odds ratios alltreatment comparisons Key OR odds ratio

For the selective preventive interventions at 3 months postnatally midwife-led debriefing or counsellingafter childbirth had the biggest effect relative to usual care (odds ratio 018 95 CrI 004 to 065)(see Figure 27) Midwife-led debriefing or counselling after childbirth had the highest probability of beingthe best (probability 096) (see Figure 28)

Results from network meta-analysis for selective preventive intervention forEdinburgh Postnatal Depression Scale threshold score at 6 monthspostnatallyA NMA was used to compare the effects of thryoxine213 and midwife-led debriefing after childbirth223

relative to usual care on EPDS threshold Data were available from two trials comparing threeinterventions213223 Figure 29 presents the network of evidence There were two treatment effects toestimate from two trials213223

Figure 30 presents the odds ratios of each intervention relative to usual care and Figure 31 presents theprobabilities of treatment rankings The total residual deviance was 399 compared with the totalnumber of data points four included in the analysis This implies a good fit of the model to the dataThe between-study SD was estimated to be 022 (95 CrI 002 to 074) which implies mild heterogeneityof intervention effects between trials

There was insufficient evidence of a difference in effect between interventions (see Figures 30 and 31)

Summary of results from network meta-analysis for selective preventiveinterventions Edinburgh Postnatal Depression Scale threshold scoreTable 36 indicates the results of the NMAs for the EPDS threshold scores and mean scores at allassessment times In general the intervention effects were inconclusive although midwife-led debriefingafter childbirth was associated with a statistically significant benefit at 3 months When interventions wereevaluated at more than one assessment the effects tended to vary over time

wife-le

riefing o

r counse

r child

tion o

g for p

FIGURE 28 Selective preventive interventions EPDS threshold score at 3 months postnatally probability oftreatment rankings (ranks 1ndash4)

Harris 2002 213

Small 2000 223

Usual care

Thyroxine

005 018 063 225 800

Thyroxine

126 (057 to 278)

095 (038 to 242)

074 (023 to 265)

vs usual care

wife-le

riefing o

r counse

r child

TABLE 36 Selective preventive interventions NMAs overall summary of main effects of interventions relative tousual care

Time postnatally

Overallrisk ofbias

Difference inmean (95 CrI)

Odds ratio(95 CrI)

6 weeks postnatally

CBT-based intervention Chabrol2002158

ndash175(ndash425 to 071)

075b 046(018 to 110)

084c High

Education on preparing for parentingSen 2006191 Buist 1999189

023 3 NE NE Lowuncleard

035b 083(030 to 223)

003c Lowuncleard

IPT-based intervention Zlotnick2011163

062b NE NE Unclear

083b NE NE Lowuncleard

Key high high risk of bias low low risk of bias NE not evaluable unclear unclear risk of biasa Probability of being the best among interventions with evaluable data at each assessmentb Best among three interventionsc Best among four interventionsd When there were two studies the risk of bias is indicated in the order in which the studies are citedNotesFor difference in mean lt ndash075 or odds ratio lt 070Not evaluable data were data not available on this outcome measure for this intervention

Results from network meta-analysis for selective preventiveinterventions for Edinburgh Postnatal Depression Scalemean scores

A NMA was used to compare the effects of CBT-based intervention158 education on preparing forparenting189191 IPT-based intervention163 midwife-led debriefing after childbirth223 and peer support149

relative to usual care on EPDS mean scores Data were available from six trials comparing fiveinterventions Figure 32 presents the network of evidence There were five intervention effects to estimate(relative to usual care) from six trials149158163189191223

Figure 33 presents the difference in EPDS mean scores of each intervention relative to usual care andFigures 34ndash37 present the probabilities of treatment rankings at 6ndash8 weeks 3ndash4 months 6ndash7 months and12 months respectively The between-study SD was estimated to be 068 (95 CrI 003 to 246) whichimplies moderate heterogeneity of intervention effects between trials The interventions associated withthe greatest reduction in EPDS mean score were the IPT-based intervention (ndash185 95 CrI ndash560 to2144 at 3ndash4 months) and CBT-based intervention (ndash175 95 CrI ndash425 to 071 at 6ndash8 weeks) None ofthe comparisons against usual care were statistically significant at a conventional 5 level

The intervention with the highest probabilities of being the best at 6ndash8 weeks was the CBT-basedintervention (probability 075) The intervention with the highest probability of being the best at3ndash4 months was the IPT-based intervention (probability 062) The intervention with the highest probabilityof being the best at 6ndash7 months was education on preparing for parenting (probability 083) Theintervention with the highest probability of being the best at 12 months was education on preparing forparenting (probability 057)

Barnes 2009 149

Buist 1999 189

Chabrol 2002 158

Sen 2006 191

Small 2000 223

Zlotnick 2011 163

Usual care

Peer support

Education onpreparing for parenting

IPT-based intervention

FIGURE 32 Selective preventive interventions EPDS mean scores network of evidence

ndash 500 ndash 250 000 250 500

6 ndash 7 months

6 ndash 8 weeks

3 ndash 4 months

12 months

6 ndash 8 weeks

3 ndash 4 months

6 ndash 7 months

12 months

045 (ndash 202 to 302)

073 (ndash 196 to 341)

Peer support

FIGURE 33 Selective preventive interventions EPDS mean scores mean differences of treatment comparisons vsusual care across all time points

CBT-bas

tion o

g for p

FIGURE 34 Selective preventive interventions EPDS mean scores probability of treatment rankings at 6ndash8 weekspostnatally (ranks 1ndash3)

tion o

g for p

FIGURE 35 Selective preventive interventions EPDS mean scores probability of treatment rankings at 3ndash4 monthspostnatally (ranks 1ndash3)

wife-le

riefing o

r counse

r child

tion o

g for p

Summary of results from network meta-analysis for selective preventiveinterventions for Edinburgh Postnatal Depression Scale mean scoresNot all interventions provided information about intervention effects at each time making it difficult todraw inferences across all interventions at each time In general the intervention effects were inconclusiveand the CrIs were wide The most beneficial interventions appeared to be the CBT-based interventionsIPT-based interventions and education on preparing for parenting However the evidence for the effect ofCBT-based intervention came from the study by Chabrol et al158 which was judged to be at high risk ofbias As such the benefit of that CBT-based intervention estimated in this NMA should be treated withsome caution In addition the evidence for the effect of IPT-based interventions at 3ndash4 months came froma trial which was a small pilot study by Zlotnick et al163 and as such the results should be treatedwith caution

The evidence from the qualitative review demonstrated that the IPT as a selective intervention wasacceptable to women and they reported benefiting from gaining realistic information about motherhoodand from being empowered to ask for help The educational intervention lsquoPreparing for parenthoodrsquoprovided participants with an additional opportunity to learn about PND while avoiding the stigma ofasking for this information Benefits of the CenteringPregnancy intervention included facilitation ofsupport particularly peer support for selective groups

support

tion o

g for p

FIGURE 37 Selective preventive interventions EPDS mean scores probability of treatment rankings at 12 months(ranks 1ndash4)

Chapter 7 Results for indicated preventiveintervention studies

Characteristics of randomised controlled trials of indicatedpreventive interventions

There were 30 RCTs in the indicated preventive interventions group in six of the seven intervention classesdefined as

5 midwifery-led interventions (n= 1)224

6 organisation of maternity care (n= 0)7 CAM or other interventions (n= 1)229

Results are presented in this order for the RCTs of indicated preventive interventions There was limitedreplication of interventions across the studies The 30 indicated preventive intervention studies aredescribed by their intervention context mechanisms and measured outcomes within the seven classes

Description and findings from qualitative studies of indicatedpreventive interventionsThere were three qualitative studies in the indicated preventive interventions group in two of the sevenintervention classes

l social support (n= 2)299301

l organisation of maternity care (n= 1)300

One study reported on the perspectives and attitudes of service providers to indicated preventiveinterventions298 For ease of reference indicated preventive interventions were given short-versionindicative labels (Table 37)

TABLE 37 Indicated preventive interventions short-version descriptive labels

First authoryear referencenumber

Short-versionindicative label Fuller description

Armstrong1999164

A structured home-visiting programme of weekly nurse home visiting supportedby a social worker and paediatrician when the child was at great risk of poorhealth and developmental outcomes

Austin 2008165 CBT-basedintervention

An antenatal cognitivendashbehavioural group intervention in a primary care settingfor pregnant women identified with mild to moderate symptoms in pregnancyandor at risk of developing depression or anxiety in the perinatal period

Austin 2008165 Educationalinformation

Information booklet for pregnant women identified with mild to moderatesymptoms in pregnancy andor at risk of developing depression or anxiety in theperinatal period

Dennis 2009205 Peer support Telephone-based volunteer peer support for women at high risk of PND

Ginsburg 2012168 CBT-basedintervention

An eight-lesson cognitivendashbehavioural-based programme Living in Harmonyfor reservation-based American Indians

Ginsburg 2012168 Educationalinformation

An eight-lesson education programme Education-Support programmefor reservation-based American Indians

Gorman 1997169 IPT-basedintervention

A preventive intervention adapted from IPT for depression for women at highrisk of PND and adjustment problems

Grote 2009170 Educationalinformation

Written educational materials about depression and strong encouragement toseek treatment at the behavioural health centre for low-income pregnantwomen scoring 13 or more on the EPDS

Grote 2009170 IPT-basedintervention

Culturally relevant enhanced brief IPT-B consisting of an engagement sessionfollowed by eight acute IPT-B sessions before birth and maintenance IPT up to6 months postpartum for low-income pregnant women scoring 13 or more on theEPDS

Marks 2003224 Midwiferycontinuous care

Continuous midwifery care of a named midwife who as far as possible followedthe women through the pregnancy delivery and postnatally for women with ahistory of major depressive disorder

Morrell 200961 CBT-basedintervention

HV training in the assessment of postnatal women combined withcognitivendashbehavioural approach sessions for eligible women who scored 12 ormore on the EPDS

Morrell 200961 PCA-basedintervention

HV training in the assessment of postnatal women combined withPerson-Centred Approach sessions for eligible women who scored 12 or moreon the EPDS

Munoz 2007173 CBT-basedintervention

Mamaacutes y BebeacutesMothers and Babies Course developed in Spanish and Englishthat uses a cognitivendashbehavioural mood management framework andincorporates social learning concepts attachment theory and sociocultural issuesfor low-income predominantly Latina women who screened positive for a majordepressive episode andor who scored 16 or more on CES-D

Petrou 2006174 Promotingparentndashinfantinteraction

Home visits from research health visitors to enhance maternal sensitivity to infantcommunicative signals and infant responsiveness and to encourage women toexpress their feelings for women at raised risk for PND

Stamp 1995195 Education onpreparing forparenting

Two antenatal groups and one postnatal group with a practical and emotionalemphasis on planning for and expectations of life changes precipitated by thearrival of a new baby for women vulnerable to developing PND A non-directivepractical and supportive programme was developed underpinned by aphilosophy that acknowledged the abilities and resourcefulness of the womenthemselves Its focus was on access to information preparation and support theextension and development of womenrsquos existing networks and goal setting

Webster 2003196 Booklet on PND Providing women in the intervention group with a booklet about PND and a listof the phone contacts of PND resources for pregnant women with risk factorsfor PND

IPT-B Interpersonal Psychotherapy ndash brief HV health visitor

RESULTS FOR INDICATED PREVENTIVE INTERVENTION STUDIES

Indicated preventive interventions psychological interventions

Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of psychological interventionsOf the 19 included studies reporting psychological interventions for the indicated prevention ofPND61121148164ndash179 only three61174177 were conducted in the UK Six types of psychological interventionswere identified CBT-based interventions61148165167168171ndash173 empowerment training175 IPT-basedinterventions166169170178179 mindfulness-based intervention121 promoting parentndashinfant interaction164174177

and psychoeducational interventions176 Comparisons were made with usual care in specificcountries61121148164166167169ndash179 and educational information165168 Seven studies evaluated groupsessions121165171173177ndash179 11 evaluated individual sessions61148164167ndash170172174ndash176 and one evaluated bothgroup and individual sessions166 Five studies took place in the home setting61164168172174 Six studies wereundertaken in the antenatal period only121168173175ndash177 two in the postnatal period only61164 and 11 in acombination of both antenatal and postnatal periods148165ndash167169ndash172174178179 The interventions wereprovided by different health-care providers (nurse social worker paediatrician psychologist counsellorhealth visitor community health workers) and group facilitators171177 The number of contacts varied andlength of contact ranged from 30 minutes168 to 2 hours121165171177 A summary of the characteristics andmain outcomes is provided in Table 38

There were no qualitative studies of indicated preventive interventions of psychological interventions

Indicated preventive interventions educational intervention

Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of educational interventionsNone of the four included studies193ndash196 reporting educational interventions for the indicated prevention ofPND were conducted in the UK Two main types of educational interventions were identified a booklet onPND193194196 and education on preparing for parenting195 Comparisons were made with usual care inspecific countries and educational information Two studies evaluated group sessions194195 and twoevaluated individual sessions only193196 No study took place in the home setting Two studies wereundertaken in the antenatal period only194196 one in the postnatal period only193 and one in a combinationof both antenatal and postnatal periods195 The interventions were provided by different health-careproviders (nurse midwife) with the number of contacts ranging from one to eight (mean 325) andduration of contact ranging from 1 to 2 hours (mean 15 hours) A summary of the characteristics andmain outcomes is provided in Table 39

There were no qualitative studies of indicated preventive interventions of educational interventions

Indicated preventive interventions social support

Characteristics and main outcomes of randomised controlled trials of indicatedpreventive interventions of social supportOnly one of the included studies206 evaluating social support for the indicated prevention of PND wasconducted in the UK Peer support was the main type of social support intervention identified a bookleton PND205206 Comparisons were made with usual care in specific countries (ie Canada205 and the UK206)Both included studies evaluated individual sessions only205206 One study took place in the home setting206

and one intervention was by telephone205 One study was undertaken in the postnatal period only205 andone in a combination of both antenatal and postnatal periods206 Both interventions were provided bydifferent peer volunteers the number of contacts varied and the length of contact was not specifiedA summary of the characteristics and main outcomes is provided in Table 40

TABLE 38 Indicated preventive interventions characteristics and outcomes of RCTs of psychologicalinterventions

Interventionsummary

Austin 2008165 Australia 277 Antenatalsetting

Group Psychologist

El-Mohandes2008167

Individually Counsellor

Ginsburg 2012168 USA 47 Homevisits

Antenatal Individually Paraprofessionals

Comparisongroup(s)

Number ofcontacts

Duration ofcontact(minutes)

Overallrisk ofbias

6 120 EPDS meanscore (dataextractedusingdigitisingsoftware)MINI

STAI (notreported)

Intention-to-treat analysesrevealed relatively low meanbaseline EPDS scores [range 688(SD 443) 816 (SD 447)] withno reduction in EPDS scores ineither group MINI depressioncriteria were fulfilled by 19of all participants at time 1but there was no reductionin depression in either group incontrast those with MINI anxietydiagnoses reduced from 28 inlate pregnancy to 16 at4 months postpartum in theCBT group with similarreductions in the control group

Unclear

2 or more 36 BDI-IIHopkinssymptomchecklist

CTS ETSE Depression at postpartuminterview was 255 in theintervention group and 290in the control group p= 0303

An integrated multiple riskfactor interventionaddressing psychosocialand behavioral risksdelivered mainly duringpregnancy can havebeneficial effects in riskreduction postpartum167

8 30ndash60 CES-D CGASDISC EPDSmean score

SSI At all post interventionassessments mothers inboth groups showedsimilar reductions indepressive symptoms andsimilar rates of MDD Bothgroups of participantsalso showed similarimprovements in globalfunctioning No changesin either group werefound on the measure ofsocial support168

Unclear

continued

TABLE 38 Indicated preventive interventions characteristics and outcomes of RCTs of psychologicalinterventions (continued )

Interventionsummary

Le 2011171 USA 217 Antenatalsetting

Group Group Facilitators

McKee 2006172 USA 90 Homevisits

Morrell 200961 UK 595 Homevisits

Postnatal Individually Health visitors

Munoz 2007173 USA 41 Antenatalsetting

Comparisongroup(s)

Number ofcontacts

Overallrisk ofbias

11 120 BDI-II score21 or moreMoodScreener

Mood Screener The cumulative incidenceof major depressiveepisodes was notsignificantly differentbetween the intervention(78) and UC(96) groups171

Unclear

A CBT intervention forlow-income high-riskLatinas reduced depressivesymptoms duringpregnancy but not duringthe postpartum period171

8 ndash BDI-II IRS NSSQ The two interventionconditions were equallyeffective in reducingdepression172

Usual care inthe UK

up to 8 60 CORE-OMEPDS score12 or moreand meanSF-36 MCS

PSI DASSF-6D SF-36 PCS

At 6 months postnatally 93 ofthe 271 (34) women in the IGand 67 of the 147 women in theCG (46) had an EPDS score12 or more The OR for a score12 or more at 6 monthspostnatally was 062 (95 CI040 to 097 p=0036) forwomen in the IG vs CG

Training health visitors toassess women identifysymptoms of PND anddeliver psychologicallyinformed sessions wasclinically effective at 6 and12 months postnatallycompared with usualcare61

12 ndash CES-D EPDSmean scoreMMS for MDE

ndash Differences in terms ofdepression symptom levelsor incidence of MDEsbetween the two groupsdid not reach statisticalsignificance in this pilottrial However the MDEincidence rates of 14 forthe intervention conditionversus 25 for thecomparison conditionrepresent a small effectsize (h= 028)173

Unclear

continued

Interventionsummary

Rahman 2008148 Pakistan 903 Antenatalsetting

Individually Community healthworkers

Empowermenttraining

Tiwari 2005175 HongKong

Antenatal Individually Midwife

Crockett 2008166 USA 36 Antenatalsetting

Counsellor

Comparisongroup(s)

Number ofcontacts

Overallrisk ofbias

Usual care inPakistan

16 ndash HDRS Weight-for-ageZ scores height-for-age Z scoresMSPSS BDQGAFS

At 6 months 97 of the 418(23) women in the IG and211 of the 400 womenin the CG (53) had majordepression The OR was 022(95 CI 014 to 036plt 00001) At 12 months27 in the IG (111 out of 412)vs 59 in the CG (226 outof 386) had major depressionThe OR was 023 (95 CI 015to 036 plt 00001)

This psychologicalintervention delivered bycommunity-based primaryhealth workers has thepotential to be integratedinto health systems inresource-poor settings148

CTS SF-36 Twenty-five women fromthe control group hadEPDS scores of 10 or morecompared with 9 from theexperimental group(relative risk 036015ndash088)175

The experimental groupreported less psychologicalabuse and minor physicalviolence and their depressionsymptom scores were lowerthan the those for the CG

4 90 DSM-IV EPDSscore 10 ormore SCID

PPAQ PSI SASself-reportquestionnaire

At 3 months postpartumthe study found no significantdifferences between the twoconditions in degree ofdepressive symptoms or level ofparental stress

Unclear

continued

Interventionsummary

Gorman 1997169 USA 45 Antenatalsetting

Grote 2009170 USA 53 Antenatalsetting

Zlotnick 2001178 USA 35 Antenatalsetting

Group Psychologist

Comparisongroup(s)

Number ofcontacts

Overallrisk ofbias

5 ndash BDI EPDSscore13 or morePANAS SCIDSCL-90-R

DAS PPAQ No significant differencesbetween the two groupswere found on self-reportmeasures of depressivesymptomatology generalpsychiatric symptomatologymarital satisfaction orgeneral postpartumadjustment at either 1 or6 months postpartum169

Unclear

8 ndash BDI DISEPDS score13 or moreSCID (DSM-IV)

BAI PPAQ newbaby subscale(not reported)SAS (Social andLeisure Domain)

At 6 months postnatallyno women in the IPT-B groupshad major depressioncompared with 16 of 23 (70)in the UC group At 6 monthspostnatally the EPDS scoresindicated a response totreatment in 22 of 25 women inthe IPT-B group (88) vs 7 of28 (25) in the CG with a largeeffect size (χ2= 2116 df= 1plt 001 Cohenrsquos h= 117)170

Unclear

Findings suggest thatenhanced IPT-Bameliorates depressionduring pregnancy andprevents depressiverelapse and improvessocial functioning up to6 months postpartum170

4 60 BDI SCID At 3 months postnatallynone of the 17 women in theintervention group comparedwith 6 of 18 women in thecontrol group (33) had majordepression There was a greaterreduction in BDI scores in the 17IG women than in the 18 CGwomen (t=350 df=33p=0001) Four antenatalsessions of IPT for financiallydisadvantaged women appearedto prevent major PND

Unclear

continued

Interventionsummary

Group Nurse

Mindfulness-basedintervention

Vieten 2008121 USA 34 Antenatalsetting

Antenatal Group Clinicalpsychologistyoga instructor

Armstrong1999164

Australia 181 Homevisits

Postnatal Individually Nurse socialworkerpaediatrician

Petrou 2006174

Cooper 2014267UK 151 Home

visitsAntenatalandpostnatal

Individually Health visitor

Comparisongroup(s)

Number ofcontacts

Overallrisk ofbias

5 60 BDI RIFT At 3 months postnatally2 of the 50 women in theintervention group (4)compared with 8 of 40 womenin the control group (20) hadmajor PND A brief antenatalIPT-based intervention forfinancially disadvantagedwomen appeared to preventmajor PND

Unclear

8 120 CES-DPANAS-X

STAI PSS ARMMAAS

Differences observedbetween treatment andwait-list controls at3-month follow-up werenot statistically significant121

PSIbreastfeedingaccidental injuryChild AbusePotentialInventory HOMEnewly-developedmeasure ofpreventive infanthealth carePSQ-18 use ofhealth services

At 6 weeks women receivingthe home-based programmehad significant reduction in PNDscreening scores as well asimprovements in theirexperience of the parental roleand improvement in the abilityto maintain their own identityEPDS in intervention group was567 (SD 414) vs 790 (SD 589)comparison group p= 0004

Usual care inthe UK

2 or more ndash EPDS meanscore SCIDfor DSM-IVdiagnoses

ASSA BSID IIMDI BSQ

The index intervention hadno discernible impact onmaternal mood or thequality of maternalparenting behavioursneither did it benefit theinfant outcomesassessed174267

continued

Interventionsummary

Wilson 2013177 UK 31 Antenatalsetting

Antenatal Group Group facilitators

Weidner 2010176 Germany 238 Antenatalsetting

Key ARM Affect Regulation Measure ASSA Ainsworth Strange Situation Assessment of Infant Attachment AWS AdultWellbeing Scale BAI Beck Anxiety Inventory BDQ Brief Disability Questionnaire BSID Bayley Scales of Infant DevelopmentBSQ Behaviour Screening Questionnaire CG control group CGAS Childrenrsquos Global Assessment Scale CI confidenceinterval CTS Conflict Tactics Scale DAS Dyadic Adjustment Scale df degrees of freedom DIS Diagnostic InterviewSchedule DISC Diagnostic Interview Schedule for Children-Computer Version DSM-IV Diagnostic and Statistical Manualof Mental Disorders-Fourth Edition ETSE Environmental Tobacco Smoke Exposure GAFS Global Assessment of FunctioningScale high high risk of bias HOME Home Observation for Measurement of the Environment HDRS Hamilton DepressionRating Scale IG intervention group IRS Interaction Rating Scale ITP-B Interpersonal Psychotherapy ndash brief low low riskof bias MAAS Mindful Attention Awareness Scale MDD major depressive disorder MDE Major Depressive EpisodesMDI Mental Development Index MINI Mini International Neuropsychiatric Interview MMS Maternal Mood ScreenerMSPSS Multidimensional Scale for Perceived Social Support NSSQ Norbeck Social Support Questionnaire OR odds ratioPANAS Positive and Negative Affect Schedule PPAQ postpartum adjustment questionnaire PSQ Postpartum SupportQuestionnaire RIFT Range of Impaired Functioning Tool SAS Social Adjustment Scale SCL-90-R SymptomChecklist-90-Revised SSI Social Support Index UC usual care unclear unclear risk of bias

Comparisongroup(s)

Number ofcontacts

Overallrisk ofbias

Usual care inthe UK

6 120 EPDS meanscore

AWS Salivarycortisol

For a small number of womenvulnerable in pregnancyrepresenting a hard-to-reachpopulation the Mellow BumpsGroup and the Chill-out inPregnancy group both appearedto have positive effects on thewomenrsquos mental healthand well-being overall at8ndash12 weeks postnatally

Usual care inGermany

22 ndash HADS GiessenSubjectiveComplaints list(physicalsymptoms)

The psychosomaticintervention had asignificant effect onanxiety scores (pndash0006)but not on depressionscores physical complaintsand characteristics oflabour and delivery176

TABLE 39 Indicated preventive interventions characteristics and outcomes of RCTs of educational interventions

Interventionsummary

Booklet onPND

Heh 2003193 Taiwan 70 Postnatalsetting

Booklet onPND

Lara 2010194 Mexico 377 Antenatalsetting

Booklet onPND andcontactnumbers

Webster2003196

Antenatal Individually Leaflet (unclear)

Stamp 1995195 Australia 144 Antenatalsetting

Group Midwife

Key CI confidence interval high high risk of bias low low risk of bias SCL-90 Symptom Checklist-90 unclear unclear risk of bias

Comparisongroup(s)

Number ofcontacts

Depressionoutcomes

Overallrisk ofbias

Usual care inTaiwan

1 60 EPDS score10 or more(Chineseversion)

At 3 months postnatallyTaiwanese women who receivedinformation at around 6 weekspostnatally had lower EPDSscores (mean 108 SD 44) thana control group (mean 121SD 300) (p= 002)

Usual care inMexico

8 120 BDI-II SCID SCL-90 anxietysubscale

At 6 months postnatally 6 of56 women in the interventiongroup (107) had majordepression vs 15 of 60 womenin the control group (25) butthere was no significant effect

Available data are consistentwith the possibility that theincidence of depression mayhave been reduced by theintervention but differentialattrition makes interpretationof the findings difficult194

Mixed results

The proportion of womenwho reported an EPDS scoreof 13 or more was 26There were no significantdifferences betweenintervention (46192 24)and control groups (50177282) on this primaryoutcome measure (OR 08095 CI 050ndash128)196

Unclear

At 6 weeks postnatally 8 out of64 women in the interventiongroup (13) scored 13 or more onthe EPDS compared with 11 out of64 women in the control group(17)

At 12 weeks postnatally7 out of 63 women in theintervention group (11) scored13 or more compared with 10out of 65 women in the controlgroup (15)

At 6 months postnatally 9 out of60 women in the interventiongroup (15) scored 13 or morecompared with 6 out of61 women in the controlgroup (10)

TABLE 40 Indicated preventive interventions characteristics and outcomes of RCTs evaluating social support

Interventionsummary

Peer support Dennis 2009205 Canada 701 Telephone Postnatal Individually Peer volunteers

Peer support Harris 2006206 UK 65 Homevisits

Individually Newpin volunteer

Key high high risk of bias low low risk of bias SCAN PSE Schedule for Clinical Assessment in Neuropsychiatry Present StateExamination UCLA University of California Los Angeles unclear unclear risk of biasStatistically significant difference is assumed at the conventional value of lt 005

Comparisongroup(s)

Number ofcontacts

Depressionoutcomes

Overallrisk ofbias

Usual care inCanada

8 ndash EPDS score13 or moreSCID

STAI UCLAloneliness scale

At 12 weeks postnatally40 out of 297 women in theintervention group (14)scored 13 or more on the EPDScompared with 78 out of315 women in the controlgroup (25) (χ2= 125plt 0001) The number neededto treat was 88 (95 CI 59to 196) The relative riskreduction was 046 (95 CI024 to 062)

Usual care inthe UK

2 or more ndash SCAN PSE ndash The onset of perinatal majordepression was 27 (830) forthe Newpin befriender groupand 54 (1935) for thecontrol group (χ2= 400p= 0045 two-tailed test)206

Unclear

Description and findings from qualitative studies of indicated preventiveinterventions of social supportTwo qualitative studies of social support interventions were included in the indicated preventiveinterventions category299301 one relating to womenrsquos perceptions and one relating to service providerperceptions of the same intervention Further details are provided in Table 41

SupportEmotional support informational support and the development of relationships with peers were reportedby participants as beneficial aspects of the telephone support intervention299

Service deliveryService providers301 were concerned that the intervention represented an invasion of the recipientsrsquo privacyand also that they would not be able to deal with unpredictable situations for which they were notqualified One peer volunteer301 reported that providing the service had resulted in the recurrence of herown past emotions and anxieties Peer volunteers felt uncomfortable discussing emotional issues with therecipients Some felt they would have benefited from further training supervision and information to sharewith the service users The peer volunteers reported that they would have liked more time to devote tothe role301

Indicated preventive interventions pharmacological agentsor supplements

Characteristics and main outcomes of randomised controlled trials ofindicated preventive interventions of pharmacological agents or supplementsAll three included studies214ndash216 evaluating pharmacological agents or supplements for the indicatedprevention of PND were conducted in the USA Four types of pharmacological agents or supplements wereidentified eicosapentaenoic acid (EPA) plus DHA214 nortriptyline273 and sertraline216 One study wasundertaken in the antenatal period only214 and two studies were undertaken in the postnatal periodonly215216 A summary of the characteristics and main outcomes is provided in Table 42

There were no qualitative studies of indicated preventive interventions of pharmacological agentsor supplements

Indicated preventive interventions midwifery-ledinterventions

Characteristics and main outcomes of randomised controlled trials ofindicated preventive interventions of midwifery-led interventionsThere was one indicated preventive intervention evaluating midwifery-led interventions conducted in theUK224 A summary of the characteristics and main outcomes is provided in Table 43

There were no qualitative studies of indicated preventive interventions of midwifery-led interventions

41Qualitativestudiesofindicated

interven

tionsch

aluatingsocial

support

Firstau

reference

number

Country

Interven

tiondetails

Delivered

Antenatalpostnatal

Groupindividual

Number

sessions

Durationofsession

Facilitatorservice

providers

Teleph

one-ba

Teleph

Postna

Individu

alMeancontacts

88(SD6

contacts)

Meanleng

contact14

1minutes

5minutes)

e1ndash

180minutes

volunteers

ndashmothe

rsfrom

thecommun

itywith

resolved

historyof

participated

urtraining

session

KeyNAno

plicab

TABLE 42 Indicated preventive interventions characteristics and outcomes of RCTs evaluating pharmacologicalinterventions or supplements

Interventionsummary

EPA and DHA Mozurkewich2013214

Nortriptyline Wisner 2001215 USA 51 Postnatalsetting

Sertraline Wisner 2004216 USA 25 Postnatalsetting

Key BRMS BechndashRafaelsen Mania Scale HAM-D Hamilton Rating Scale for Depression HDRS Hamilton Depression RatingScale high high risk of bias low low risk of bias MINI Mini International Neuropsychiatric Interview unclear unclear riskof bias

Comparisongroup(s)

Number ofcontacts

Depressionoutcomes

Overallrisk ofbias

2 or more ndash BDI MINI ndash No differences betweengroups in BDI scoresor other depressionendpoints at any of thethree time points aftersupplementation214

EPA-rich fish oil andDHA-rich fish oilsupplementation didnot prevent depressivesymptoms duringpregnancy or postpartum214

2 or more ndash HDRS(HAM-D)

BRMS 6 out of the 26 women in thenortriptyline intervention group(23) compared with 6 out ofthe 25 women in the controlgroup (24) had a postnatalrecurrence of depression

2 or more ndash HDRS SCID Asberg SideEffects rating

Recurrences in the 17-weekpreventive treatment periodoccurred in four of theeight women takingplacebo (proportion 05095 CI 016ndash084) and inone of the 14 womentaking sertraline(proportion 007 95 CI000ndash034) (p= 004Fisherrsquos exact test)216

43Indicated

interven

tionsch

aracteristicsan

doutcomes

ofRCTs

evaluatingmidwifery-ledinterven

Interven

summary

author

reference

number

Country

number

randomised

Timing

Typeof

session

Provider

Comparison

group(s)

Number

contacts

Duration

(minutes)

ression

outcomes

Mainfindings

Midwife

rycontinuo

uscare

98Anten

setting

postna

Individu

Midwife

intheUK

EPDSmean

At3mon

postna

tallythe

EPDSmean

scoreforthe43

controlg

dforthe

theinterven

(SD654

Unclear

Nosign

ificant

differen

KeyCAME

textua

lAssessm

Maternity

rience

Maternity

ServiceQue

stionn

aireNR

notrepo

clearun

clearriskof

Indicated preventive interventions organisation ofmaternity care

Characteristics and main outcomes of randomised controlled trials ofindicated preventive interventions of organisation of maternity careNo indicated preventive intervention for preventing PND was identified concerning the organisation ofmaternity care

Description and findings of qualitative studies of selective preventiveinterventions of the organisation of maternity careOne qualitative study of an intervention evaluating the organisation of maternity care was included in theindicated preventive intervention category300 Further details are provided in Table 44

SupportRecipients of the intervention300 reported the support they received from the health professionals deliveringthe service as helpful and the relationship with the service provider appeared to be of great importanceWomen reported that they were able to rely on the service and that if they needed the service urgently itwas available to them

the service was closing and I just rang up and was like lsquoI really need some helprsquo and they calledme straight back the next day (M)y clinical nurse immediately started seeing me within a weekbecause they could see how desperate I was for some help

Participant300

They also valued a close relationship they were able to form with their clinician and reported on their kindapproach which enabled a feeling of safety300

Empowerment (self-esteem)The authors reported that the women learned to cope without the service and that it allowed them togain confidence in themselves300

Service delivery and barriers to participationWomen reported feeling intimidated by the thought of referral to the specialist perinatal and infant mentalhealth service300 The authors reported that those who did feel able to access the service fully said that theywould have liked the service to be extended beyond the infantrsquos first birthday and felt that they were notready to be discharged which caused them stress and anxiety300

interven

tionsch

aluatingorgan

Firstau

yearreferen

cenumber

Country

Interven

tiondetails

Delivered

antenatalpostnatal

Groupindividual

Numbers

ingroup

Number

sessions

Duration

ofsession

Facilitatorservice

providers

Myors20

0Australia

Specialistpe

rinatal

infant

service

Second

arycare

locatio

postna

Individu

Multip

lecontact

Nursepsychiatrist

psycho

logistsocial

workers

KeyNAno

plicab

Indicated preventive interventions complementary andalternative medicine or other interventions

Characteristics and main outcomes of randomised controlled trials ofindicated preventive interventions of complementary and alternativemedicine or other interventionsThe only included study evaluating CAMs or other interventions for the indicated prevention of PND wasconducted in the USA229 A summary of the characteristics and main outcomes is provided in Table 45

There were no qualitative studies of indicated preventive interventions of CAM or other interventions

Results from network meta-analysis for indicated preventiveinterventions for Edinburgh Postnatal Depression Scalethreshold score

Of the indicated preventive intervention trials 12 were included in the NMA (see Appendix 10 Table ofindicated preventive intervention studies omitted from network meta-analysis) Four trials were excludedbecause they could not be connected to the main network of evidence148177229 and 12 were excluded as aresult of lack of available EPDS data121166167171172176178179206214ndash216

The four trials excluded because they could not be connected to the main network were undertaken inChina (Hong Kong)175 Mexico194 Pakistan148 and Taiwan193

Of the 14 trials excluded as a result of lack of available EPDS data four were at high risk of bias and noneof these were associated with significant differences in depression121172176177 The UK-based trial was small(n= 31) and the results suggested that psychoeducational interventions in pregnancy may benefit womenwith major psychosocial needs177

Of the 14 trials excluded as a result of lack of available EPDS data six were at unclear risk ofbias166171178179206229 Five of these trials were small with fewer than 100 participants166178179206229

The largest of these trials with 217 participants concluded lsquoA CBT intervention for low-income high-riskLatinas reduced depressive symptoms during pregnancy but not during the postpartum periodrsquo171 Two ofthe three trials examining IPT-based intervention found a significant effect using the BDI or DSM-IV[Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV)] criteria178179 but the otherdid not166 In the active acupuncture study there were only 20 participants in each group229 and theUK-based Newpin trial found a significant reduction in the onset of perinatal major depression using theSchedule for Clinical Assessment in Neuropsychiatry (SCAN)206

One of the four trials at low risk of bias found that EPA- and DHA-rich fish oil supplementation did notprevent depressive symptoms214 No difference was found in the rate of recurrence in women treated withnortriptyline compared with those treated with placebo215 There were significantly fewer recurrencesof depression in women taking sertraline preventive treatment compared with women taking placebo216

A CBT-based intervention that integrated multiple risk interventions delivered mainly during pregnancyhad a non-significant effect in reducing risks for smoking depression and intimate partner violencebut there was a difference in favour of the intervention group167

TABLE 45 Indicated preventive interventions characteristics and outcomes of RCTs evaluating CAM or other

Interventionsummary

Acupuncturefor depression

Manber 2004229 USA 61 Antenatalsetting

Individually Acupuncturespecialist

Key BDI Beck Depression Inventory HDRS Hamilton Depression Rating Scale high high risk of bias low low risk of biasunclear unclear risk of bias

Comparisongroup(s)

Number ofcontacts

Depressionoutcomes

Overallrisk ofbias

Acupuncturenon-specific

12 30 BDI HDRS ndash At 10 weeks postnatallythe mean BDI score in the16 women in the acupuncturegroup was 69 (SD 77) In the19 women in the active controlit was 108 (SD 98) and in the19 women in the massagegroup it was 102 (SD 66)There was no pure control

Unclear

Limited by small sample

Results from network meta-analysis for indicated preventive intervention forEdinburgh Postnatal Depression Scale threshold scores at 6 weekspostnatallyA NMA was used to compare the effects of education on preparing for parenting and promotingparentndashinfant interaction relative to usual care on EPDS threshold Data were available from two studiescomparing three interventions166197 Figure 38 presents the network of evidence There were twointervention effects to estimate from two studies

Figure 39 presents the odds ratios of each intervention relative to usual care and Figure 40 presents theprobabilities of treatment rankings The total residual deviance was 412 compared with the total numberof data points four included in the analysis This implies a good fit of the model to the data Thebetween-study SD was estimated to be 023 (95 CrI 001 to 074) which implies mild heterogeneity ofintervention effects between studies

Armstrong 1999 164

Stamp 1995 195

Usual care

Promoting parent ndash infant interaction

FIGURE 38 Indicated preventive interventions EPDS threshold score at 6 weeks postnatally network of evidence

005 018 063 225 800

021 (006 to 063)

071 (021 to 225)

348 (066 to 2013)

vs promoting parent ndash infant interaction

vs usual care

FIGURE 39 Indicated preventive interventions EPDS threshold score at 6 weeks postnatally odds ratios alltreatment comparisons

Promoting parentndashinfant interaction and education on preparing for parenting reduced the odds of highEPDS scores compared with usual care although the effect was statistically significant only for promotingparentndashinfant interaction at a conventional 5 level (see Figure 39)

Promoting parentndashinfant interaction had the highest probability of being the best (probability 084)(see Figure 40)

Results from network meta-analysis for indicated preventive intervention forEdinburgh Postnatal Depression Scale threshold scores at 3 monthspostnatallyA NMA was used to compare the effects of peer support and education on preparing for parentingrelative to usual care on EPDS threshold Data were available from two studies comparing threeinterventions197207 Figure 41 presents the network of evidence There were two intervention effects toestimate from three studies

oting p

t ndash infa

nt inte

tion o

g for p

FIGURE 40 Indicated preventive interventions EPDS threshold score at 6 weeks postnatally probability oftreatment rankings (ranks 1ndash5)

Dennis 2009 205

Stamp 1995 195

Usual care

Peer support

FIGURE 41 Indicated preventive interventions EPDS threshold score at 3 months postnatally network of evidence

Both peer support and education on preparing for parenting have reduced odds of high EPDS scorescompared with usual care However the effects were not statistically significant at a conventional 5 level(see Figure 42) Peer support has the highest probability of being the best (probability 069) (see Figure 43)

005 018 063 225 800

Peer support

047 (021 to 103)

067 (018 to 237)

144 (033 to 637)

vs peer support

vs usual care

FIGURE 42 Indicated preventive interventions EPDS threshold score at 3 months postnatally odds ratios alltreatment comparisons

support

tion o

g for p

FIGURE 43 Indicated preventive interventions EPDS threshold score at 3 months postnatally probability oftreatment rankings

Results from network meta-analysis for indicated preventive intervention forEdinburgh Postnatal Depression Scale threshold scores at 4 monthspostnatallyA NMA was used to compare the effects of booklets on PND and promoting parentndashinfant interactionrelative to usual care on EPDS threshold Data were available from two studies comparing threeinterventions166198 Figure 44 presents the network of evidence There were two intervention effects toestimate from two studies

Figure 45 presents the odds ratios of each intervention relative to usual care and Figure 46 presents theprobabilities of treatment rankings The total residual deviance was 397 compared with the totalnumber of data points four included in the analysis This implies a good fit of the model to the dataThe between-study SD was estimated to be 022 (95 CrI 001 to 070) which implies mild heterogeneityof intervention effects between studies

Armstrong 1999 164

Webster 2003 196

Usual care

Booklet on PND

005 018 063 225 800

Booklet on PND

067 (024 to 174)

079 (036 to 170)

120 (034 to 418)

vs usual care

The odds ratio for both promoting parentndashinfant interaction and booklet on PND was less than 1suggesting a beneficial effect compared with usual care although the results were not statisticallysignificant at a conventional 5 level (see Figure 45) Promoting parentndashinfant interaction has the highestprobability of being the best (probability 060) (see Figure 46)

Results from network meta-analysis for indicated preventive intervention forEdinburgh Postnatal Depression Scale threshold scores at 6 monthspostnatallyA NMA was used to compare the effects of CBT-based intervention PCA-based intervention andeducation on preparing for parenting relative to usual care on EPDS threshold Data were available fromtwo studies comparing four interventions61197 Figure 47 presents the network of evidence There werethree intervention effects to estimate from two studies

oting p

t ndash infa

nt inte

Booklet o

FIGURE 46 Indicated preventive interventions EPDS threshold score at 4 months postnatally probability oftreatment rankings (ranks 1ndash3)

Stamp 1995 195

Morrell 2009 61

Usual care

Figure 48 presents the odds ratios of each intervention relative to usual care and Figure 49 presents theprobabilities of treatment rankings The total residual deviance was 412 compared with four data pointsincluded in the analysis This implies a good fit of the model to the data The between-study SD wasestimated to be 022 (95 CrI 001 to 073) which implies mild heterogeneity of intervention effectsbetween studies

005 018 063 225 800

059 (026 to 138)

065 (028 to 157)

170 (048 to 717)

110 (047 to 257)

287 (065 to 1528)

263 (057 to 1443)

vs usual care

CBT-bas

tion o

g for p

The CBT- and PCA-based interventions had reduced odds of high EPDS scores compared with usual careEducation on preparing for parenting had an increased odds of a high EPDS score at 6 months comparedwith usual care However none of the odds ratios were statistically significant at a conventional 5 level(see Figure 48) The CBT-based intervention has the highest probability of being the best (probability 056)(see Figure 49)

Summary of results from network meta-analysis for indicated preventiveintervention for Edinburgh Postnatal Depression Scale threshold scoresIn general the intervention effects were inconclusive although promoting parentndashinfant interaction wasassociated with a statistically significant benefit at 6 weeks Intervention effects tended to vary over timewith the most beneficial treatments being promoting parentndashinfant interaction at 6 weeks peer supportat 3 months promoting parentndashinfant interaction at 4 months and CBT- and PCA-based interventionsat 6 months

Results from network meta-analysis for indicated preventiveintervention for Edinburgh Postnatal Depression Scalemean scores

A NMA was used to compare the effects CBT-based intervention educational information IPT-basedintervention midwifery continuous care peer support PCA-based intervention and promotingparentndashinfant interaction relative to usual care on EPDS mean scores Data were available from 10 studiescomparing eight interventions61166167170ndash172175176207226 There were seven intervention effects to estimate(relative to usual care) from 10 studies Figure 50 presents the network of evidence

Armstrong 1999 164

Austin 2008 165

Dennis 2009 205

Ginsburg 2012 168

Gorman 1997 169

Grote 2009 170

Marks 2003 224

Munoz 2007 173

Petrou 2006 174

Morrell 2009 61

Usual care

Peer support

IPT based

Midwifery continuous care

FIGURE 50 Indicated preventive interventions for EPDS mean scores network of evidence Dashed lines representthree-arm trials

Figure 51 presents the differences in EPDS mean scores of each intervention relative to usual careThe between-study SD was estimated to be 195 (95 CrI 069 to 355) which implies moderateheterogeneity of intervention effects between studies However there is considerable uncertainty aboutthe between-study SD because of the relatively small number of studies that provided data relative to thenumber of intervention effects being estimated The interventions associated with the greatest reduction inEPDS mean score were IPT-based intervention (ndash425 95 CrI ndash787 to 043 at 6ndash7 months) CBT-basedintervention (ndash218 95 CrI ndash539 to 115 at 12 months) and PCA-based intervention (ndash205 95 CrIndash590 to 212 at 12 months) None of the comparisons with usual care were statistically significant at aconventional 5 level Figures 52ndash55 present the probabilities of treatment rankings at 6ndash8 weeks3ndash4 months 6ndash7 months and 12 months respectively

The interventions with the highest probabilities of being the best at 6ndash8 weeks were the IPT-basedintervention and promoting parentndashinfant interaction (probability 060 and 032 respectively)

The interventions with the highest probabilities of being the best at 3ndash4 months were educationalinformation (probability 024) CBT-based intervention (probability 021) promoting parentndashinfantinteraction (probability 020) and peer support (probability 020)

The intervention with the highest probability of being the best at 6ndash7 months was IPT-based intervention(probability 077)

The interventions with the highest probabilities of being the best at 12 months were CBT- and PCA-basedinterventions (probability 043 and 041 respectively)

ndash 500 ndash 250 000 250 500

3 ndash 4 months

3 ndash 4 months6 ndash 7 months12 months

6 ndash 7 months

6 ndash 8 weeks3 ndash 4 months6 ndash 7 months12 months

ndash 138 (ndash 607 to 387)ndash 034 (ndash 306 to 301)ndash 218 (ndash 539 to 115)

ndash 112 (ndash 435 to 193)ndash 086 (ndash 527 to 364) 014 (ndash 427 to 447)ndash 012 (ndash 433 to 424)

Peer support

FIGURE 51 Indicated preventive interventions EPDS mean scores mean differences of treatment comparisons vsusual care across all time points

CBT-bas

oting p

tndashin

fant i

tional

FIGURE 52 Indicated preventive interventions EPDS mean scores probability of treatment rankings at 6ndash8 weekspostnatally (ranks 1ndash5)

wifery

contin

uous car

CBT-bas

oting p

tndashin

fant i

support

tional

FIGURE 53 Indicated preventive interventions EPDS mean scores probability of treatment rankings at 3ndash4 monthspostnatally (ranks 1ndash6)

Summary of results from network meta-analysis for indicated preventiveintervention for Edinburgh Postnatal Depression Scale mean scoresNot all interventions provided information about intervention effects at each time making inferencesacross all treatments at each time difficult In general the intervention effects were inconclusive and theCrIs were wide The most beneficial treatments appeared to be IPT-based intervention educationalinformation CBT-based intervention and PCA-based intervention A summary of the results for thethreshold and the EPDS mean scores is presented in Table 46

The qualitative evidence suggested that the social support intervention adequately provided emotional andinformational support to women Women reported that they felt able to rely on a perinatal and infantmental health service if they needed to access them urgently and appreciated the support of the healthprofessionals delivering the service However barriers to accessing the service included a feeling ofintimidation around being referred to such a service stigma and concerns about being discharged beforethey felt ready

CBT-bas

oting p

tndashin

fant i

FIGURE 55 Indicated preventive interventions EPDS mean scores probability of treatment rankings at 12 months(ranks 1ndash4)

CBT-bas

oting p

tndashin

fant i

support

tional

TABLE 46 Indicated preventive interventions NMAs overall summary of main effects of interventions relative tousual care

Time postnatally

Overall riskof bias

Probability ofbeing the besta

Odds ratio(95 CrI)

6 weeks postnatally

Promotingparentndashinfantinteraction164

ndash112 (ndash435 to 193) 060b 021 (006 to 063) 084c Low

CBT-basedintervention173

ndash138 (ndash607 to 387) 021d NE NE Unclear

Educationalinformation168

Peer support205 ndash093 (ndash511 to 332) 020d 047 (021 to 103) 069c Low

Education onpreparing forparenting195

NE NE 067 (018 to 237) 030c Low

ndash086 (ndash527 to 364) 020d NE NE Low

NE NE 067 (024 to 174) 060c Low

IPT-basedintervention169170

ndash425 (ndash787 to 043) 077e NE NE Unclear

PCA-basedintervention61

ndash121 (ndash501 to 293) 010e 065 (028 to 157) 037f Low

ndash205 (ndash590 to 212) 041f NE NE Low

ndash218 (ndash539 to 115) 043f NE NE Lowunclearg

Key high high risk of bias low low risk of bias NE not evaluable unclear unclear risk of biasa Probability of being the best among interventions with evaluable data at each assessmentb Best among two interventionsc Best among three interventionsd Best among six interventionse Best among seven interventionsf Best among four interventionsg Where there were two studies the risk of bias is indicated in the order in which the studies are citedFor difference in mean lt ndash075 or odds ratio lt 070 Not evaluable data were data not available on this outcome measurefor this intervention

Chapter 8 Results of realist synthesis what worksfor whom

Introduction to Best Fit Realist Synthesis

Having characterised the principal seven classes of intervention and having identified focal interventionsfrom among the group- and individual-based approaches the team sought to examine the main servicemodels for prevention of PND in relation to the underlying programme theory and mechanisms

Results of the review

The lsquoBest Fit Realist Reviewrsquo engaged with 96 studies relating to 13 separate interventionprogrammes7842ndash4461146148151152154160163164166170178179184190205206208219221222224236251252262264277ndash340

CenteringPregnancy was the most represented in the literature (with 22 studies)61146148151154164170179190205208219221251252262264327335ndash338 Next came telephone peer support and IPT plus telephone (nine studies each)followed by midwifery redesigned postnatal care (eight) Then followed IPT-brief (seven) midwife-managedcare (seven) midwife-led brief counselling (six) the Newpin Project (six) Health Visitor PoNDER Training(six) Thinking Healthy Programme (five) and the two-step behavioural educational intervention (five)Finally home-based intervention and IPT plus Reach Out Stand strong Essentials for new mothers (ROSE)were both covered by three studies

Eleven trials were from the effectiveness review 25 of the studies represented the views of womenreceiving an intervention and five represented the views of service providers One study collected the viewsof both women and service providers Two represented a cost study or economic evaluation One studycollected measures of womenrsquos satisfaction and costs339 Eleven studies were either reviews or evidencesyntheses The remaining 40 studies were study reports but were not RCTs qualitative studies or economicevaluations Eight of the qualitative studies were already included in the qualitative synthesis ofintervention studies (See Appendix 9)

The realist review began by engaging with the spreadsheet-based matrices of intervention classes andtheir relative effectiveness and with the qualitative synthesis of intervention study findings The dearth ofqualitative intervention studies further required that the realist synthesis engage with wider qualitative datafrom beyond the group of intervention studies These studies are characterised from here onwards as PSSSstudies Such studies identify strategies used by women who had not experienced PND that they believehelped to prevent the condition Although such data must be treated with caution given that they reflectwomenrsquos anticipation of a hypothetical situation the team believed that this perspective would providea counterpoint to interventions in which content and delivery had been primarily devised by healthprofessionals The PSSS studies allow comparison between what women feel is helpful and what is actuallybeing delivered by the interventions themselves

Description of included personal and social support strategy studiesIn total 23 studies (n= 29 citations) were identified reporting qualitative data on the perspectives andattitudes of women who had not experienced PND regarding PSSSs that they believe helped to prevent thecondition (see Appendix 9 Personal and social support strategy studies population characteristics)

Study respondents in the personal and social support strategy studiesThe number of participants contributing qualitative evidence across all studies where reported wassummed and totalled 801 (one study7 did not provide the number of participants who contributed to thequalitative findings) Fifteen studies provided data from participants from a general population in thecountry of study7286302303305312313316ndash325 while the remaining studies examined evidence from minoritygroups within the country of study The minority groups were either a culturally different group basedwithin the country of study (n= 6)292306ndash311314315318 or a selective group (n= 2)296ndash298304 For details ofparticipant characteristics see Appendix 9

Study setting of the personal and social support strategy studiesTen studies were conducted in the UK304306ndash315319321322324 seven studies were conducted in theUSA286292296ndash298302303318320 one in Switzerland316 one in Canada317 one in Norway323 one in India325

one in China305 and one in multiple centres7

Synthesis of findings across personal and social support strategystudies

Several themes relating to the PSSSs which helped women prevent PND were identified across theincluded studies Included studies focused on either general population women minority groups whichwere culturally different from the general population of the country of study or in a small number ofcases selective groups (low-socioeconomic status or vulnerable groups) Two studies305325 focused on thegeneral population of the country of study but highlighted findings related to particular cultural practices

Based on an actual or promising assessment of effectiveness the review team specified thirteeninterventions requiring further in-depth analysis These 13 interventions became the focus for subsequentinvestigation of study clusters (Table 47)

TABLE 47 Thirteen focal interventions for exploration by realist review principles

Intervention category Initiative Target population Setting

Psychological Health Visitor PoNDER Training Universal and indicated UK

Psychological Home-based intervention Indicated Australia

Psychological IPT plus telephone follow-up Universal China

Psychological IPT standard antenatal careplus the ROSE programme

Indicated USA

Psychological IPT ndash Brief Indicated USA

Educational Two-step behaviouraleducational intervention

Selective USA

Social Support Telephone peer support Indicated Canada

Social Support The Newpin Project Indicated UK

Social Support Thinking Healthy Programme Indicated Pakistan and developing world

Midwifery-led interventions CenteringPregnancy Selective USA and Australia

Midwifery-led interventions Midwife-led brief counselling Selective Australia

Midwifery-led interventions Midwife-managed care332 Universal UK

Midwifery-led interventions Midwifery redesignedpostnatal care

Universal UK

RESULTS OF REALIST SYNTHESIS WHAT WORKS FOR WHOM

Examination of the RCTs in conjunction with searches for qualitative research revealed 22 published trialreports associated with the 13 interventions (see Table 48) These reports became the lsquoindex papersrsquo forour study clusters

Searching for CLUSTER documents for realist synthesis

Google Scholar citation searches (lsquoforward chainingrsquo) were conducted for each of the 22 published studyreports141 A total of 1888 citations were identified (including duplicates) The mean number of citationswas 86 (range 0ndash232) Lists of results for articles citing an index paper were examined carefully for sharedauthorship a common study identifier or for other common study-level denominators (eg setting orinstitution) When a directly connected (lsquosiblingrsquo) report was identified this was used to populate synthesisof the findings from PSSS studies Appendix 7

In addition when a similar intervention study (eg differing in setting population etc) was identifiedthis was recorded as a kinship study Finally systematic reviews narrative reviews and qualitative evidencesyntheses on the topic were also identified The reference lists of all 22 original published reports(Table 48) as well as the reference lists of all lsquosiblingrsquo studies were scrutinised (lsquobackward chainingrsquo) forearlier sibling studies (eg protocols pilot studies feasibility studies etc) or related lsquokinship studiesrsquo(eg studies sharing a common intervention or underpinning theory)

Preliminary synthesis and construction of a theoretical model

A formative stage of the synthesis required becoming familiar with the focal interventions to sensitise tothe study data and to broadly characterise the different programmes against their defining dimensionsTable 49 attempts to locate the included programmes against the following dimensions

l whether the programme is delivered at an individual or group level or it has elements of both (lsquomixedapproachrsquo) or whether it is not directly targeting the women but reaching them indirectly throughhealth professional training

l whether the programme is delivered face to face whether it is delivered remotely or whether it usesboth methods (lsquohybrid deliveryrsquo)

l whether the programme is delivered by health professionals or by lay support or it is delivered by both(lsquojoint deliveryrsquo)

This formative analysis helped in looking for similarities and differences across programmes for examplein characterising the different mechanisms by which lay support might work compared with delivery byhealth professionals

Although specific components of one-to-one or group types of approach are determined by the reviews ofeffectiveness and acceptability these two types of approach are underpinned by discernibly differentassumptions Consequently the mechanisms by which such approaches might operate also carry importantdifferences These are best illustrated by placing the two types of approach in juxtaposition Howeverinterventions may blend both approaches For example CenteringPregnancy an essentially group-basedapproach offers the opportunity for individual consultation with health professionals IPT is initiallyconducted in a group environment but is followed up by one-to-one telephone contact (Table 50)

Subsequent synthesis involved detailed itemisation of programme components from each cluster of relatedstudy reports use of multiple reports was essential as not all study reports provided a full description of theintervention The descriptions of the interventions often lacked sufficient detail to allow replication beyondthe original programme341 The innovative template for intervention description and replication (TIDieR)framework was used as a template for elicitation of relevant programme components342 Appendix 16 containsthe TIDieR templates for all thirteen focal interventions with as complete details as cluster reporting allowed

TABLE 48 Results for citation searches of index papers for realist synthesis

Study report (first author year reference number) Number of Google Scholar citations

Psychological

Health Visitor PoNDER Training

1 Morrell 200961 44

2 Morrell 2009151 105

Home-based intervention

3 Armstrong 1999164 169

4 Armstrong 2000251 97

5 Fraser 2000252 93

IPT standard antenatal care plus the ROSE programme

6 Zlotnick 2006179 117

IPT plus telephone follow-up

7 Gao 2010154 15

8 Gao 2012327 10

IPT-brief

9 Grote 2009170 75

Educational

Two-step behavioural educational intervention

10 Howell 2012190 9

11 Howell 2014335 1

12 Martin 2013336 0

Social support

Telephone peer support

13 Dennis 2009205 102

The Newpin Project

14 Harris 2008206 0

Thinking Healthy Programme

15 Rahman 2008148 209

Midwifery-led interventions

CenteringPregnancy

16 Ickovics 2007262 199

Midwife-led brief counselling

17 Gamble 2005221 105

18 Shields 1997219 37

19 Shields 1998337 43

20 Turnbull 1996338 232

21 MacArthur 2002146 168

22 MacArthur 2003264 58

Total references 1888

Identification of provisional lsquobest fitrsquo conceptual framework forrealist synthesisSearches of Google Scholar identified two outputs from a single Veteran Affairs project on group-basedapproaches343344 In line with the lsquobest fit frameworkrsquo345346 these study reports were sufficiently generic tobe used as a source of an lsquoanalytical frameworkrsquo (Figure 56) for examining group care approaches duringthe perinatal period

Population of the conceptual frameworkElements of the analytical conceptual framework (see Figure 56) were deconstituted into fields on a dataextraction form Two fields were modified a priori in recognition of the topic mortality (re-interpreted assuicide ideation) and biophysical markers (re-interpreted as physical signs and symptoms) The Best FitFramework approach provides for inclusion of additional inductive elements once the deductive stage ofthe synthesis is completed

Identification of existing theory underpinning specific mechanismsFive main bodies of theory seemed to underpin the specific mechanisms of featured interventions

l social cognitivelearning theory and self-efficacyl social supportsocial exchange theory (eg Brugha et al152)l locus of control (eg Brugha et al152)l empowerment (eg CenteringPregnancy)l attachment theory (eg home-based intervention and IPT interventions)

TABLE 49 Dimensions of the featured interventions how it is delivered

Dimension Individual Mixed approach Group Training

Face to face Midwife-managed caremidwifery redesignedpostnatal care

IPT standard antenatalcare plus ROSEprogramme

CenteringPregnancyThinking Healthy Programme

Health VisitorPoNDER Training

Hybrid delivery Midwife-led briefcounselling plustelephone postpartumthe Newpin Projecttwo-step behaviouraleducational intervention

ndash IPT plus telephone follow-up ndash

Remote Telephone peer support ndash ndash ndash

TABLE 50 Dimensions of the featured interventions who is involved

Healthcareprofessional

Midwife-managed caremidwifery redesignedpostnatal caremidwife-led briefcounselling plustelephone postpartumtwo-step behaviouraleducational intervention

IPT standard antenatalcare plus the ROSEprogramme

IPT plus telephone follow-up Health VisitorPoNDER Training

Joint delivery ndash ndash CenteringPregnancy ndash

Lay support The Newpin Projecttelephone peer support

ndash Thinking Healthy Programme ndash

bull T2

bull H

TNbull

bull C

esbull

bull Fu

bull M

bull Le

rsbull

bull D

tsbull

bull Te

bull O

esbull

bull B

bull Se

cybull

bull In

bull O

esbull

bull M

bull Pa

bull B

bull So

bull H

FIGURE56

Analytical

aluategroupvisitsRep

roducedwithpermissionfrom

Quinones

etal343Notea

Includes

derraceethnicity

educationhea

literacy

ruralitygeo

graphy

chronic

conditionsmorbidityan

dother

patientdem

ographicsNotesocioeconomic

influen

cessuch

asfinan

strain

(egprice

ofgas)directly

affect

patientpopulationKey

CHFCADco

ngestive

rtfailu

recoronaryartery

obstructivepulm

onarydisea

ertensionKQk

eyquestion

mergen

DMtype2diabetes

mellitus

The theories underpinning the mechanisms for each study are provided in Table 51 Table 52 indicatesthe theories relevant for the prevention of PND Table 53 indicates the mechanism of application of thetheories according to the approach used for example one-to-one or group approach

TABLE 51 Specific theories underpinning mechanisms

Initiative Implicitexplicit presence of theory

CenteringPregnancy CenteringPregnancy was developed and piloted by a certified nurse-midwifeafter experience with successful family-centred approaches to prenatal careand in recognition of repetitiousness [sic] of one-on-one prenatal care forproviders Uses a model of empowerment

Health Visitor PoNDER training Health visitors were trained to deliver psychologically informed sessionsbased on distinct psychological theories either cognitivendashbehaviouralprinciples347 or person-centred principles348

Home-based intervention Attachment theory349 states that parentsrsquo bonding with their own childrenand treatment of them is affected by their own earlier attachment historyand internal working models Attachment theory emphasises theimportance of consistency in relationships and sensitive understandingof reactions to separation loss and rejection The theory of resilience350

recognises personal resilience factors (eg positive orientation toproblem-solving) and environmental factors (eg the help of a supportiveadult)351352 Although some factors are relatively fixed others can bemodified such as access to support By exploring individual and familystrengths positive experiences and resources are built upon and enhanced

IPT standard antenatal care plus ROSEprogramme IPT plus telephone follow-upIPT-brief

IPT353 is grounded in interpersonal theories354 and attachment theories355

It is based on the hypothesis that clients who experience social disruptionare at increased risk of depression IPT specifically targets interpersonalrelationships and is designed to assist clients in modifying either theirrelationships or their expectations about relationships IPT could help newmothers in

l role transitions in which clients have to adapt to a change in lifecircumstances IPT aims to help to re-appraise the old and new roleto identify sources of difficulty in the new role and fashion solutions forthese roles

l interpersonal disputes these occur in marital family social or worksettings Clients may have diverging expectations of a situation and thisconflict is excessive enough to lead to significant distress IPT aims toidentify sources of dispute faulty communication or unreasonableexpectations It intervenes by communication training problem-solvingor other techniques that aim to facilitate change in the situation

l interpersonal deficits in which clients report impoverished interpersonalrelationships in terms of both number and quality of the relationshipsIPT aims to identify problematic processes such as dependency orhostility and aims to modify these processes

Midwife-led brief counselling The intervention was based on two theoretical perspectives relating toviolence and maternal distress356357 focus group discussions withchildbearing women and midwives and reviews of the literature

Midwife-managed care The predominant model of shared care ndash divided among midwives hospitaldoctors and GPs (family physicians) ndash has been called into question Thisinitiative was designed to address the hypothesis that midwife-managedcare would result in fewer interventions similar (or more favourable)outcomes similar complications plus greater satisfaction with care andenhanced continuity of care and carer

continued

TABLE 51 Specific theories underpinning mechanisms (continued )

The Newpin Project340 A lifespan model of psychosocial origins of depression in women358

pinpoints the role of stressful life eventsdifficulties (often involvinghumiliating losses) in bringing on depressionfresh-start events (promisinghope of a new beginning) in promoting remission

Midwifery redesigned postnatal care No explicit theory The intervention was based on UK government reportsstating that there was a need for wide-ranging changes to maternityservices emphasising poor assessment and frequently inappropriate deliveryof postnatal care A service led by midwives with continuity of care andinvolvement of women which is supportive and sensitive to individualneeds and preferences is at the centre of the maternity carerecommendations

Telephone peer support The intervention was based on research related to maternal dissatisfactionwith peer support Lazarus and Folkman (1984)359 theorised that copingincorporates problem-resolution and emotion-regulation while employingaffective cognitive and behavioural response systems Bandura (1977)360

and Bandura (1986)361 social cognitive theory peer support influences healthoutcomes by (1) decreasing isolation and feelings of loneliness (2) swayinghealth practices and deterring maladaptive behaviours or responses(3) promoting positive psychological states and individual motivation(4) providing information regarding access to medical services or thebenefits of behaviours that positively influence health and well-beingand (5) preventing risk for progression of and promoting recovery fromphysical illness

Thinking Healthy Programme Holistic approach designed to counter lsquodefunct theory of ldquomindndashbodyrdquodualismrsquo

Two-step behavioural educationalintervention

Prior research suggests that postpartum physical symptoms overload fromdaily demands and poor social support play a major role in generation ofdepressive symptoms

TABLE 52 Programme theories for preventing PND

Programmetheory Label

Programme theory ndash PND willbe prevented if Relevant theory Elements

By activity

PT1 Developing trust Women develop meaningfulrelationships with other womenin the group and withhealth-care providers285363

Social cognitivetheory

Group interaction

PT1 Asking for help Women are made aware that itis legitimate to ask for help364

and can identify whom to ask365

Social norms Modelling withingroup

PT2 Learning by doing Women acquire practical366 andcommunication skills367 thatequip them for their new roles366

Social learning theorylocus of controlself-efficacy

Practical sessionsdemonstrationsrole play

PT3 Feeling supported Women feel supported by theirpartner health professionalspeer supporters or groupmembers to help them feelcomfortable reduce their anxietyand help them cope withchallenges283285364368

Social support Group sessionstelephoneindividual sessions

PT4 Accessing information Women are able to accessinformation not before or afterbut when they need it369

Social learning theorylocus of control

Group or individualinformation sessions

PT5 Sharing information Women are able to harvestresources to support coping184

from their health-care provider370

or from other group members

Social exchangetheory

Group orinformation sessions

Symbolic

PT6 Feeling normal Women come to realise thattheir experience is notuncommon and that otherwomen come through it364369

Social norms Group sessionsor individualinteraction withpeer or professional

PT7 Dispelling the myth ofthe ideal motherbirthbaby

Women come to realise that thenarratives of the idealmother316371 birth372 and babyare social constructions

PT8 Making time for self Women discover that it islegitimate to make time forthemselves320371 within ababy-centric situation373

PT programme theory

TABLE 53 Mechanisms and underpinning theory for generic group and one-to-one approaches

Mechanism

Underpinningtheory (whenidentified) Group approaches One-to-one approaches

Appraisal support(functionalsupport)

Social exchangetheory374375

Positive even where facilitatorappears unsupportive other groupmembers may compensate

Positive individuals may developrapport and trust with theirnominated contact

Negative individuals may feelinhibited within a group setting

Negative individuals may perceivenominated contact as judgementalor unsympathetic

Emotional support(functionalsupport)

Positive individuals may developrapport and trust with and feelable to confide in their nominatedcontact

Negative individuals may not beappropriately matched withnominated contact

Informationalsupport (functionalsupport)

Positive facilitator may validateinformation quality on behalf of thegroup

Positive health professionalpeersupporter may validate informationquality and provide tailoredinformation

Positive other group members mayask a question of relevance to amore reticent member

Positive individuals may feelcomfortable in asking sensitivequestions

Positive reticent individuals maygrow in confidence to askquestions

Negative health professionalpeersupporter may provideinappropriate unhelpful or factuallyincorrect information

Negative group members mayprovide unfiltered informationleading to incorrect decision orincomplete picture

Negative individuals may leavepersonalised concerns unexpressed

Negative individualspartners mayfeel uncomfortable in askingsensitive questions

Instrumentalsupport (functionalsupport)

Positive women may share ideasfor sources of practical aid

Positive facilitator may share ideasfor sources of practical aid

Negative individual women mayexperience increased frustration ifsources are not forthcoming

Negative facilitator may not havefull understanding of practicalrealities

Support-seekingstrategies

Attachmenttheory355

Positive group members accesswidest range of suggestedstrategies

Positive health professionalpeersupporter may be able to tailorsuggested strategies

Negative others in group may havea limited repertoire of strategies toshare

Negative health professionalpeersupporter may have limitedrepertoire of strategies to share

Interpersonalrelationships

Interpersonaltheory354

Positive other group members mayact as buffer or sounding board forrelationship difficulties

Positive health professionalpeersupporter may become confidantfor relationship difficulties

Negative group may have limitedtime to address specific individualrelationship difficulties

Negative individual may feelinhibited from sharing relationshipdifficulties with health professionalpeer supporter

Negative individuals may feelinhibited from sharing relationshipdifficulties with others

TABLE 53 Mechanisms and underpinning theory for generic group and one-to-one approaches (continued )

Mechanism

Normalisation Normalisingthroughconnectiontheory376

Positive other group members mayaffirm validity of individualrsquos feelingor experience

Positive health professionalpeersupporter may validate individualrsquosfeeling or experience based onprevious caseload or professionalknowledge

Positive facilitator may validateindividualrsquos feeling or experiencebased on previous caseload orprofessional knowledge

Negative health professionalpeersupporter may communicatefrequently experiencedphenomenon as routine andappear to minimise individualrsquospersonalised experience

Negative others in group may nothave experienced same feeling orevent Individual may feel strangeor isolated

Negative health professionalpeersupporter may perpetuateunrealistic expectations

Negative others in group mayperpetuate or amplify unrealisticexpectations

Coping Coping theory359 Positive individual is exposed todifferent models of coping and canselect resources appropriately

Positive health professionalpeersupporter may identify mostappropriate coping resources tomatch to individual

Negative individual may comparethemselves unfavourably to othergroup members

Negative health professionalpeersupporter may privilege their ownpreferred strategies

Self-efficacy Self-efficacytheory377

Positive group members may helpto normalise rationalisations fortheir symptoms

Positive care provider may help tonormalise rationalisations for theirsymptoms

Negative group members mayaffirm belief that PND isunpreventableuntreatable

Negative care provider may affirmbelief that PND is unpreventableuntreatable

Continuity of care Not identified Positive group facilitation andmembership may be relativelystable

Positive individual receivescoherent and cohesive care from asole provider

Negative group facilitation andmembership may be inconsistent

Negative individual may becomeoverly dependent upon soleprovider

Modellingbehaviours

Social learningtheory360

Positive other group members maybe appropriate and realistic rolemodels

Positive individuals may rehearseappropriate behaviours in a safeenvironment

Negative group may promoteunhelpful norms thatcounterbalance positive behaviours

Negative individual may notperceive health professionalpeersupporter as appropriate or realisticrole model

Preparing forparenting

Not identified Positive facilitator and other groupmembers may contribute to realisticexpectations

Positive health professionalpeersupporter may help to activelymanage expectations

continued

The social cognitive theory of depression proposes that lsquowomen for whom motherhood is a highly valuedrole may be particularly vulnerable to depression if events or difficulties threaten this rolersquo378 Interventionsthat address this theory therefore seek to equip the woman with self-efficacy so that she is better able tomanage such events or difficulties or has multiple strategies by which she might attempt to address themIncreased self-efficacy may be seen in the management of her own symptoms or more generally in beingable to cope with the practical aspects of motherhood that might otherwise be viewed as difficult orproblematic A further aspect to this theory is the modification of the womanrsquos understanding of themotherhood role so that she is less likely to fall victim to unrealistic expectations of either herself orof others

The social support theory of depression is underpinned by social exchange theory Social support has beenfound to facilitate the adaptation to and transition to motherhood and facilitates the flow of emotionalconcern instrumental aid information and appraisal between people including partners and mothersInterventions that address this theory therefore seek to reduce the psychological stress of the transition tomotherhood379 Strategies include the building up of social support networks prior to the birth and beingbetter able to mobilise such support when needed Group-based interventions may serve to extend socialsupport again in preparation for the birth or as a resource to be accessed after childbirth Social exchangetheory requires a structure through which an interactive process might occur and preventive strategies mayhelp in both the identification of and mobilisation of such structures for interaction378

The idea of the locus of control that is lsquowhether a person perceives what happens to her as being withinher own control or in the hands of external forcesrsquo380 is believed to be an important aspect ofpsychological functioning Clearly this is closely linked with self-efficacy as discussed above Howeversome commentators caution380 that in a childbirth context this may not necessarily translate into greaterinvolvement in decision-making as for some women such involvement may actually increase feelings ofanxiety Interventions that engage with the idea of locus of control provide a woman with an opportunityto discuss all aspects of the motherhood experience fully with staff The woman receives the right amountof information that they personally require Receiving the right amount of information both lsquopreloadedrsquo(ie prior to the birth) and subsequently lsquoon demandrsquo reduces their anxiety about aspects of themotherhood experience and increases their satisfaction with aspects of the birth experience Againthe mechanism of modifying expectations to make them more realistic is present in such interventions

Mechanism

Negative facilitator and othergroup members may focus onlabour rather than parenthood

Negative health professionalpeersupporter may base advice solelyon their own experience

Negative health professionalpeersupporter may focus on labourrather than parenthood

Targetingdepressivesymptoms

Vulnerability-stress theory358

Positive even though not everyindividual experiences everysymptom there is an increasedlikelihood that at least one memberexperiences a symptom

Positive health professionalpeersupporter may be able to tailorsupportadvice to specific needs ofindividual

Targeting anxietysymptoms

Positive not every individualexperiences every symptom butthere is an increased likelihood thatat least one member experiences asymptom

The empowerment model of prevention of depression is based on the assumption that women are likelyto experience negative partner support and therefore need information and coping resources by which tohandle this Interventions that address this theory therefore seek to provide information to help womento identify particular strategies that may be helpful to them Community resources are identified fromwhich women may draw as appropriate Empowerment approaches often allow an individualised focus foran intervention so that support can focus on areas of particular need for each woman

The attachment theory of depression proposes that postpartum depression develops when a motherrsquosattachment needs are not being satisfied by her partner whom she feels is irresponsive or inaccessible toher381 Although attachment theory originally focused on the importance developing a strong emotionalbond between an infant and their mother more recently this has been extended to include adultrelationships such as the partner and the mother or mother-in-law Attachment provides a useful resourceduring times of uncertainty such as characterise the anxiety-filled birth and postnatal periods Attachmenttheory attempts to explain why some women seek to be close to their partner or significant othersbut fear being rejected by them and why others seek to avoid closeness Interventions that address theattachment theory seek to develop attachment typically with the partner so that social support may bereadily accessed as and when required They seek to develop mechanisms by which need for support maybe communicated and recognised

This discussion demonstrates that these theories are not distinct but frequently operate in close proximityCollectively they explain many intervention components for individual-based and group-centredapproaches Other interventions derive their imperative not from an explicit theoretical basis but frompolitical or social drivers such as the agendas of the UK government264 or of the World HealthOrganization148 For a fuller discussion of principal theories underpinning strategies for treatment and byimplication prevention see the useful summary by Beck381

Development of a programme theory

A key issue in developing a programme theory with regard to two different modes of delivery that isgroup-based (one-to-many) and individual-based (one-to-one) approaches relates to whether they offercompeting alternatives to meet the same needs or they seek to address different sets of needs The tables ofcomponents (see Appendix 7) assist in identification of important mechanisms that are common to bothapproaches those that can substitute for each other or those that are unique to one of the two approaches

Group-based interventionsIn the case of the group under a lsquoresource-based modelrsquo (ie the idea that a group is identifyingsharing and subsequently using its collective emotional and experiential resources) members of a groupmay provide aspects of information experience or support beyond the resources of a singlefacilitator302312313321 However this relies on the existence of mechanisms for releasing the resources foruse by the whole group There is evidence of facilitators being aware of resources or experience within agroup that the individuals themselves felt unable or unwilling to share293 Consequently the facilitators feltpowerless to offer such experiences without the approval of the individual themselves Use of group-basedmechanisms places additional requirements for group coherence382 the development of trust with a largernumber of individuals and the existence of ground rules that minimise the chance of harmfulgroup behaviours

Continuity of careContinuity of care may be present through the ongoing participation of one or more group co-ordinatorsThe CenteringPregnancy programme identifies lsquostability of group leadershiprsquo as an lsquoessential elementrsquo ofthe approach383 Continuity is also sought within team midwifery-based support approaches224 but thatdoes not necessarily translate into the personalised and tailored care required for the building ofconfidence trust and satisfaction with care If a facilitator does not function well with or relate well

personally to several or indeed all of the group then this may potentially cause more harm than aproblematic one-to-one approach However this may be partially compensated for through a form ofsubstitution by good relationships within the group

Individual-centred interventionsWith regard to individual interventions it is perhaps unhelpful to focus on the lsquoindividualrsquo part as theintervention (in contrast to the acknowledged effect of the lsquogrouprsquo) The individual approach offerspotential benefits that may or may not be realised For example under a resource-based model aparticular supporter whether professional or lay may not have experience to draw upon and mobilise forthe benefit of the individual Continuity of care a claimed advantage of individual-based interventionsmay not be realised if staff changes or team processes interfere with this This may explain why Denniset al384 found a non-significant effect for continuity of care in their systematic review There may not bea rapport between supporter and woman If an individual relationship is not built up then trust andrelationships are impaired Other benefits such as sharing of confidential personalised information arenot realised Dennis et al384 refer to this in the specific context of revealing PND to a health professionalHowever this may be equally important in prevention when seeking to broach the subject of potentialsymptoms or causative factors385 It is helpful to highlight the personalised targeted nature of theindividual-based approaches not the fact of the individual relationship per se

Considerations shared by group-based and individual-centred interventionsThe analysis has revealed the shared importance of three preparatory stages in the intervention Principallythese concern (1) recruitment whether of health professionals or of lay supporters (2) training againirrespective of whether professionals or lay supporters and (3) the process of targeting or matching theneeds of those requiring support to those delivering support In addition mechanisms for sustainabilitywithin a programme also surface as being important considerations

RecruitmentRecruitment is a key intervention in relation to lay support Lay supporters are typically volunteers and areoften motivated by a desire to help or to give something back301

TrainingClinical staff must make a considerable investment of time to supplement their clinical expertise withfacilitation counselling or support skills Midwives to create a favourable impression within aCenteringPregnancy intervention have to be sufficiently skilled knowledgeable and warm to providesuggestions for group discussion and to allow unstructured discussion all of which were appreciated by groupmembers277 The intervention by Morrell287 compared training for health visitors in assessment and two differentmethods of psychological support Deficiencies in delivery of care sometimes imply a need for further training

For lay supporters the potential training burden is substantial For example it may include experientialtraining such as role-playing and supervision information on peer support strategies and topic-specificinformation about PND and medications as well as organisations or further sources to which they couldrefer386 Dennis386 describes the use of a 121-page training manual

MatchingBehavioural interventions require creation of a rapport between service provider and recipients of careThose delivering group interventions must be viewed as accessible and welcoming by members of thegroup Indeed effective facilitation requires that the facilitator progressively suppresses his or her own roleso that the group becomes functional with minimum and judicious input In the individual telephonecounselling intervention participants were matched with peer volunteers lsquoif the mother desiredrsquo205

However this so-called matching was based on residency and ethnicity and was performed by theco-ordinator The Newpin Intervention saw young befrienders being matched with younger parents206387

However demographic lsquomatchingrsquo may not be sufficient and numerous other variables could beconsidered when seeking to establish compatibility

Support to providersA further ongoing requirement for both approaches is supervision of or at least support to thosedelivering support (whether professionals or lay supporters) This is particularly the case for formalpsychological approaches such as IPT which often require supervision as a component of interventiondelivery The availability of such support may have a subsequent effect on retention of the facilitatorssupporters the sustainability of the overall programme and indeed on further recruitment

Another consideration for both group and individual approaches that is not determined exclusively by typeof intervention delivery relates to the convenience of the intervention sessions Delivery of sessions at homeor over the telephone and integration with routine health-care visits may help to increase the acceptabilityand feasibility of intervention delivery as well as adherence327388 Hybrid models may seek to optimise thepattern of home visits and regular visits to a health-care provider Opportunities for improved co-ordinationare offered by using such visits to give advice on nutrition child health child development programmespositive parenting programmes vaccination programmes routine childbirth education sessions andcommunity health programmes389 Group interventions can seek to achieve improved acceptability andfeasibility by being offered in conjunction with individual health-care appointments as in theCenteringPregnancy model

Components of the interventionsSeveral features recurred frequently in the qualitative syntheses of interventions and of personal and socialstrategies as either actual or suggested components for the intervention irrespective of the chosenmethod of delivery In some cases the feature is implicit within suggestions of what might have helpedFor example the value of family support or of instrumental support translates into a requirement forintervention content that both affirms the validity of help-seeking and provides practical strategiesfor eliciting such support A useful intervention when time and resources permit includes the following

l make provision for continuity of carel legitimise help-seeking without framing this as an inability to copel offer strategies for identifying supportl equip women to delegate tasks without surrendering mother rolel offer strategies for eliciting emotional spiritual and instrumental supportl identify coping strategies to allow self-helpl help women to access information as and when requiredl feel able to share feelings and experiences without experiencing premature closurel facilitate normalisation of feelingsl create realistic expectations about the birthl create realistic expectations about motherhood rolesl create realistic expectations about health professional support and roles and health servicesl challenge social norms of the ideal birth the ideal baby or the ideal motherl anticipate baby-centric focus of family and health professionalsl identify strategies for acknowledging and meeting motherrsquos own needsl prepare women for emotional labilityl anticipate fatigue pain and slow recovery from labourl help women adjust their routines to motherhoodl widen focus beyond delivery and birthl gain strengthjoy from babyl develop attachment with infantl acquire practical skills (breastfeeding changing nappies bottle feeding bathing)l understand appropriate use of medication alternative medicine and counselling servicesl acknowledge and build upon cultural variationl adjust to cultural barriers regarding communication or provision of support

SustainabilityA further key consideration relates to the sustainability of the intervention or programme Unlike otherself-management or peer support programmes primarily within the domain of chronic diseases pregnancyis a time-limited condition with definable antenatal and postnatal periods Sustainability cannot be offeredby continuity of group membership Sustainability may be offered by structural components for examplea common venue or ongoing facilitators or by process elements such as training manuals and programmesor a standard curriculum There is some evidence within the reviewed studies of a cohort approach whichseeks to engage a group of mothers to be at a common point and then take them together through theantenatal birth and postnatal period Certainly group membership seems less of an issue under a cohortmodel than with an escalator model in which mothers can enter or exit at any point in the programmeHowever the cohort model is in turn predicated upon having sufficient critical mass of women atapproximately the same point in their pregnancy for the group to be viable Here considerations of optimalgroup size need to be considered against what is feasible and practicable

Recruitment of the next generation of peer supporters could in theory be achieved from within eachcohort although timing is an issue as a recent mother adjusting to such a significant life event does notcorrespond to the typical model of one likely to volunteer Therefore some mechanism for medium-termfollow-up may be needed to keep in touch with potential future peer supporters

Construction of pathways or chains from lsquoifndashthenrsquo statements

The subsequent stage to production of lsquoifndashthenrsquo statements is to seek to integrate these into causalpathways or chains

Mechanisms for improving appropriateness of strategiesFigures 57 and 58 present schema demonstrating the way in which lsquoifndashthenrsquo statements might illuminateparticular paths or dependencies290

These representations illustrate that a key point in the delivery of interventions whether group orindividual based is the establishment of a relationship with a care provider whether professional or a layhelper Matching of care provider to women whether individually or collectively becomes a key factor inthe success of such interventions Building up such a relationship allows the establishment of trust whichthen allows open and frank information exchange285 When such communication is present it leads inturn to a better understanding of the needs of the expectant mother The establishing of relationshipsexplains at least in part why continuity of care283 figures prominently in discussions of the requirementsfor good-quality antenatal care

Confidingin care

provider

Identificationof personalised

strategiesby provider

Continuityof care

Relationshipwith careprovider

FIGURE 57 The ways in which lsquoif-thenrsquo statements might illuminate pathways for individual approachesData source McNeil et al 2013290

In group-based interventions the requirement for a successful relationship is further compoundedRelationships need to be built up between mother and care provider and between mother and othersin the group283289 However this element of lsquoriskrsquo to the functioning of the group may potentially becompensated for by the likelihood that support for the group may compensate for inadequacies in thefacilitation and also that the group has more resources in terms of experience to share and a lsquolike mindrsquo390

to offer in support of each individual mother When support is being provided by care provider andor bywomen in a group this may take away some of the pressure on the relationship with fathers or significantothers (such as in-laws)

That women need to build up relationships in order for the intervention to work is seen in the experiencethat groups may initially struggle285 Subsequently they typically weather initial periods of individual anxiety

On adverse effectsSome women do not welcome the group approach and so in quantitative terms are lost to trials prior torandomisation Similarly most of the qualitative studies recruited women who had agreed to participate ina group-based approach This represents an important area of potential methodological bias Likewiseparticipation tends to be described in very forgiving terms for example in the number of women attendingone or more sessions Theoretically this means that the women are likely to be being delivered a suboptimallsquodosersquo of care In practical terms there is the possibility that health provider resources are not used effectivelyor women may be unable to access groups because available slots are occupied by non-attenders In additionthere was some evidence that discomfort experienced by partners over the nature of discussions may havecaused them to disengage with a subsequent perception of lack of support from the viewpoint of the womenthemselves283 A further complication relates to the potential inclusion of fathers Fathers may experiencedifficulty in contributing to the group277 either because of their own shyness or because women felt that menwere uncomfortable with intimate discussions283 Alternatively women may feel reticent in bringing uptopics when in a mixed group that includes fathers If women themselves fail to maintain an adequateattendance level and thus experience a consequent lack of group support they may perceive an inability toimplement strategies that they have learned286

Communication with a care provider andor with a group should not be viewed simply in positive termsGroups or care providers may albeit unwittingly create expectations that become difficult or impossiblefor an individual mother to fulfil371 A failure to meet either perceived or actual norms may contributeto a feeling of inadequacy Social comparison may also be unfavourable if others in the group are handlingchallenging situations with more ease even if this reflects individual proficiency rather than the benchmarklevel for the group as a whole There was some evidence that established group members would takesignificant steps to avoid upsetting other group members by creating expectations (eg in their supportrelationships material circumstances or the pregnancy experience) that they might be unable subsequentlyto fulfil293

Diversityof group

Sharing ofpersonalstrategies

(provider andgroup)

Self-identificationof personalised

strategies

Relationshipwith group

FIGURE 58 The ways in which lsquoif-thenrsquo statements might illuminate pathways for group approaches

Although much is made of the benefits of bringing together women who are facing the commonchallenges associated with pregnancy labour and childbirth it should be recognised that this is notwithout risk Given the recognised susceptibility of these women to emotional feelings it can be seen tobe potentially volatile to bring together women when the response of another might well attenuatethe emotional effect A further consideration within a group context is that a lack of privacy during theintervention may result in a mother feeling that her individual care has been sacrificed to the requirementsof the group The very structured CenteringPregnancy protocol also poses specific logistic problems ifwomen perceive that the format of the sessions is not ideal with a 2-hour session being too long289 orthere being too long a period of time between first and second group meetings277

A shared concern for both individual- and group-based approaches relates to the fact that any type ofservice provision raises expectations from the service If these expectations are subsequently unrealisedthen this can be an additional source of frustration to women who already feel unsupported Improvedaccess to a caregiver through a targeted intervention may subsequently raise expectations that might notbe met either in individual follow-up care from the provider or by front-desk support staff in theirinteractions with mothers283 Qualitative research revealed specific logistic concerns related to the fact thatthe choreographed and structured nature of group sessions may induce a feeling of being rushed by ahealth professional during the intervention Specifically within a military setting CenteringPregnancy wasseen to neglect consideration of the associated workload and resource constraints So although theCenteringPregnancy Intervention appears to be generally well received constraint of available resourcescould have a disproportionate that is non-symmetrical effect if service providers are seen to be scrimpingand saving on costs of care Women may therefore feel that their care is not perceived as a priority

Other considerations relate to specific facilitation difficulties in which a health professional is perceived asbeing too controlling or not suitably facilitative in engaging with the wishes of the group A tensionbetween encouraging women to bring their family in some cases when this facilitates their access andattendance but acknowledging the disruption this may pose in other instances can lead to the perceptionthat the service is not family centred and that older children are not welcome

Testing of the programme theory and integrating quantitativeand qualitative findings

Having identified hypothesised components for successful inclusion in an intervention or programmeenabled us to re-examine their presence or absence in the featured interventions Although this approachis necessarily limited by the quality of reporting of each intervention this effect was minimised by using allavailable published reports of each intervention not solely the primary trial report It was assumed thatthe emphasis of the reporting would largely reflect the corresponding emphasis of particular featureswithin an intervention That is if a feature is mentioned it is more likely to be considered important to aninterventionrsquos mechanisms of action whereas if a feature is unclear or omitted particularly given word limitconstraints it is correspondingly unlikely to be considered a key feature although not necessarily absentA further limitation relates to the limited ability of an approach based on reporting to establish whethera feature was deliberately planned in the conception of an intervention or was implemented fortuitously oropportunistically Nevertheless its presence would indicate that it is feasible both as a feature of theexisting intervention and as part of any planned enhancement

Finally consideration of desired qualitative features alone is not sufficient for exploration of the candidateinterventions At some point these features must be correlated with data on the effectiveness of eachintervention Table 54 makes an initial link between the presence or absence of reported features and anoverall assessment of effectiveness However it is important to recognise that this simply represents acorrelation and cannot be considered evidence of a cause and effect relationship

Response from the service user group to optimal characteristicsidentified from the qualitativerealist reviews

Consultation with the PPI group revealed that many characteristics listed resonated with group membersrsquoown experience and feelings One informant commented that they felt that lsquothe list was meaningful andshows good insight into the pregnancy experience and early motherhoodrsquo while another stated that lsquoitcaptures the main concernsrsquo and a third agreed that it was meaningful They did identify that the wordingof the list would need careful attention if it is to be translated into use with women themselves asopposed to health professionals

Modifications to the listOne informant endorsed the need to equip woman to delegate tasks without surrendering the motherrole She made an implicit connection with challenging the concept of the lsquoideal motherrsquo in stressing towomen that lsquohelp with mothering could be necessary and to avoid making this shameful or neglectfulrsquoMembers of the PPI group offered specific observations on the timing of some of the suggested strategiesPractical skills (such as breastfeeding changing nappies bottle feeding bathing) were considered lsquoveryimportant skills that need to be acknowledged before the birthrsquo It was felt that these should beemphasised because as also revealed by the literature reviews lsquotoo much focus is on the birthrsquo It was alsoimportant that womenrsquos own needs be acknowledged before the birth

I would add also to tell mothers to look after themselves before and after the birth by doing one thinga day they enjoy five minutes of filing nails eating something they really enjoy and simple everydaypleasures which are achievable

PPI group member

Finally information on PND needs to be available from the start for example at antenatal classes

Additions to the listIn addition members of the PPI group volunteered observations that triangulated with findings identifiedelsewhere in the review processes In particular the involvement of and role of partners was essentialwith a need to educate partners regarding symptoms and a requirement to lsquokeep them involved and tohelp them understand what is going onrsquo Comments resonated with the strategies offered by IPT namelylsquoto avoid potential possible relationship difficultiesbreakdown which obviously wouldnrsquot be helpful to thewomen with PNDrsquo The importance of attachment extends beyond the mother and baby requiring thatpartners enjoy lsquosome level of involvement to encourage the later bonding process with baby ndash or it couldbecome very much just the womanrsquos experiencersquo

Other findings from the review reflected by participant responses included the importance of the need tolegitimise help-seeking without framing this as an inability to cope given that women may lsquofear theirchildren may be taken away from them if they open up as to how they are feelingrsquo The key role ofcontinuity of care was affirmed particularly in the context of the caregiver being able to identify changesin the woman and therefore offer personalised strategies for eliciting emotional spiritual and instrumental(ie practical) support

TABLE 54 Matrix indicating presence or absence of reported features with overall assessment of effectiveness

Element from qualitativefindings Two-step CenteringPregnancy

Midwife-ledbrief counselling

Mid-routineprimary care

Continuity of care ndash ndash

Legitimise help-seeking ndash ndash ndash ndash

Identify support ndash ndash ndash

Delegate without surrender ndash ndash ndash ndash ndash

Strategies for elicitingsupport

ndash ndash

Coping strategies ndash ndash ndash ndash ndash

Access information asrequired

ndash ndash

Able to share feelingswithout experiencingpremature closure

ndash ndash ndash ndash ndash

Normalisation of feelings ndash ndash ndash ndash

Realistic expectations aboutbirth

Realistic expectations aboutmotherhood roles

Realistic expectations ofprofessionals and healthservices

ndash ndash ndash

Challenge lsquoidealrsquo ndash ndash ndash ndash ndash

Anticipate baby-centricfocus

Acknowledge motherrsquosown needs

ndash ndash ndash ndash

Acknowledge emotionallability

Anticipate fatigue painand recovery from labour

Adjust routines ndash ndash ndash ndash

Focus beyond delivery andbirth

Gain strengthjoy frombaby

Develop attachment withinfant

Acquire practical skills ndash ndash ndash ndash

Use of medicationalternative medicine andcounselling

Cultural variation ndash ndash ndash ndash ndash

Cultural barriers regardingcommunication or support

PoNDER Home based IPT phone IPT Rose IPT-brief Telephone support Newpin Thinking Healthy

ndash ndash ndash ndash ndash ndash

ndash ndash ndash

ndash ndash ndash ndash ndash ndash ndash ndash

ndash ndash ndash

ndash ndash

ndash ndash ndash

ndash ndash ndash ndash ndash ndash ndash

ndash ndash

ndash ndash ndash

Other important features felt to help avoid PND included

l being informed about and prepared for the risks of reccurrence with subsequent pregnanciesl having a supportive GPl not being put under pressure to breast feed if a woman feels uncomfortable doing sol providing access to other new mums for example groups

An observation not identified in the literature related to lsquohelp with identifying babyrsquos criesrsquo A womandescribed how she lsquofelt anxious and found it hard to trust and to connect with [her] babyrsquo She suggestedthat help in interpreting babyrsquos cries might be based on the work of an Australian musician who haslsquoobserved babiesrsquo cries and discovered how we can interpret them before they become fully fledgedit is called Dunstanrsquos baby language391

Additional nuances emerging from the consultationOne informant while recognising that the strategies listed were important highlighted practical difficultiesin implementing the strategies For example triggering asking for help may prove problematic becauselsquowhat a woman experiences is ldquonormalrdquo for her and therefore she might not know that she is depressedand therefore not ask for helprsquo Similarly equipping a woman with strategies for identifying support is alsodependent on a woman herself recognising that she needs support

Delegation of tasks will not always be possible if a woman has no one to help her or if a partner is of nohelp and only increases her anxiety Individual ability to lsquomanage everything themselvesrsquo varies fromwoman to woman and this needs to be recognised by health-care providers Other comments alsohighlighted the individualised nature of response to help advice and support

Anything that is said to an anxious or depressed woman can have a negative effect but also a positiveeffect Her ability to cope must not be doubted I think professionals need to be very aware

Summary of findings from realist synthesis review

When planning a group-based intervention an intervention is

l more likely to succeed if a facilitator has been trained in group leadership and facilitationl more likely to succeed if a facilitator has personal resources that they can bring to the groupl more likely to succeed if a facilitator creates a rapport with the groupl more likely to succeed if the group creates a favourable group dynamicl less likely to succeed if the facilitator is seen as controlling or not responding to the wishes of

the group

When planning a one-to-one peer-based intervention an intervention is more likely to succeed

l if a peer has been matched on other than simple demographic variablesl when peers are recruited based on extroversion and good communication skills

When planning a one-to-one professional mediated intervention an intervention is more likely tosucceed if

l a relationship of trust is built up between the woman and the care providerl the health-care provider has significant personal resources on which to draw

A face-to-face intervention is more likely to be successful if a health-care provider responds to visual verbaland non-verbal cues that reflect how a woman is feeling

An intervention delivered at a distance is more likely to be successful if a supporter makes more contactshas more conversations and leaves messages

Training interventions for health professionals or peer supporters are more likely to be successful if they

l include problem-solving strategies such as role playl include demonstrations of practical skills that can subsequently be modelled with individuals and

groups of womenl are relevant to the community as they equip health professionals or peer supporters with appropriate

skills to deal with the range of people who receive services within a multicultural society

Chapter 9 Assessment of cost-effectiveness

Systematic review of existing cost-effectiveness models

Identification of cost-effectiveness studiesA comprehensive search was undertaken to identify systematically cost-effectiveness literature comparingthe costs of different interventions to prevent PND The search used a combination of thesaurus andfree-text terms The search comprised four facets combined together Facet 1 comprised terms for thepopulation (pregnant and postnatal women) Facet 2 comprised terms for prevention Facet 3 comprisedterms for known risk factors of PND Facet 4 was generic terms for interventions To retrievecost-effectiveness literature the four facets of the searches were combined with an economic evaluationssearch filters The searches were performed by an information specialist (AC) in November and December2012 The search strategy is reported in Appendix 1 The economic evaluations filter for MEDLINE isprovided in Appendix 1 Search strategy used for cost-effectiveness studies with economic evaluations filterfor MEDLINE The list of electronic bibliographic databases searched for cost-effectiveness literature ispresented in Appendix 1 Electronic databases searched for the cost-effectiveness literature All citationswere imported into Reference Manager version 12 and duplicates deleted The Preferred Reporting Itemsfor Systematic Reviews and Meta-Analyses (PRISMA) flow chart for the studies included in the healtheconomics review is presented in Figure 59

Potentially relevant papersscreened and identified

for retrieval(n = 2420)

Studies excluded at title andabstract sift (n = 2401)

Studies excluded at full paper sift

(n = 4)

Studies excluded abstract only (n = 5)

Total studies screened (n = 19)

Total full papers screened (n = 14)

Additional papers (n = 3)

Total included full papers (n = 13)nine economic evaluations

alongside trials three decisionmodel and one cost study

FIGURE 59 The PRISMA flow chart of studies included in the health economics review

Study selection criteria and procedures for the health economics reviewPapers were eligible for inclusion if they included costs or health-related quality-of-life measurements ofPND that could be used in an economic decision model As only a limited number of studies addressingprevention only were found the inclusion criteria were kept broad to include papers evaluating screeningfor and treatment of PND as well as prevention of PND in order to minimise the risk of potentially usefuldata being excluded When multiple papers of the same studies were published the most detailed or mostrecent (as appropriate) were selected as recorded in Table 55

There were 2420 papers were identified in the search The reasons for exclusion at the full paper stageare shown in Table 55 There were two studies for which multiple papers for the same study werefound4557392393 and in both cases the more detailed paper was selected45392 An additional paper that waspublished after the search was completed was identified by a member of the project team who was anauthor on the paper and the paper was included396 It was not identified in a systematic way and otherpapers that were published after the search was conducted will have been missed A second paper wasidentified by a member of the project team during the search for quantitative studies and was included inthis health economic review56 This paper had been excluded at the title and abstract stage on the basis ofthe paper title A further paper was identified during the economic modelling process397 It had beenexcluded at the title and abstract stage as PND or associated terms were not included in the title orabstract Of the 13 papers identified61174199264392ndash394398ndash400 nine described an economic evaluation thatwas conducted alongside a trial5361174199264299392393400 three papers described an economic decisionmodel4556394 and one paper described a cost study398

Overview of papers included in the health economics reviewAlthough all included papers described an economic evaluation of a PND intervention they wereheterogeneous in many aspects including the population intervention comparator and outcomesevaluated The nine economic evaluations5361174199264299392393400 and the one cost study398 are described inTable 56 and the three economic decision models4556392 are described in Table 57

Population considered in the health economics reviewThe population under consideration differed between studies Two of the studies evaluating treatmentinterventions included only women diagnosed with PND392399 The other two studies that evaluatiedthe incremental cost of PND included women regarded as having PND400 and women at risk of PND51

In the Dagher et al400 study women were regarded as having PND if they scored 13 or more on the EPDSat 5 weeks postpartum The Petrou et al174 study included high-risk women identified antenatally at26ndash28 weeksrsquo gestation using the Cooper predictive index401 including both psychological and social riskfactors Women were diagnosed with PND using the Structured Clinical Interview for the Diagnostic andStatistical Manual of Mental Disorders-Third Edition Revised diagnoses at 8 weeks 18 weeks 12 monthsand 18 months postpartum The population in the screening papers4556 was all postnatal women Forthe papers broadly evaluating the prevention of PND the population differed with some studies includingall postnatal women61199264397 and three studies evaluating women who had been identified as atincreased risk of developing PND61174396

TABLE 55 Reasons for exclusion of full papers in the health economics review

First author year reference number Reason for exclusion

Stevenson 2010392 Two papers on same study392393 the more detailed paper was selected392

Paulden 200957 Two papers on same study4557 the more detailed paper was selected45

Buist 2002394 Non-economic evaluation neither costs nor health-related quality of lifereported

Darcy 2011395 Non-economic evaluation neither costs nor relevant health-related quality oflife reported

ASSESSMENT OF COST-EFFECTIVENESS

56Economic

evaluationsan

dtheco

ststudyincluded

inthehea

ltheconomicsreview

Study(first

authorye

reference

number)

Country

Interven

Population

Sample

Outcomes

Maineconomic

outcomereported

Quality-of-life

Timehorizo

nResult

leby20

dHealth

visitors

giving

itivendashbe

haviou

selling

health

visitors

health

visitorcontacts

depressedwom

anprean

sttraining

visitor

timeprean

sttraining

health

visitorcosts

ndash6mon

n-sign

ificant

decrease

inmean

costsoccurred

overall

Englan

Dtreatm

aspecialised

redwith

routineprim

arycare

enwith

en(30in

theinterven

controlg

Meancostsfor

enusingPB

androutineprim

carenu

pressed

at6mon

Increm

entalcost

persuccessfully

treatedwom

ndash6mon

Amovefrom

routine

arycare

ldincuran

additio

nalcostof

pound194

rsuccessfullytreated

ndashEm

ployed

postna

pressed

non-de

pressed

Totalh

resourcesused

Differen

health-care

resourcesused

11weeks

Themeantotalcost

alth-care

resourcesused

681high

depressedgrou

intheno

pressed

teleph

one-ba

ersupp

ortcompa

lcarefor

thepreven

High-riskwom

en(screene

tally)

610wom

en(296

intheinterven

controlg

Daverted

health-service

ofinterven

volunteerop

portun

itycosthired

housew

orkchild

Daverted)

ndash12

AnICER

ofCA$1

Davoide

d continued

56Economic

evaluationsan

dtheco

ststudyincluded

inthehea

ltheconomicsreview

(continued

Study(first

authorye

reference

number)

Country

Interven

Population

Sample

Outcomes

Maineconomic

outcomereported

Quality-of-life

Timehorizo

nResult

Australia

arycare

commun

ity-based

interven

toprom

otethehe

wmothe

yareas

16interven

areaseigh

interven

tionan

controlg

Costof

interven

tionan

alth-careresource

Costpe

theinterven

andcost

perarea

SF-36(but

notrepo

Average

rurala

nareasNosign

ificant

differen

health-careresource

usewhe

ninterven

tionareas

redwith

controla

MacArthu

dDesigne

lemidwife

rycare

incommun

itysettings

tailoredto

enrsquosindividu

edswith

afocus

ontheiden

tification

andman

ysical

psycho

logicalh

rather

onroutineob

servations

selected

clusters

controlg

interven

health-service

EPDSscores

Totalh

resourcesused

Costpe

ofprob

depression

avoide

ndash12

Anincrem

entalcost

ofpound7

ofprob

depression

preven

Morrell

Englan

bytraine

dcommun

ortworkers

Postna

623(311

interven

tiongrou

controlg

contacts

health

services

efunctio

nalsocial

ortscalescores

EPDSscoresothe

rmeasuresof

health

outcom

health

servicecosts

6weekan

Nosign

ificant

differen

resource

use(excep

tforthesupp

workerservice)

Study(first

authorye

reference

number)

Country

Interven

Population

Sample

Outcomes

Maineconomic

outcomereported

Quality-of-life

Timehorizo

nResult

Morrell

dHealth

visitor

psycho

logically

inform

edtraining

interven

At-riskwom

en(screene

tally)an

ostnatal

At-riskwom

Costof

health

visitor

training

servicecontacts

interven

controlEPDSscores

Increm

entalcosts

andQALY

sSF-6D

Psycho

logical

approa

dominated

control

pndashlower

andhigh

ermean

Petrou

visitorvisits

At-riskwom

en(screene

tally)

151(74in

interven

tiongrou

incontrol

contacts

health

services

Increm

entalcost

permon

avoide

ndash18

Increm

entalcostpe

avoide

pound4310

Petrou

Englan

dndash

High-riskwom

contacts

health

services

Increm

entalcostof

treatin

Dndash

Meancost

enwith

pound241

9meancost

perwom

enwith

PNDpound2

KeyICER

increm

entalcost-effectiven

essratio

DUpsychiatric

parent

itQALY

ality-adjustedlife-year

57Economic

decisionmodelsincluded

inthehea

ltheconomicsreview

Study(first

authorye

reference

number)

Country

Interven

Population

Costsused

Quality-of-life

Outcomemea

horizo

nResults

Englan

dScreen

ingforPN

I)Allpo

enCostof

screen

oftreatin

eratePN

increm

costsan

dincrem

entalQ

EPDS(cut-offscoreof

6)ICER

pound4110

rstrategies

edfrom

pound2319

pound814

Steven

Englan

dGroup

enwith

Costof

SF-6D(m

Meancost

perQALY

ofpound4

2(pound36

pbell20

Zealan

dScreen

ingforPN

D(three-que

questio

nnaire)

enCostof

screen

oftreatin

Revickia

depression

values

increm

costsincrem

sincrem

PNDcasesde

tected

increm

entalP

casesresolved

nalcaseof

tected

Dresolved

KeyICER

increm

essratio

PSAprob

abilisticsensitivity

analysisQALY

The methods used to identify higher-risk women also varied between studies The Dukhovny et al396 andMorrell et al61 studies both used the EPDS but at different cut-off points (score greater than 9 and scoregreater than 11 respectively) and at different time points (24ndash48 hours after hospital discharge and at6 weeks postnatally respectively) Both the 2002 and the 2006 Petrou et al papers53174 identified womenantenatally at 26ndash28 weeksrsquo gestation using the Cooper predictive index401

Interventions in the health economics reviewOf the 13 included papers

l Six were broadly concerned with the prevention of PND61174199264396397

l Four evaluated different strategies for treating PND53392399400 and of these four two were concernedwith the additional cost of treating PND53400

l Two evaluated screening for PND4556

l One focused on the impact on health visitorsrsquo time before and after they were given training incognitivendashbehavioural counselling398

The health impact of the intervention on PND was measured in 10 of the studies455661174199264392ndash394399 themeasure used differed between studies and included the number of cases of or duration of PND and theEPDS scores The Appleby et al398 study did not report the impact of the intervention on PND as it wasfocused on the impact on health visitors and their time spent per depressed woman The Petrou et al53

study and the Dagher et al400 study did not contain an intervention as they were focused on theincremental cost of treating PND in a high-risk population and among employed women respectively

Health-related quality-of-life data in the health economics reviewSeven of the papers used a measure of health-related quality of life455661199392397400 Five of these papersused a generic measure61199392397400 whereas the other two used a patient-generated utility value4556

Of those that used a generic measure two used the SF-6D61392 two used the SF-36199397 and one usedthe SF-12400 The SF-36 and SF-12 cannot be used in their basic form to estimate quality-adjusted life-year(QALY) values but can be converted into the SF-6D which provides values that can be used to estimateQALY values for use in an economic decision model Only the mean and SD were reported for the SF-12PCS and MCS at 5 postnatal weeks400

The remaining two papers45401 used patient-generated utility values from a study by Revicki and Wood402

in which patients diagnosed with depression valued hypothetical depression-related states using a standardgamble approach From this study402 Hewitt et al45 used the value given for moderate depression andapplied this to women suffering with PND in their decision model In contrast Campbell et al56 usedvalues for severe symptoms mild or moderate symptoms subthreshold symptoms drug and psychologicaltreatment response and response without drug-associated disutility for different health states within theirmodel There are several issues with using the utility values from the Campbell et al56 study First thehealth state valued was a general depression health state and not a specific PND health state Secondthe sample size reported of 70 patients was relatively small and made up of patients suffering withdepression and not specifically PND Third the health-state values were estimated using a patientpopulation although the preferred approach is to use a general population sample to value health states403

The PoNDER trial61 collected SF-6D data using the UK tariff at a baseline of 6 weeks and then at 6 12and 18 months postnatally and these scores were used in the economic evaluation to calculate QALYsThe PoNDER trial61 also collected data on the EPDS at the same time points The paired data on thechange in SF-6D and EPDS scores were used by Stevenson et al392 to map change in EPDS to change inSF-6D which was then used in the decision model392

Comparison between the QALY estimates used in the three papers is not possible because of the way theywere calculated and presented Hewitt et al45 and Campbell et al56 used utility values from the Revicki andWood study402 Hewitt et al45 used values of 063 for women with PND and 086 for women without PND

and Campbell et al56 used values of 030 for severe symptoms 063 for mild or moderate symptoms 080 forsubthreshold symptoms and response with drug and psychological treatment and 086 for response withoutdrug-associated disutility Whereas Morrell et al61 presented the mean difference in QALY values at 6 monthsfor women in the control and intervention groups Stevenson et al392 presented the mean QALY gain

Costs and health-care resources reported in the health economics reviewAll included studies reported health-service use for interventions evaluating the prevention or treatment ofPND The nine economic evaluations alongside trials and the one cost study all reported costs associatedwith the resource use reported during the trials or study whereas the decision models used estimates fromthe literature and expert opinion Costs were inflated using the hospital and community health servicesindex for studies based in England404 Canadian costs were inflated using the Canadian ConsumerPrice Index health and personal care index405 US costs were inflated using the medical care Consumer PriceIndex406 Australian costs were inflated using the Australian Total Health Price Index407 and the New Zealandcosts were inflated using the average of the US and English indexes The costs used in the economicevaluations identified in the literature review are presented in Table 58

In their economic decision model Hewitt et al45 included costs for screening using the EPDS and BDIbased on 5 minutes of health visitorsrsquo time plus the licence fee for the BDI screening tool The costs oftreatment of PND were based on NICE clinical guidelines for the treatment of PND and were costed usingrelevant NHS reference costs The cost for an undiagnosed woman with depression was estimated as oneadditional GP visit Stevenson et al392 included costs for an intervention group CBT which were based onresource use reported in a RCT and from expert opinion408 Campbell et al56 included the cost of screeningand the cost of treatment based on unit costs of health staff and prescriptions Screening was assumed totake 5 minutes using the EPDS and 3 minutes using the brief three PHQ questions49 A further 30-minuteappointment with a GP was assumed for all women who screened positive Half of the women who wereseverely depressed and did not respond to treatment were assumed to have 1 day of inpatient care inhospital and a further GP appointment Treatment costs were adjusted for non-compliance with 10of the total treatment costs applied to these women

For their economic evaluations alongside trials Petrou et al53 estimated the health-care resources usedfrom delivery to 18 months by the population of high-risk women and differentiated between those whodeveloped PND and those who did not Women diagnosed with PND had higher overall resource usea reported difference of pound392 which inflated at 20123 prices increased to pound601404 Part of the Petrouet al53 2002 sample included women who were taking part in the Petrou et al174 2006 RCT The report of2006 trial174 described resource use for the intervention group additional health visitor visits and thecontrol group routine primary care and not for women who developed PND and those that did notMother and infant costs were included in both studies

A broader perspective was taken in the Dukhovny et al396 study which included both health-care andnon-health-care costs For the intervention the public health cost and the opportunity cost of thevolunteersrsquo time was included Costs for the intervention group and the usual-care group were reportedat 12 weeks These included health-care costs as well as costs for hired housework hired child care andfamilyfriend and partner time off work Mother and infant costs were included

The 2009 Morrell et al61 paper collected health-care resource use for women in their trial Total resourceuse estimates were split into control and intervention groups over periods of 6 and 12 months Theprimary analysis was carried out using the 6-month data which included the costs incurred by the motherA further analysis on the 12-month data was also carried out which included the costs incurred by themother and also the baby The total resource use was further split into an analysis of at-risk women andan analysis of all women and additionally split between the two intervention approaches of CBA and PCAThe study also collected data on the additional training that would be required for health visitors to beable to provide the psychologically informed intervention sessions and estimated that the additionaltraining would increase the health visitorsrsquo cost per hour of client time by pound2 from pound77 to pound79

TABLE 58 Costs used in economic evaluations included in the health economics review

Resource userecorded in study

Category ofcost Cost Base year

Inflated cost(201213) Perspective

Appleby 2003398 Health visitor timepre-training

Per woman pound81 1998 pound135 Health-care system(NHS) perspective ndash

health visitor timePer depressedwoman

pound116 pound193

Per treatedwoman

pound107 pound178

Health visitor timepost-training

Per woman pound79 pound132

Per depressedwoman

pound108 pound180

Per treatedwoman

pound109 pound182

Boath 2003399 Mean cost PBDUpatient

PBDU cost pound991 19923 pound1905 Health-care system(NHS) and widersocietal costsperspective ndash

health-care resourceuse Mother andinfant costs included

GP and healthvisitor

pound203 pound390

Secondary care pound0 pound0

Cost to client pound302 pound581

Medication pound44 pound85

Total pound1540 pound2960

Total excludingcost to client

pound1238 pound2380

Mean cost perroutine primarycare patient

PBDU cost pound0 19923 pound0

pound266 pound511

pound607 pound1167

Dagher 2012400 Mean cost perwoman with PND

Emergencydepartmentvisits

US$84 2001 US$131 Health-care systemperspective(USA) ndash health-careresource useUnclear if infantcosts included

Inpatienthospital stays

US$607 US$949

Outpatientsurgeries

US$93 US$145

Physicianrsquosofficeurgentcare centrevisits

US$124 US$194

Mental healthcounselling

US$138 US$216

Total US$1046 US$1636

pound984a

continued

TABLE 58 Costs used in economic evaluations included in the health economics review (continued )

Mean cost perwoman withoutPND

US$13 2001 US$20

US$80 US$125

Outpatientsurgeries

US$138 US$216

MD officeurgent carecentre visits

US$12 US$189

US$13 US$20

Total US$365 US$571

pound343a

Dukhovny2013396

Telephone-basedpeer support group

Public healthcosts

CA$667 2011 CA$674 Health-care systemand wider societalcosts perspective(Canada) ndashhealth-care resourceuse and wider costsincluded Motherand infant costsincluded

Volunteeropportunitycosts

CA$126 CA$127

Hiredhousework

CA$234 CA$236

Hired child care CA$194 CA$196

Familyfriendand partnertime of work

CA$2374 CA$2398

Health-careutilisation total

CA$901 CA$910

Nursing visits CA$252 CA$255

Provider visits CA$371 CA$375

Mental healthvisits

CA$43 CA$43

Inpatientadmissions total

CA$227 CA$229

Mother CA$42 CA$42

Infant CA$185 CA$187

Ambulance CA$8 CA$8

Total CA$4497 CA$4543

pound2474a

Routine primarycare

Public healthcosts

NA 2011 NA

Hiredhousework

CA$180 CA$182

CA$1983 CA$2003

CA$1080 CA$1091

Mental healthvisits

CA$57 CA$58

CA$389 CA$393

Mother CA$73 CA$74

Ambulance CA$6 CA$6

pound1860a

Gold 2007397 Cost of theintervention

Rural cost perwoman

AU$172 2002 pound127a Cost of theintervention andhealth-care resourceuse (Australia)Urban cost per

womanAU$129 pound95a

Rural cost perarea

AU$272490 pound200959a

Urban cost perarea

AU$313900 pound231499a

MacArthur2003264

Control group Total costs pound542 1998 pound902 Health-care system(NHS) perspective ndash

health-care resourceuse Infant costs notincluded

Postnatal carecost

pound126 pound209

Intervention group Total costs pound470 pound783

Postnatal carecosts

pound190 pound317

continued

Morrell 2000199 Cost ofinterventionadditional supportworker visits

ndash pound160 1996 pound279 Health-care system(NHS) perspective ndash

cost of theintervention andhealth-care resourceuse Mother andinfant costs included

Total resourcesintervention(6 months)

ndash pound815 pound1420

Total resourcescontrol (6 months)

Morrell 200961 Total resourcesused all women(6 months)

Control pound272 20034 pound350 Health-care system(NHS) perspective ndash

CBA pound253 pound326

PCA pound250 pound322

Total resourcesused at-riskwomen(12 months)

Control pound374 pound481

Petrou 2006174 Cost of additionalhealth visitor visits

Petrou 200253 Total resourcesused women withPND

health-care resourceuse Mother andinfant costs includedTotal resources

used womenwithout PND

Hewitt 200945 Cost ofintervention

EPDS (5 minuteshealth visitortime)

pound8 20067 pound9 Health-care system(NHS) perspective ndash

cost of screeningand treatment

BDI (5 minuteshealth visitortime andlicense fee)

pound9 pound10

Cost of treatmentof PND

Structuredpsychologicaltherapy

pound447 pound517

Supportive care pound414 pound479

Stevenson2010392

Group CBT Onesession per weekfor 8 weeks2-hour longgroups of four tosix women

cost of interventiontreatment

Campbell200856

Psychologicaltherapy (IPT- orCBT-basedintervention)eight sessions(50 minutes each)provided by aclinical psychologist

ndash NZ$268 20067 NZ$318 Health-care systemperspective (NewZealand) ndash cost ofscreening andtreatment

pound166a

Social supportthree groupsessions (fivewomen) and threetelephone contactsby a qualifiedcounsellor(30 minutes each)

ndash NZ$59 NZ$70

pound37a

Combinationtherapy16 sessions(50 minutes each)of psychologicaltherapy by aclinical psychologistand 12 weeksrsquoantidepressanttherapy

ndash NZ$561 NZ$666

pound347a

Key GBP Great British pounds PBDU psychiatric parent and baby day unit NA not applicablea Costs converted using XE Currency Convertor (wwwxecom) exchange rates correct as of 11 March 2014 1 AU$= 055

GBP 1 USD= 06 GBP 1 CAD= 0545 GBP and 1 NZ$= 052 GBP

The Morrell et al199 paper reported the cost of the intervention under study (additional care by trainedcommunity postnatal support workers) and the total health-care resources used by the intervention andcontrol groups Total health-care resource use was reported at 6 weeks and 6 months Mother and infantcosts were included

MacArthur et al264 collected total health-care resources used for the intervention and control groups inthree matrices (presented in Table 59) A subset of the total health-care resources referred to as postnatalcare costs was also presented These costs included the standard community services offered to postnatalwomen including midwife home visits GP home visits and the postnatal check For all matrices total costswere lower in the intervention group than in the control group while postnatal care costs were higher inthe intervention group than in the control group for matrices A and B and lower for matrix C Costs formatrix A were estimated based on crude data from midwivesrsquo diaries and GPsrsquo records A further analysiswas conducted that included replacement data from womenrsquos health diaries when estimates frommidwives were unavailable (matrix B) Using this approach the total costs for the control group decreasedfrom pound542 to pound479 whereas the cost of postnatal care increased slightly from pound126 to pound134 A thirdanalysis using the womenrsquos health diaries to estimate the frequency of midwivesrsquo and GP appointmentswas undertaken (matrix C) Using this approach the total costs decreased compared with matrix A to pound509and the costs of postnatal care also increased compared with both matrices A and B to pound161 The totalcost for the intervention group also fell from pound470 to pound457 and the costs for postnatal care decreasedfrom pound190 to pound152 (see Table 66) As the intervention was not intended to impact on health visitorshealth visitor costs were not included in the total resource use Costs incurred by the babies were alsonot included

Boath et al399 reported the median and mean of total cost for women receiving treatment in a specialisedpsychiatric parent and baby day unit and for women receiving routine primary care Costs to the motherand baby were included in the analysis

TABLE 59 Costs by matrices A B and C derived from trial of midwifery redesigned postnatal care

Matrix Category of cost

Mean of cluster means

Control (pound) Intervention (pound)

Matrix A Total costs 542 470

Postnatal care costs 126 190

Matrix B Total costs 479 469

Matrix C Total costs 509 457

Data source MacArthur et al264

Appleby et al398 concentrated on what the impact of additional training would be in terms of the amountof time health visitors spent with the women under their care The amount of time spent with eachwoman depressed woman and treated woman before and after the training on cognitivendashbehaviouralcounselling was recorded and costed using the 1998 Unit Costs of Health and Social Care409 Furtherdetails on the definition of depressed or treated women were not provided

The Dagher et al400 study estimated the extra health-care resources used by women with PND comparedwith those used by women without PND Health-care use was estimated using self-reported data from thewomen themselves The data on health-care use were then costed using 2001 unit prices of servicesprovided by the Blue Cross Shield of Minnesota The incremental cost for women with PND comparedwith women without PND was US$1065 Converted to British pounds using exchange rates correct as ofMarch 2014 this is equivalent to a difference of pound641 It is not clear whether or not this included thehealth-care costs of the infant as well as the mother

Gold et al397 evaluated the economic side of the PRISM (Program of Resources Information and Supportfor Mothers) trial The PRISM trial evaluated primary care and community-based strategies to improve thephysical and mental health of new mothers Costs were collected in relation to the intervention andhealth-care resource use in the intervention and control areas No significant differences were foundin health-care resource use between the areas The cost of the intervention was estimated in Australiandollars at AU$272490 in rural communities and AU$313900 in urban areas Inflated from 2002 prices to201213 prices using the Australian Total Health Price Index407 and converted to British pounds usingexchanges rates correct as of July 2014 which resulted in costs of pound200959 and pound231499 respectivelyThe average cost per woman was AU$17240 for rural areas and AU$12870 for urban areas whichresulted in a cost of pound127 and pound95 respectively when inflated and converted

The differences in the population intervention and objective for each study make a comparison of thedifferent costs across the papers difficult However as a number of papers report costs of treatmenta speculative comparison could be made Boath et al399 at 6 months reported the highest cost for thoseundergoing treatment in the parent and baby day unit at pound2380 and a lower cost for those undergoingroutine primary care at pound1167 Stevenson et al392 estimated the cost of treating PND with groupCBT-based intervention as pound1687 but did not include any additional GP appointments or secondary carethat a woman with PND may have received Hewitt et al45 estimated the total cost of standard care forwomen with PND as pound996 This is lower than the best comparator for the cost of routine primary carereported by Boath et al399 Petrou et al53 found a difference of pound601 in health-care resources used betweenhigh-risk women with PND and high-risk women without PND This is the lowest of all the estimates of thePND treatment studies possibly because the control group comprised high-risk women rather than a universalpopulation of all women and therefore it estimated the additional cost of treating PND in a high-riskpopulation The difference between the resource use of women with PND and the resource use of non-high-riskwomen may have been greater Based on these figures pound1000 would be a reasonable estimate for the cost ofroutine care for women with PND

In the studies not based in England with costs converted to British pounds Dagher et al400 estimated theincremental cost as pound641 This is similar to that found in the Petrou et al53 study but lower than otherEngland-based estimates This could be because of differences in the health-care systems of the twocountries It could also be as a result of the way health-care resource use was recorded Dagher et al400

relied on self-reported estimates of health-care use from the women in the study and used a recall periodof up to 3 months whereas Boath et al399 used womenrsquos case notes Stevenson et al392 used costestimates from a RCT and Hewitt et al45 costed out treatment guidelines

Main results reported in the health economics reviewThe outcomes and time horizons evaluated varied between the studies For the economic evaluationsalongside trials outcomes were evaluated at various time points between 12 weeks and 24 months Bothdecision models used a time horizon of 1 year Four papers reported costs only53397398400 Appleby et al398

found that giving health visitors training in cognitivendashbehavioural counselling was associated with astatistically non-significant decrease in mean costs incurred by health visitors Petrou et al53 found a lowermean cost per high-risk woman without PND than per woman with PND in terms of total health-careresources used with a difference of pound601 in 20123 prices The Morrell et al199 paper found no significantdifference between NHS resource used in the intervention and control groups apart from the cost of theintervention itself The other economic evaluations264396 alongside trials used incremental costs against avariety of outcome measures including the number of cases of PND prevented month of PND avoided174

and incremental cost per successfully treated woman399 The Morrell et al61 paper reported incrementalcosts and QALYs and found that psychological interventions dominated the control group with lowermean costs and a higher mean QALY gain Dagher et al400 reported an incremental cost of US$1065 forwomen with PND compared with women without PND

All three decision models reported a cost per QALY and included univariate and multivariate sensitivityanalyses Hewitt et al45 found that the incremental cost-effectiveness ratio (ICER) for the screeningintervention EPDS (cut-off score of 16) to be pound41103 per QALY This ranged between pound23195 andpound814623 for different screening strategies compared in the sensitivity analyses The highest ICER valueswere found when a low EPDS cut-off value was used Campbell et al56 reported an ICER of NZ$3461a cost per additional case of PND detected of NZ$287 and a cost per additional case of PND resolved ofNZ$400 In the sensitivity analyses the ICER ranged from NZ$2959 to NZ$9607 per QALY Stevensonet al392 reported a mean cost per QALY of pound46462 for group cognitive therapy for women with PND Inthe sensitivity analyses this ranged between pound19230 and pound61948 with the lower value representinga set of values favourable to CBT-based intervention and still believed to be plausible A probabilisticsensitivity analysis (PSA) an expected value of perfect information analysis (EVPI) and an expected value ofpartial perfect information (EVPPI) on four variables were also conducted The results of the PSA reporteda mean cost per QALY of pound36062 with the results suggesting that some runs had a cost per QALY ofunder pound30000 The results of the EVPI and EVPPI estimated a maximum value of pound64M to remove alluncertainty with large values for removing uncertainty in the cost treatment variable and the relationshipbetween the EPDS and SF-6D variable

Summary of appropriateness of previously published modelsNone of the reviewed models were entirely appropriate for answering the decision problem addressedwithin this review Thus a de novo model was constructed

The de novo model

The conceptual modelThe purpose of the de novo model was to estimate the incremental QALYs and incremental costs of eachintervention in the NMA of EPDS scores compared with usual care From these data fully incrementalanalyses could be conducted to establish the most cost-effective intervention and the robustness of theseconclusions The conceptual model used an area under the curve approach to calculate the summation ofweekly EPDS scores over a year Data from the NMA of EPDS values identified five time points baseline(common to all treatments) 6ndash8 weeks 3ndash4 months 6ndash7 months and 1 year For simplicity the EPDSscore between assessments was approximated by a linear relationship A further simplification was thatdeaths were not included in the model it was believed that this would have little impact on the resultsgiven the dearth of information on the effect (if any) of interventions on mortality

A 1-year time horizon was chosen to align with previous modelling work392 and to acknowledge the factthat PND is assumed to be lsquostandardrsquo depression after 12 months postpartum and that different treatmentoptions may become available to the woman However it is implausible that any change in utility wouldimmediately be removed after 12 months and therefore a sensitivity analysis assessed the impact ofaltering the assumption that all effects were assumed to have dissipated at 12 months This analysis hasthe limitation that the duration of residual benefit is uncertain and that other events such as a subsequentpregnancy could occur that would limit the generalisability of the results in all women For the base-casediscounting was not applied For the sensitivity analysis a discount rate of 35 was applied to utility inthe second year as recommended by NICE403

Figure 60 illustrates the approach in which data exist for all time points (which is the case only for usualcare) whereas Figure 61 provides an illustrative example when only one data point (in addition to theassumed baseline value) is reported The summation of EPDS scores for other combinations of numbersand position of reported time points are calculated using the same method Separate analyses wereundertaken for the universal the selective and the indicated preventive intervention groups and the resultswill be presented in this order

0 1 2 3 4

Time point

FIGURE 60 An illustrative example of calculating the area under the curve when data for an intervention areavailable for all time points

0 1 2 3 4Time point

FIGURE 61 An illustrative example of calculating the area under the curve when data for an intervention areavailable only at time point 3

For reasons that will be detailed later the area under the curve is divided into two constituent parts untiltime point 1 (0 to 6ndash8 week data) and from time point 1 to time point 4 (6ndash8 weeks to 1 year) In theinitial time period the area under the curve is calculated by the addition of rectangle A to triangle BIn the subsequent time period the area under the curve is the summation of rectangles C E and G and oftriangles D F and H

In this example in order to differentiate between the EPDS values before time points 0 and 1 and betweentime points 1 and 4 an estimation of the EPDS value at time point 1 must be made This estimationassumes a linear progression between time points 0 and 3 (for which data were reported in this illustrativeexample) with the estimated point depicted by the blue star at time point 1 in Figure 61 In the base caseit was assumed that at 1 year (time point 4) the EPDS values would be equal for the intervention and usualcare This is depicted as the light-blue star at time point 4 in Figure 61 In order to assess the impactwhere it was assumed that any change in EPDS score would persist beyond 1 year a sensitivity analysiswas undertaken which assumes that the value at time point 4 would be the average between the lastreported data point and the usual-care value at time point 4

Model parametersThe parameters required for the model have been divided into four broad categories

1 the effectiveness data for each intervention2 the incremental costs associated with each intervention3 the relationship between utility and EPDS scores4 the relationship between total health costs and EPDS scores

The effectiveness data for each interventionThe data used within the mathematical model were taken directly from the Convergence Diagnostic andOutput Analysis (CODA) samples generated from the NMA of EPDS values This approach has theadvantage that correlation between parameters is preserved

The incremental costs associated with each interventionThe incremental cost was estimated for each intervention for each study included in the NMA of EPDSscores The incremental cost was assumed to be the additional costs associated with the interventionabove usual care costs When more than one study was used to inform the effectiveness of anintervention for example both Norman et al123 and Songoslashygard et al129 were used for the exerciseintervention in the universal population the average cost from the two studies was taken This simplisticapproach was deemed reasonable because of the assumed between-study heterogeneity values used inthe NMAs which would provide similar weightings for each study in calculating intervention efficacy

The size of groups for the group interventions was based on information provided in the studies whenavailable and advice from clinical experts otherwise The group size was assumed to be 12 for exercise-basedintervention groups eight for CBT group-based interventions and six for antenatal group interventionsThe total cost for group interventions was based on the length and number of group sessions multiplied bythe staff costs and then divided by the number in the group to give a cost per woman When the length ofappointment or session was not specified in the study it was assumed to be 2 hours for antenatal groupsessions and 1 hour for CBT-based interventions or IPT interventions For both calcium and selenium theintervention cost is assumed to be the drug cost only with no additional tests assumed to be required becauseof the prescribing of these supplements For educational information that is given out or posted to recipientswe assumed a cost of pound1 per booklet or educational information to cover the costs of postage and printingand accompanying staff costs

Some studies included an economic evaluation Although these studies included a difference in total costof health-care resource use for the intervention compared with the control the absolute cost of theintervention was used This was done for consistency with the costing approach applied to the otherinterventions in which an economic evaluation had not been carried out In one case the analysis byMorrell et al61 of all women the only change in total resource use was presented for the costs of CBT andPCA For this reason change in total resource use has been used which results in a negative cost for theintervention In the case of at-risk women Morrell et al61 presented change in health visitor costs andchange in total resource used As the intervention focused on health visitors the change in health visitorcosts was used to cost the intervention In the CBT group the intervention resulted in fewer healthvisitor visits and therefore a negative cost for the intervention was applied

A NHS and personal social services perspective was taken This meant that only costs that would fall on theNHS or personal social services in full were included in the costing of the interventions Other costs suchas volunteer opportunity costs and loss of earnings were excluded

Staff costs were taken from the 2013 Unit Costs of Health and Social Care404 and are outlined in Table 60The cost per hour of client contact with qualifications was used when available A cost per hour wasavailable for all staff roles apart from GP costs (with or without qualifications) For some staff roles forexample clinical psychologist health visitor community nurse and social worker both a unit cost per hourand a cost per hour of client contact were available The average difference between the unit cost perhour and the rate per hour of client contact (+182) was applied to those staff roles for which only acost per hour was available However the rates for social workers were excluded from the calculation ofaverage difference as the difference value was deemed to be an outlier being an increase of 383When both community and hospital costs were provided for a staff role the average of the two was usedIn addition to those costs presented in Table 60 a mean cost of face-to-face contact was used for healthvisitors at pound47 and for a GP appointment lasting 117 minutes at pound41

TABLE 60 Staff costs from the Unit Costs of Health and Social Care

Role Unit cost per hour (pound)Per hour of client contactincluding qualification costs (pound)

Physiotherapist (average community andhospital)

3500 6362b

Occupational therapist (average communityand hospital)

3500 6362b

Community clinical psychologist 5900 15900a

Health visitor 4900 7100

Midwife (community nurse) 4800 7000

Clinical support worker nursing (community)a 2100 3000b

CBT-based interventiona 5000 9900

Hospital dietitian 3500 6362b

Speech and language therapist (averagecommunity and hospital)

3500 6362b

GP per patient contact lasting 117 minutes ndash ndash

GP out of office per hour ndash 26700

Social worker (childrenrsquos services) 5700 21800

Notea Qualification costs not includedb Increased using an average of 182Data source Personal Social Services Research Unit404

The 2013 Unit Costs of Health and Social Care404 did not include costs for midwives From the economicevaluations that had included the cost of midwives two had used local costs61174 and one had used thecost of a district nurse264 The second approach was followed and the cost for a community nurse wasused as a substitute for the cost of a midwife

For CBT-based interventions and IPT-based interventions when it was not specified in the study who deliveredthe content or when the content was delivered by psychology students the reported cost of CBT-basedinterventions in the 2013 Unit Costs of Health and Social Care404 was used When it was specified that aclinical psychologist had given the intervention the cost of a clinical psychologist was used404 Any additionalcosts of training have not been included in the staff costs unless the additional cost was specified inthe study61

The costs of each intervention are detailed separately for the three populations

The costs associated with interventions for the universal preventiveinterventionsFor the universal preventive interventions a number of assumptions were made for specific interventionsA general description of the interventions is given in Table 61

Norman et al123 included an education session for the intervention group as well as the exercise sessionsThe education session were given by physiotherapists dietitians speech pathologists health psychologistsand midwives We have assumed that four out of the eight sessions were given by physiotherapists andthe other professions gave one session each For Matthey et al184 the baby play intervention and theeducation on preparing for parenting were both delivered by a clinical psychologist and either a socialworker or occupational therapist For simplicity the average cost of a social worker and occupationaltherapist was used in addition to the clinical psychologist cost The Gunn et al225 study specified that the6-week GP appointment was changed to a 1-week appointment However women could still havethe 6-week appointment if required In costing the intervention a conservative approach was taken andit was assumed that all women would have an additional GP appointment

In the case of the two studies looking at the effect of supplements208212 the costs of the supplementswere taken from the British National Formulary410 In the Mokhber et al212 study women took 100 microgof selenium per day for 6 months A 10-ml bottle contained 500 microg of selenium and therefore 37 fullbottles were required for the 6-month period Horrison-Hohner et al208 specified that the 2000mg ofcalcium per day was started at between 11 and 21 weeksrsquo gestation The assumption was made that themidpoint of 16 weeks would be used and therefore the calcium would be taken for 24 weeks assuming anormal pregnancy duration of 40 weeks A 60-tablet pack of 1000mg tablets would last 30 days and awoman would therefore require six whole 60-tablet packs over this period

No incremental cost was applied to the Shields et al219 study for the universal preventive interventionswhich ensured that each woman saw a named midwife or member of the same team throughout thepregnancy and postnatal

The following approaches were used for the studies that had an economic evaluation component to thetrial To cost the MacArthur et al264 study postnatal care costs were calculated using the matrix Aapproach to costing which uses data from midwivesrsquo diaries and GP records For the Morrell et al61 studythe differences between total costs for PCA-based and CBT-based interventions and the cost of usual carewere used because no figures related to the cost of the intervention were given for the all-women groupFor the earlier Morrell et al199 economic evaluation the additional cost of the support worker visits given inthe paper were used as the cost of the intervention Costs from all economic evaluations were uplifted to20123 prices using the hospital and community health services404

TABLE 61 Assumed intervention costs for the universal preventive interventions

Type ofintervention Study Intervention Cost (pound)

Sourcereference

Norman 2010123 Education group received written educationmaterial every week for 8 weeks through the post

800 ndash

Exercise Norman 2010123 8-week programme of 1 hour of group physicaltherapy exercises given by a physical therapist anda 30-minute education session delivered byhealth-care professionals each week

6786 PSSRU404

Songoslashygard2012129

12-week programme of 1-hour group sessions ledby physiotherapists

6362 PSSRU404

Average cost 6574 ndash

Selenium Mokhber 2011212 100 microg of selenium per day until delivery takenfor approximately 6 months

14985 BNF410

Booklet on PND Sealy 2009186 Posted an educational pamphlet at 4 weekspostnatal

100 ndash

Midwifery redesignedpostnatal carea

MacArthur2003264

Changes to postnatal care to systematicidentification and management of womenrsquoshealth problems led by midwives with GP contactonly when required

10764 MacArthuret al264

Baby play Matthey 2004184 One additional session lsquobaby playrsquo and additionalmail-outs (one antenatal and one postnatal) theextra session run by a clinical psychologist (author)and either a female social worker or occupationaltherapist

10194 PSSRU404

Matthey 2004184 One additional session which focused onpostpartum psychosocial issues and additionalmail-outs (one antenatal and one postnatal)the extra session run by a clinical psychologist(author) and either a female social worker oroccupational therapist

10194 PSSRU404

PCA-basedb

interventionMorrell 200961

all womenPsychologically informed interventions by healthvisitors

ndash2800 Morrell et al61

CBT-basedb

Early contact Gunn 1998225 Changing the 6-week GP appointment to a1-week appointment (assumes all women stillhave 6-week appointment in addition)

4100 PSSRU404

Women prescribed 1000mg of calcium twice aday between 11 and 21 weeksrsquo gestation untilbirth

7896 BNF410

Midwife-managedcare

Shields 1997219 Midwife-managed care ndash seen by same namedmidwife (or team) through pregnancy birth andpostnatal period

000 ndash

Lumley 2006147 Education and training programmes for GPs andMCHNs 10 hours of workshops simulatedpatients two clinical practice audits andevidence-based guidelines for GPs A similareducation programme provided for MCHNs with12 hours training (year 1) and 3 hours (year 2)Information kit for mothers appointment offull-time community development officer

9479 Gold et al397

Social supporta Morrell 2000199 Additional support worker visits 27900 Morrell et al199

Key MCHN maternal and child health nurse PSSRU Personal Social Services Research Unita These studies included a change in total health-care costs which are discussed in the textb Only change in total resource use available for these studies

Both MacArthur et al264 and Morrell et al199 included a change in total health-care costs For MacArthuret al264 the use of the change in total health-care cost would make the intervention of midwifery redesignedcare cost saving The intervention would go from costing pound108 to saving pound119 per woman compared withusual care For Morrell et al199 the use of change in total health care would increase the cost of theintervention of social support from pound279 to pound307 per woman

The PRISM trial evaluated by Lumley et al147 also had an economic evaluation reported in Gold et al397

The cost per woman in urban areas was used to cost the intervention as it was felt that this would betterrepresent the cost of applying the intervention in England (and Wales) than the rural cost The cost wasuplifted using the Australia Total Health Costs Index and converted to British pounds (pound) using anexchange rate of AU$055 to pound1 which was applicable in July 2014411

The costs associated with interventions for the selective preventive interventionsFor the selective preventive interventions an additional assumption was made for the Barnes et al149 studywhich evaluated volunteer home visits Volunteers were given 12 half days of training The cost of thetraining was estimated to be pound150 per day per six volunteers This gave a cost of pound150 per volunteer fortraining and it was assumed that the volunteers would see only one family the impact of this assumptionon the overall results will be discussed in the results section A general description of the otherinterventions is given in Table 62

The costs associated with interventions for the indicated preventive interventionsFor indicated preventive interventions a number of assumptions were made for specific interventionsA general description of the interventions is given in Table 63 and when needed more detail is provided

For the three studies that had an economic evaluation component we used the additional health visitorcosts from Petrou et al174 the public health costs from Dukhovny et al396 and the difference from thecontrol arm in terms of the cost of health visitor contacts from Morrell et al61 for both the CBT and PCAarms of the trial for at-risk women

TABLE 62 Assumed intervention costs for the selective preventive interventions

Type ofintervention Study Intervention Cost (pound) Source of cost information

Midwife-leddebriefing

Zlotnick 2011163 1-hour session with a trainedmidwife

7000 Small et al223

Chabrol 2002158 Five individual 1-hour sessions ndashprovided by study interventionists

49500 PSSRU404

Barnes 2009149 1-hour prevention session between2 and 5 days postnatally given bymaster level psychology students

9900 PSSRU404

Peer support Buist 1999189 Volunteers 12 half-days of training 15000 PSSRU404

Sen 2006191 Four additional classes run bymidwives nursepsychologistpsychologist

27567 PSSRU404

Zlotnick 2011163 One individual visit prenatal andpostnatal five antenatal groupsessions lasting 2 hours

25667 PSSRU404

ndash Average cost 26617 ndash

Key PSSRU Personal Social Services Research Unit

TABLE 63 Assumed intervention costs for the indicated preventive interventions

Source of costinformation

Midwiferycontinuous care

Marks 2003224 Named midwife who as far as possible followedthe woman through pregnancy delivery andpostnatally

000 ndash

Armstrong1999164 Fraser2000252

Average of 22 home nurse visits over 12 monthsA weekly case conference held where child healthnurses met with teamrsquos social worker andcommunity paediatrician

184947 PSSRU404

aPetrou 2006174 Additional health visitor visits 18500 Petrou et al174

Peer support aDukhovny2013394

Telephone-based peer support 36643 Dukhovny et al392

Gorman1997169

Five individual sessions on IPT for depression 49500 PSSRU404

Grote 2009170 Engagement session followed by eight acuteIPT-brief sessions before birth and maintenanceIPT in either biweekly or monthly sessions up to6 months postnatally

183150 PSSRU404

Grote 2009170 Written materials and encouragement to seek careif needed

100 ndash

Ginsburg2012168

Eight weekly 30ndash60 minutes in home (or in office)education sessions delivered by Apacheparaprofessional family health educators and threebooster sessions

81675 PSSRU404

Austin 2008165 Booklet 100 ndash

Ginsburg2012168

Eight weekly 30ndash60 minute in home (or in officesessions) of cognitivendashbehaviourally basedprogramme delivered by Apache paraprofessionalfamily health educators and three booster sessions

81675 PSSRU404

Austin 2008165 CBT-group-based intervention comprised sixweekly 2-hour sessions (and a later follow-upsession) of CBT delivered by a clinical psychologistand specially trained midwife

40075 PSSRU404

Munoz 2007173 CBT-based intervention 12-week moodmanagement course and four booster sessionsconducted at approximately 1 3 6 and12 months postpartum Groups of 3ndash8 pregnantwomen

87450 PSSRU404

aMorrell 200961

at-risk womenPsychologically informed interventions by healthvisitors

PCA-basedintervention

aMorrell 200961

300 Morrell et al61

Key PSSRU Personal Social Services Research Unita These studies included a change in total health-care costs which are discussed in the text

These three studies also included change in total health-care costs compared with usual care61174396 Theuse of total health-care costs would make PCA cost saving with a reduction in the cost of the interventionfrom pound3 to ndashpound27 per woman compared with usual care61 Data from this trial would also increase the costsaving associated with a CBT-based intervention from pound35 to pound58 However the effect on the overall costof CBT-based interventions would be a reduction from pound514 to pound509 in the average cost for CBT-basedinterventions Using change in total health-care costs would reduce the cost of peer support from pound366 topound269396 The cost of the promoting parentndashinfant interactions would fall very slightly for the Petrou et al174

study from pound185 to pound184 with a minimal impact on the overall cost of promoting parentndashinfantinteraction with this value remaining at pound1017 to the nearest pound

Marks et al224 specified that the intervention was to use existing midwifery resources therefore no costwas applied to this intervention Fraser et al252 specified that a weekly case conference was held betweenthe home visit nurse and the team social worker and community paediatrician although the durationof the meeting was not reported It was stated that 40 of families were referred to a social worker andthat the mean number of visits from the nurse per woman was 22 The study did not specify how longeach nurse home visit was therefore the mean cost of a face-to-face contact with a health visitor wasused to cost this part of the intervention For costing the case conferences we assumed 22 meetingsbetween the home visit nurse social worker and the community paediatrician for each family referred toa social worker We assumed that the costs of the person who would represent the paediatrician shouldthis intervention be made available in England and Wales would equal that of a GP and assumed thata duration of 10 minutes per meeting per family In the Ginsburg et al168 study which compared aCBT-based intervention with an education-based intervention Apache paraprofessional health educatorswere used to deliver both programmes The cost of CBT-based intervention was used in the analysis forboth interventions as they were delivered by the same professionals in the study Unlike the groupingof trials in the universal preventive interventions and selective preventive interventions the trials groupedas certain types of intervention in the indicated group have a much wider range of individual costsIt is unclear what the effect on the results would be if the groupings were made differently

The relationship between utility and Edinburgh Postnatal Depression ScalescoresIn order to allow a meaningful comparison of the cost-effectiveness of interventions for the preventionof PND with other technologies competing for scarce resources it was necessary to transform thedepression-specific measure (the EPDS) into a preference-based single index that can be applied to alldiseases Data were obtained from the PoNDER trial61 which provided absolute values of EPDS and SF-6Dfor individuals at three different time points 6 weeks 6 months and 1 year These data are depicted asscatterplots in Figures 62ndash64

It is seen that there is a moderate relationship between EPDS and SF-6D scores with an R2 of 0281 with aprediction that a unit improvement in EPDS score would be associated with a 001 improvement in utility

It is seen that there is a stronger relationship between EPDS and SF-6D scores at 6 months than 6 weekswith an R2 of 0474 with a prediction that a unit improvement in EPDS score would be associated with a002 improvement in utility

10 20 3015 255EPDS score (6 months)

R2 linear = 0474

y = 093 + ndash002x

FIGURE 63 The relationship between EPDS and SF-6D scores at 6 months

10 20 3015 255EPDS score (6 weeks)

R2 linear = 0281

y = 073 + ndash96Endash3x

FIGURE 62 The relationship between EPDS and SF-6D scores at 6 weeks

It is seen that there is a moderate relationship between EPDS and SF-6D scores at 12 months with an R2

value of 0403 with a prediction that a unit improvement in EPDS score would be associated with a 002improvement in utility

The coefficient of the relationships between EPDS and SF-6D scores appeared to be different for thefirst 6-week period to that at 6 months and 12 months Thus the data for 6 months and 12 months werepooled with the resulting relationship between EPDS and SF-6D in the combined data set shown inFigure 65

R2 linear = 0403

06y = 093 + ndash002x

10 20 3015 255EPDS scores (6 and 12 months)

R2 linear = 0448

y = 093 + ndash002x

FIGURE 65 The relationship between EPDS and SF-6D scores using data at both 6 and 12 months

When using the combined data for 6 and 12 months it is seen that there is a moderate relationshipbetween EPDS and SF-6D scores with an R2 value of 0448 with a prediction that a 1-point improvementin EPDS scores would be associated with a 002-unit improvement in utility An advantage of combiningthe data is to reduce the uncertainty in the relationship

The assumed relationship between EPDS and SF-6D scores used within the model is shown in Table 64The constant in the regression equation is not considered relevant as this will be applicable toall interventions

The relationship in Table 64 was used to calculate an area under the curve estimate for utility which wasthen divided by the number of weeks in a year (52178) to obtain a QALY value Subtracting the value ofusual care from that of an intervention gave the estimated incremental QALY gain associated withthat intervention

The relationship between total health costs and Edinburgh PostnatalDepression Scale scoresData were obtained from the PoNDER trial61 which provided absolute values of EPDS score and totalhealth costs for individuals at three different time points 6 weeks 6 months and 1 year These data aredepicted as scatterplots in Figures 66ndash68

It is seen that there is a very weak relationship between EPDS score and total health costs at 6 weeks withan R2 value of 0049 with a prediction that a 1-unit improvement in EPDS would be associated with a pound10decrease in costs across the 6-week period

R2 linear = 0049

y = 199E2 + 977x

FIGURE 66 The relationship between EPDS score and total health costs at 6 weeks

It is seen that there is a very weak relationship between EPDS score and total health costs at 6 monthswith an R2 value of 0018 with a prediction that a 1-unit improvement in EPDS score would be associatedwith a pound2 decrease in costs in the period from 6 weeks to 6 months

It is seen that there is a very weak relationship between EPDS score and total health costs at 12 monthswith an R2 value of 0020 The regression analysis predicts that a 1-unit improvement in EPDS score wouldbe associated with a pound2 decrease in costs across the period from 6 months to 12 months

R2 linear = 0018

y = 7152 + 213x

FIGURE 67 The relationship between EPDS score and total health costs at 6 months

y = 2123 + 23x

R2 linear = 0020

Owing to the weak relationship between the EPDS scores and total health-care costs across all timeperiods and the slight absolute cost impact it was decided not to model a relationship between EPDSscores and total health-care costs

The analyses undertakenProbabilistic analyses were undertaken to examine the impact of uncertainty on the results using 1000probabilistic draws For effectiveness data the measures of uncertainty came from the CODA samplesprovided by the NMA of EPDS values For the relationship between EPDS and SF-6D the initial andsubsequent time periods coefficients were sampled assuming a normal distribution and using the meanand standard error provided in Table 64 The values between the initial and subsequent period wereassumed to be independent

The probabilistic analyses allowed a graphical display of uncertainty in the form of a cost-effectivenessacceptability curve412 (CEAC) which indicates the probability that an intervention was the mostcost-effective A fully incremental analysis was undertaken to determine the efficiency frontier and theintervention estimated the most cost-effective assuming a cost per QALY threshold of pound20000 which is avalue NICE considers to be appropriate in funding decisions401 A further analysis calculated the incrementalcosts associated with interventions in order that the cost per QALY compared with usual care was pound20000

In addition the EVPI413 was estimated The EVPI provides an indication of the maximum amount a funderwould be prepared to pay to remove all uncertainty from the decision Measures to reduce the uncertaintymay take the form of a RCT or may come from other forms of research The EVPI is calculated directlyfrom the results of the probabilistic analyses by subtracting the net monetary benefit (NMB)414 associatedwith the strategy perceived to be most cost-effective from the NMB associated with the optimal strategy ineach of the PSA configurations and dividing by the number of PSA runs The EVPI estimate is thenmultiplied by the number of women assumed to be affected by the decision over forthcoming years

The NMB is calculated as incremental QALYs multiplied by the willingness-to-pay threshold (assumed to bepound20000 per QALY in our calculations) minus the incremental costs and is often compared with a chosenstrategy for example current care NMB can be compared directly with the largest value being for thestrategy that is most cost-effective

An example of calculating the EVPI is provided in Table 65 assuming only three PSA iterations and resultspresented per 100 people In the example the intervention is more cost-effective as it has an average NMBof pound20000 [(pound50000 ndash pound30000+ pound40000)3] compared with pound0 [(pound0+ pound0+ pound0)3] for current careHowever if the most cost-effective intervention was selected for each PSA run the average NMB would bepound30000 [(pound50000+pound0+ pound40000)3] representing an EVPI of pound10000 (pound30000 ndash pound20000) per 100people Should the decision affect 10000 people the EVPI would be pound1000000 (10000 times pound10000100)If all uncertainty was removed from the model then this would be seen as cost-effective assuming thepound20000 per QALY threshold if the cost of removing the uncertainty was less than pound1000000

TABLE 64 Assumed relationship between EPDS and SF-6D scores used within the model

Time period Coefficienta Standard error on the coefficient

Between baseline and time point 1 0018421 0000312

Between time point 1 and 1 year 0009602 0000301

Notea A one-unit decrease in EPDS is associated with this gain in utility

The EVPI can be extended to assess the value of perfect information not for all variables within the modelbut for a selected subgroup This is referred to as the EVPPI415

For the analyses conducted within this report two sets of parameters were defined the first set being theeffectiveness parameters (the CODA output from the NMA of EPDS values) and the second set beingthe relationship between EPDS scores and SF-6D scores The first group evaluated in the EVPPI analysesassumed that a trial would be commissioned evaluating all interventions for the relevant population Thesecond group assumed that data were collected for a period of at least 12 months The EVPPI analysesused the 1000 probabilistic draws for each group setting each draw to a simulated set of known lsquoperfectrsquodata while maintaining the random variability previously sampled for the remaining EVPPI group Theseanalyses were performed to assess the relative impact of removing uncertainty in the efficacy of theinterventions compared with that of removing uncertainty in the utility mapping

In order to translate value of information in terms of cost per woman into a societal value it was assumedthat a willingness to pay of pound20000 per QALY was applicable that the information would be of benefit towomen giving birth over a period of 10 years and that in England and Wales the number of women peryear who would benefit from the improved knowledge would be 720000 in case of the universalpreventive interventions 108000 in the case of the selective preventive interventions and 72000 in thecase of indicated preventive interventions The number for the universal preventive interventions wasestimated using the average numbers of maternities between 2010 and 2012 reported by the Office forNational Statistics416 and rounded to the nearest 10000 Our clinical experts also estimated that 10 ofwomen would fall in indicated preventive interventions and 15 in the selective preventive interventionsThe duration for which the greater knowledge provides benefit to society is uncertain Although it isarbitrary 10 years seemed a reasonable period of time to assume that either there were no additionalinterventions for preventing PND or considerable service reconfiguration would occur Note that this isdifferent from the duration of benefit assumed for each woman which remained for a 1-year period

Results

The estimated quality-adjusted life-year gain compared with usual care foreach interventionThe estimated QALY gains per woman for each intervention in the universal preventive interventionsselective preventive interventions and indicated preventive interventions are provided in Figures 69ndash71The trials included in each intervention group are fully detailed in Chapter 4 In all analyses the absoluteestimated QALY gain in the base case was relatively low and never exceeded 0026 (equivalent to 10 daysof perfect health) In several instances the intervention was shown to be less effective than usual careIn the sensitivity analyses in which it was assumed that the EPDS score associated with an interventionbecame equal to that of usual care at 2 years the effect of the intervention was typically larger as wouldbe expected However this was not true for all interventions as in some time points in some interventionsthe intervention was estimated to be more effective than usual care but at other time points usual carewas estimated to be more effective

TABLE 65 Illustration of EVPI calculation

PSA runCurrent care per 100 people(referent) NMB (pound)

Intervention per 100 peopleNMB (pound)

Most cost-effective optionper 100 people NMB (pound)

1 0 50000 50000

2 0 ndash30000 0

3 0 40000 40000

Average fromPSA runs

0 20000 30000

ndash 00

QALYs gained

wife-m

wifery

Calciu

m Selen

ium Bab

y play

CBT-bas

l support

Booklet o

tion p

ing fo

gnancy

tional

ct with

nd com

munity

tegies

FIGURE69

Theestimated

increm

entalQALY

compared

withusual

associated

withea

chuniversalp

interven

ndash 0020

ndash 0015

ndash 0010

ndash 0005

wife-le

riefing o

counse

lling af

hildbirt

CBT-bas

support

tion o

Base caseConvergence at 2 years

FIGURE 70 The estimated incremental QALYs per woman compared with usual care associated with each selectivepreventive intervention

ndash 006

ndash 004

ndash 002

wifery

contin

uous car

CBT-bas

oting p

t ndash infa

nt inte

support

tional

FIGURE 71 The estimated incremental QALYs per woman compared with usual care associated with each indicatedpreventive intervention

Calculating cost per quality-adjusted life-year valuesThe data presented in Figures 69ndash71 were combined with the assumed costs of each intervention toestimate a cost per QALY value for each intervention compared with usual care and also to allow a fullyincremental analysis to be undertaken These data are provided in Tables 66ndash71 for universal preventiveinterventions indicated preventive interventions and selective preventive interventions and for the base-caseand sensitivity analyses on time of EPDS score convergence In all tables the intervention estimated to be mostcost-effective at a willingness-to-pay threshold of pound20000 per QALY is shaded

TABLE 66 Cost per QALY values for the universal preventive interventions base case

Intervention

Assumedincrementalcost (pound)a

MeanincrementalQALYsa

Cost per QALYcompared withusual care (pound)

Percentageof timesgeneratingmore QALYsthan usualcare ()

Incrementalcost whichresults in acost perQALY ofpound20000 (pound)b

Fullyincrementalanalyses costper QALY (pound)c

ndash2800 00131 Dominating 848 262 ndash

ndash2400 00130 Dominating 832 259 Dominated

Usual care ndash ndash ndash ndash ndash Dominated

000 ndash00068 Dominated 664 ndash136 Dominated

Booklet on PND 100 00076 131 683 153 Dominated

Early contactwith careprovider

4100 00058 7116 694 115 Dominated

Exercise 6574 ndash00004 Dominated 495 ndash9 Dominated

Calcium 7896 00086 9189 697 172 Dominated

Primary careand communitycare strategies

9479 00009 101876 518 19 Dominated

Baby play 10194 ndash00031 Dominated 402 ndash62 Dominated

Midwiferyredesignedpostnatal care

10764 00236 4570 892 471 12961

Selenium 14985 00019 78422 542 38 Dominated

Social support 27900 ndash00052 Dominated 333 ndash103 Dominated

Notea Compared with usual careb A negative number denotes that an intervention would need to be less costly than usual carec All incremental values are in terms of per woman Dominating means costing less than an intervention producing the

same or more QALYs or producing more QALYs at the same or lower cost Dominated means costing more than anintervention producing the same or fewer QALYs or producing fewer QALYs at the same or higher cost

TABLE 67 Cost per QALY values for the selective preventive interventions base case

Intervention

Cost per QALYcomparedwith usualcare (pound)

Incrementalcost whichresults in acost per QALYof pound20000 (pound)b

Usual care ndash ndash ndash ndash ndash ndash

9900 00025 39343 561 50 Extendedlydominated

Peer support 15000 ndash00092 Dominated 268 ndash184 Dominated

26617 00158 16811 933 317 16811

49500 00147 33640 796 294 Dominated

same or more QALYs or producing more QALYs at the same or lower cost Dominated means costing more than anintervention producing the same or fewer QALYs or producing fewer QALYs at the same or higher cost Extendedlydominated means that a combination of two other interventions can produce the same number of QALYs for a lowercost than the single intervention

TABLE 68 Cost per QALY values for the indicated preventive interventions base case

Intervention

300 00067 447 635 134 447

Peer support 36643 00035 103928 589 71 Dominated

101723 00055 183696 618 111 Dominated

116325 00254 45884 889 507 62251

TABLE 69 Cost per QALY values for the universal preventive interventions sensitivity analysis

Intervention

4100 00131 3119 705 263 Dominated

Exercise 6574 00015 44486 529 30 Dominated

9479 00054 17658 588 107 Dominated

10764 00363 2963 928 727 9340

Social support 27900 00013 221579 524 25 Dominated

TABLE 70 Cost per QALY values for the selective preventive interventions sensitivity analysis

Intervention

MeanincrementalQALYa

Midwife-leddebriefing orcounsellingafter childbirth

26617 00193 13785 864 386 13785

49500 00292 16966 793 584 23191

The values from each of the individual PSAs run were also used to generate an estimate of the probabilitythat each intervention provided more QALYs than usual care

Producing cost-effectiveness acceptability curvesCost-effectiveness acceptability curves have been produced for the base case for each of the threepopulations These are reproduced in Figure 72ndash74

TABLE 71 Cost per QALY values for the indicated preventive interventions sensitivity analysis

Intervention

Assumedincrementalcosta

Cost per QALYcomparedwith usualcare

Fullyincrementalanalysesc

300 00119 251 629 239 251

101723 00060 168468 563 121 Dominated

116325 00604 19259 915 1208 23943

The three universal preventive interventions with a relatively high probability of being optimal areusual care (for low willingness to pay per QALY levels) midwifery redesigned postnatal care andPCA-based intervention

All-strategies bar peer support have a reasonable probability (gt 10) of being the most cost-effectiveselective preventive intervention As the willingness to pay per QALY value increases the probability thatIPT-based intervention is optimal increases indicating it is expected to produce the greatest mean numberof QALYs

Usual careMidwife-managed careMidwifery redesigned postnatal careCalciumSeleniumBaby playCBT-based interventionPCA-based interventionSocial supportBooklet on PNDEducation on preparing for pregnancyEducational informationEarly contact with care providerPrimary care and community care strategiesExercise

Willingness-to-pay threshold per QALY (pound000)

ndash 5 10 15 20 25 30 35 40 45 50

FIGURE 72 The CEAC for the universal preventive interventions

Willingness-to-pay threshold per QALY (pound000)ndash 5 10 15 20 25 30 35 40 45 50

Usual careMidwife-led debriefing or counsellingafter childbirthCBT-based interventionIPT-based interventionPeer supportEducation onpreparing for parenting

FIGURE 73 The CEAC for the selective preventive interventions

The three indicated preventive interventions strategies with a relatively high probability of being optimalare usual care (for low willingness to pay per QALY levels) midwifery continuous care and PCA-basedintervention As the willingness to pay per QALY value increases the probability that IPT-based interventionis optimal increases indicating it is expected to produce the greatest mean QALYs

At a willingness to pay of pound0 per QALY both usual care and midwifery continuous care were deemedoptimal as they shared the lowest cost per intervention The CEAC has been modified to allocatethe optimal strategy to the one with more QALYs in each probabilistic run (51 midwifery continuouscare and 49 usual care)

Interpretation of the cost-effectiveness results producedA brief interpretation of the results for each population is provided However a number of factors apply toall populations these are detailed in advance of the individual sections and serve to highlight theconsiderable uncertainty in the results

The analyses undertaken are limited to those interventions that reported EPDS mean values All otherinterventions are excluded adding uncertainty to any conclusion In all analyses the mean absolute QALYgain estimated was small (less than 0061 in all analyses) and may not be seen as a worthwhileimprovement should services needed to be reconfigured to achieve such benefits The current resultspresented assume that capacity of staff is infinite and changes can be achieved without incurring costswhich is an oversimplification

Uncertainty is large regarding the most cost-effective intervention in all populations Once a willingness topay of pound20000 per QALY is reached no intervention had a probability of being the optimal strategy ofgreater than 50

Furthermore the costings of each strategy have by necessity been relatively crude Additional knowledgeregarding the costs of any intervention deemed possibly cost-effective will improve the robustness ofany decision

Usual careMidwifery continuous careCBT-based interventionIPT-based interventionPCA-based interventionPromoting parent ndash infant interactionPeer supportEducational information

FIGURE 74 The CEAC for the indicated preventive interventions

Interventions for the universal preventive interventionsMidwifery redesigned postnatal care was estimated to be the most cost-effective intervention assuming awillingness to pay of pound20000 per QALY However in over 10 of simulations midwifery redesignedpostnatal care was estimated to produce fewer QALYs than usual care in the base-case analysis BothPCA-based intervention and CBT-based interventions dominated usual care and would also be candidatesfor introduction in the NHS Midwifery redesigned postnatal care remained the intervention estimated tobe most cost-effective when a duration of benefit to the woman of 2 years was assumed

Interventions for the selective preventive interventionsEducation on preparing for parenting was estimated to be the most cost-effective of the interventionsevaluated with a cost per QALY of approximately pound17000 No other intervention appeared cost-effectivecompared with usual care alone unless a residual benefit lasting until year 2 was assumed The meanQALYs produced by the peer support intervention were estimated to be lower than those produced byusual care meaning that uncertainty in the intervention costs described previously would not affect theconclusions regarding the cost-effectiveness of this strategy Education on preparing for parentingremained the intervention estimated to be most cost-effective when the duration of benefit to the womanof was assumed to be 2 years However the cost per QALY of an IPT-based intervention compared witheducation on preparing for parenting was reduced to approximately pound23000

Interventions for indicated preventive interventionsA PCA-based intervention was estimated to be the most cost-effective intervention although this wasestimated to produce more QALYs than usual care on only 64 of simulations No other interventionappeared cost-effective compared with usual care alone unless a residual benefit lasting until year 2 wasassumed A PCA-based intervention remained the intervention estimated to be most cost-effective whenthe duration of benefit to the woman was assumed to be 2 years However the cost per QALY of anIPT-based intervention compared with a PCT-based intervention was reduced to approximately pound24000 ifa benefit of 2 years was assumed

Assessing the impact of using total health-care costs when these were availablerather than intervention costsIn the universal preventive interventions the changes in assumed costs of the midwifery redesignedpostnatal care intervention and the social support intervention did not alter the intervention estimated tobe the most cost-effective assuming a willingness to pay of pound20000 per QALY This remained as midwiferyredesigned postnatal care which now dominated all other interventions using mean values Social supportremained dominated by usual care using mean values

No studies reported total health-care costs in the selective preventive interventions

In indicated preventive interventions changes to the assumed costs of a PCA-based intervention aCBT-based intervention peer support and promoting parentndashinfant interaction did not alter theintervention estimated to be the most cost-effective assuming a willingness to pay of pound20000 per QALYwhich remained a PCA-based approach The PCA-based intervention still dominated peer support andpromoting parentndashinfant interaction using mean values while a CBT-based intervention remainedextendedly dominated by a PCA-based approach and an IPT-based approach using mean values

Value of information results

Expected value of perfect information resultsFigure 75ndash77 present the EVPI per woman for the three defined populations In all of the figures the valueincreases as the willingness to pay increases indicating that there is genuine uncertainty in the mosteffective intervention Assuming a willingness to pay of pound20000 per QALY the population EVPI values arevery large in excess of pound150M for all analyses which would more than cover the costs of studies aimed atreducing the uncertainty in model parameters

Assuming that 720 million women would benefit from improved knowledge in the universal preventiveinterventions and a willingness to pay of pound20000 per QALY the population EVPI was estimated to bepound193B (pound267 times 720 million)

Assuming that 108 million women would benefit from improved knowledge in the selective preventiveinterventions and a willingness to pay of pound20000 per QALY the population EVPI was estimated to bepound205M (pound190 times 108 million)

(pound)

Willingness-to-pay per QALY (pound000)ndash 5 10 15 20 25 30 35 40 45 50

FIGURE 75 The EVPI associated with the universal preventive interventions

(pound)

ndash50

100150200250300350400450500

FIGURE 76 The EVPI associated with the selective preventive interventions

Assuming that 720000 women would benefit from improved knowledge in indicated preventiveinterventions and a willingness to pay of pound20000 per QALY the population EVPI was estimated to bepound166M (pound230 times 720000)

Expected value of partial perfect information resultsAs previously stated the EVPPI analyses were undertaken assuming two broad groups the efficacy data thatrepresented the correlated CODA output from the NMA and the mapping of EPDS scores to utility values

The EVPPI for the mapping group was zero indicating that the value assigned to the relationship betweenEPDS and utility would not alter the conclusion regarding which intervention was most cost-effective Instark contrast having perfect data on the relative efficacies of the interventions could result in a differentdecision on the most cost-effective intervention and would be valuable For all populations the EVPPI forthe efficacy group equalled the EVPI value It is seen in Figure 78 that the impact of uncertainty in theefficacy data dwarfs that within the mapping

(pound)

ndash100200300400500600700800900

FIGURE 77 The EVPI associated with the indicated preventive interventions

Universal Selective Indicated

(pound)

EVPIEVPPI efficacy

FIGURE 78 Results of the EVPI and EVPPI analyses The value for the EVPPI for mapping is zero

Discussion of the assessment of cost-effectiveness of interventionsAlthough the cost-effectiveness analyses undertaken allow the most cost-effective intervention in eachpopulation to be estimated these results are far from definitive Limitations with the analyses include

l Interventions that did not report EPDS values have been omitted from the analysesl The incremental costs for each strategy have by necessity been estimated in a simplistic manner

Costs of restructuring services if required have not been includedl The possibility of erroneous grouping of trials as a single intervention within indicated preventive interventionsl Simplistic assumptions have been made in estimating the area under the curve when data are not

available for all time points

Limitations with providing a definitive conclusion regarding the most cost-effective intervention include

l that absolute QALY gains estimated are small for all interventionsl that there is considerable uncertainty in the direction of the estimates of QALY change compared with

usual care for all interventions thus usual care could conceivably be the most effective intervention inall three populations

Value of information analyses were undertaken to estimate the monetary value of removing uncertainty inthe efficacy data These values were shown to be exceedingly high in the order of hundreds of millionsof pounds which would be sufficient to cover the costs of future research Although the relationshipbetween EPDS and utility was not shown to influence the decision given current information shouldfuture research be undertaken it is recommended that utility data be collected In addition detailed costingdata for each intervention should be recorded in any future research

Chapter 10 Discussion

Introduction

The purpose of the current review was to evaluate the clinical effectiveness and cost-effectivenessacceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women toprevent PND In this chapter the principal findings of the NMAs and the economic evaluation areinterpreted alongside an assessment of the strengths and limitations of the review and the overallstrengths and limitations of the individual trials Uncertainty about intervention effects implications forfurther research and implications for practice are highlighted

Up until 10ndash15 years ago management of depression in postpartum women was a neglected area59 andeven less attention was paid to the prevention of PND in research or practice59 However with increasingknowledge about perinatal mental health59 and particularly its potential long-term impact on thedevelopment of infants33 the need for preventive approaches has become more apparent

The breadth of approaches aimed at preventing PND evaluated in clinical trials reflects the uncertaintyaround the aetiology of the condition and which of the many associated factors might be amenable tointervention Some factors such as a history of depression (before pregnancy during pregnancy orpostnatally) or a familial or genetic component are unalterable but levels of risk may be reduced Otherfactors such as lack of social support are potentially amenable to intervention

Description of the interventions

As far as we are aware this is the most comprehensive review of interventions to evaluate the clinicaleffectiveness and cost-effectiveness acceptability and safety of antenatal and postnatal interventions forpregnant and postnatal women to prevent PND In total 86 RCTs are included Trials are categorised intoone of three levels of preventive intervention (universal selective and indicated) relevant for particularpopulations of women the findings for each of these levels of preventive interventions is reported alongwith the limitations and implications

The earlier Cochrane review of psychosocial and psychological interventions to prevent PND417 searchedto 30 November 2011 and the current review searched to July 2013 Our review included diverseinterventions to prevent PND not just psychosocial and psychological which is important given the diverseaetiology of PND

The review includes trials from 16 countries Trials were classified as psychological (including specifictherapeutic approaches) educational social pharmacological organisation of maternity care midwifery-led interventions and CAM or other approaches to the prevention of PND All of the universal preventiveinterventions were considered applicable to selective and indicated populations Not all selectivepreventive interventions or indicated preventive interventions were applicable to a universal populationEvidence for some of the interventions was available neither for all populations nor for all follow-up timesmeaning an evaluation of some interventions is necessarily incomplete

The trials which followed up participants until 12 months postnatally provided information about enduringeffects Those trials which had a short-term follow-up of 6 weeks or 3 months did not provide informationabout whether or not any effect was sustained over the full postnatal year

Levels of preventive intervention

We defined selective preventive interventions as those provided for maternal populations identified on thebasis of social risk (eg teenage parenting or poverty) and indicated preventive interventions as thoseprovided for populations with individual risk (eg history of depression or a high score on a symptomchecklist) Universal preventive interventions were provided for all pregnant and eligible postnatal women

Categorising the trials into three levels of preventive intervention relevant for particular populations ofwomen facilitates decisions on service provision from a service provider or commissioner perspective Theidentification of populations of perinatal women for either selective or indicated preventive interventionscan follow an assessment of risk of PND only among a population of perinatal women suitable foruniversal preventive interventions Risk assessment requires specialised skills The exceptions are forparticular pregnant or postnatal women already known to health services because of a personal historyongoing depression or anxiety or because of their social circumstances

Within the trials definitions of risk were inconsistent Some trials used clinical criteria such as HIV-positiveserostatus or a screen for trauma symptoms Other trials applied social criteria such as being teenagefirst-time pregnant unmarried from specific ethnic groups (such as Navajo or White Mountain ApacheAmerican Indian) or screened positive for domestic violence in the past year Other trials used a depressiondiagnostic instrument or a measure of depressive symptoms Even where a common instrument hadbeen used to identify depressive symptoms there was inconsistency in the threshold scores used todefine level of risk Some judgement was required for allocating trials to one of the three levels ofpreventive intervention

Conceptualisation of postnatal depression and the potentialfor prevention

Although depression can range on a continuum from mild symptoms to major depressive disorder it isclassified in psychiatry and for research purposes within a dichotomy of diagnosed depression or notdepressed The spectrum of symptoms in one personrsquos state or mood can vary daily and weekly Weregarded depression in postnatal women as depression which may have begun before pregnancy duringpregnancy or after the baby was born Trials for which the main focus was treatment of antenataldepression were included if they included a postnatal measure of depressive symptoms or a depressiondiagnosis that is the antenatal treatment of depression was regarded as the prevention of PND Theimplications of depression for a pregnant mother and her developing baby are different from theimplications of depression for a new mother and her newborn and developing infant There wasinconsistency in the definition of antenatal depression as different self-completed measures of depressivesymptoms (eg EPDS or BDI) or depression diagnostic instruments (eg DSM-IV or ICD-10) were used

Focus of the included interventions

Although all of the trials included a measure of PND the primary aim of the trials varied from beingprimarily about PND prevention antenatal well-being birth outcomes general health generalpsychological well-being infant outcomes and family outcomes The deliberately broad inclusion criteriawithin our review enabled the capture of all potentially effective interventions whether PND was a primaryor secondary outcome notwithstanding selective reporting and publication bias

DISCUSSION

Network meta-analyses

A novel feature of this review was that inferences about intervention effects were made using a NMAThe NMA was used to determine the clinical effectiveness of individual antenatal and postnatal interventionsfor preventing PND and to generate the joint distribution of individual antenatal and postnatalinterventions which was used to characterise the uncertainty around inputs for the economic model

A NMA requires trials to form a connected network of interventions to enable intervention effects to besynthesised and compared That is trials included in the review could only be included in the NMA if theyshared at least one intervention in common with at least one other study In addition trials must haveprovided information on the outcome measure of interest The assumption made in the analysis was thatany trials that were excluded because they did not provide information on the outcome of interest weremissing at random

Trials were excluded from the NMA if lsquousual carersquo was considered to be sufficiently different from that inthe UK or if the outcomes reported did not include the EPDS

Clinical effectiveness of universal preventive interventions

Of the trials included in the NMA interventions most likely to be the best among those evaluable at eachassessment were

l at 3 months postnatally midwifery redesigned postnatal care146

The most promising interventions were selected only from the set of interventions which formeda network

Psychological interventionsIn the PCA-based intervention of health visitor training (the PoNDER trial) health visitors were trained in theassessment of postnatal women combined with up to eight sessions for eligible women in one arm aPCA and in the other arm a CBA61 The control group and the intervention group health visitors had anongoing relationship with the women as part of their usual care This trial had a low risk of bias and hadthe longest follow-up of 18 months The trial had an accompanying economic evaluation which indicateda high probability that the intervention was cost-effective but required what was considered a lengthytraining for health visitors including ongoing clinical supervision and reflective practice equivalent intotal to 8 days The economic model indicated that among the universal preventive interventions thePCA-based intervention61 was a candidate for introduction in the NHS The trial findings were published in2009 and were not included in the 2007 NICE guidance on antenatal and postnatal mental health38

Pharmacological or supplementsThe calcium trial was included within a trial examining the prevention of pre-eclampsia Outcomes weremeasured at only 3 months postnatally The trial was assessed as having a high risk of bias overall Theauthors were unable to explain the disparate outcomes in the two centres Portland and Albuquerque208

Midwifery-led interventionsThe intervention in the trial of redesigned midwifery-led community postnatal care was designed to enablemidwifery care in community settings to be tailored flexibly according to the individual needs of thewomen The focus was on the identification and management of womenrsquos physical and psychologicalhealth rather than on routine observations146 The trial had a low risk of bias Women in the interventiongroup had a final check with their midwife at 10ndash12 weeks which replaced the GP contact at 6ndash8-weeksand overall GP consultation rates during the year were reduced in the intervention group The economicevaluation indicated that among the universal preventive interventions this intervention was the mostcost-effective given current knowledge

Despite some evidence of clinical benefit and cost savings the findings did not substantially changepractice or influence guidance Following the 2004 revision to the GP contract funding for maternity carewas no longer allocated on an lsquoitem of servicersquo basis but was included in a global sum paid to GPs418

No recent studies have assessed the benefit of the GP role in postnatal care The National ServiceFramework419 recommended that all women should be provided with access to a midwife for up to28 days post birth NICE guidance420 on routine postnatal care of women and their babies recommendedthat postnatal contacts should be based on an individual womanrsquos need However many care providers inEngland continue to discharge some women from midwifery care at around 10ndash14 days postnatally tohealth visitor care with a routine GP contact offered at 6ndash8 weeks postnatally Current NHS resourceconstraints mean that women are likely to be offered far fewer community contacts than were available inthe trial of redesigned midwifery-led community postnatal care146 The historical definition of the postnatalperiod and fragmented organisation of maternity services across health-care sectors have hitherto beenmajor barriers to revising practice in line with evidence despite policy recognition of the importance ofeffective maternity care to promote life-long health and to reduce inequalities66

In the trial of midwife-managed care within a Midwifery Development Unit (MDU)220 825 women wereassessed at only 7 weeks postnatally using an unvalidated nine-item version of the EPDS rather than theusual 10-item EPDS This model provided a high degree of continuity of care and carer with the aim thatwomen should receive care from no more than four midwives during their hospital and communitypregnancy labour and postnatal care MDU midwives therefore worked in both community and hospitalsettings Birthing rooms used by MDU women were less clinical than those generally available and hospitalpostnatal care was provided in a dedicated postnatal ward that was designed to provide a more home-likeenvironment The authors advised at the time that further research should be carried out on the midwifersquostraining in support especially emotional support The benefits of this approach merit consideration butthe various components would require significant changes in midwifery working to those utilised in mostof the UK and would also require changes to facilities if the model was replicated

Universal preventive interventions not included in the networkmeta-analysisSome interventions could not be compared in the NMA because trials did not provide the required dataFor trials not included in the NMA there should be caution about relying too heavily on whether or not atest of hypothesis was statistically significant in a particular trial for example when the trial results showeda p-value less than 005 and the investigators concluded that the intervention was effective One of theuniversal preventive intervention trials excluded from the NMA was conducted in the UK150 This trial ofunclear risk of bias examining the frequency of health visitorsrsquo visits found no impact on most outcomes

A US trial of education on preparing for parenting (a psychosocial prevention programme implementedthrough childbirth education programmes to enhance the co-parental relationship parental mental healththe parentndashchild relationship and infant emotional and physiological regulation) with 169 participants hadan unclear risk of bias and found lsquoa [statistically] significant intervention effect on maternal depression andanxietyrsquo using subset of seven items CES-D163

DISCUSSION

An Australian trial of lsquoTowards Parenthoodrsquo with 143 women in the education on preparing for parentingclass of interventions was of unclear risk of bias found lsquo[statistically] significantly lower levels of depression(BDI-II) post-treatment than participants in routine carersquo185 The different elements of the intervention couldnot be evaluated separately

Summary of qualitative findings for universal preventive interventionsFourteen of the 21 qualitative studies of interventions examined a universal preventive interventionIncluded studies provide at least moderate certainty with regard to their findings Universal approachesmust recognise that for a number of women the practical considerations regarding access to theintervention convenience and challenges of integration with other responsibilities (such as other childrenor work commitments) may provide significant barriers to attendance at a substantive number of sessionsor even attendance at all Group-based approaches seemed to offer a wide range of resources andstrategies beyond those offered by the facilitator and provided that they do not prove too resourceintensive or create unrealistic expectations of services may be a useful supplement to provisionGroup-based approaches may compensate for limitations in the formal care provision by providing additionalsocial support provided the group process is facilitated adequately However an important considerationrelates to whether or not group approaches are able to offer sufficient individualised attention andcontinuity of care Continuity of care was confirmed as an important operator across several interventionsand viewed as important by the EP committee in that it enabled women to build up a relationship of trustwith their health-care provider This enabled both free communication of problems or concerns and thentailoring of support strategies to the needs of the individual woman Midwifery redesigned careinterventions seek to offer improved continuity However such continuity is not an automatic product of asingle named provider or a stable team it requires rapport and skills in facilitation if it is not to become anadditional source of stress or anxiety

The CenteringPregnancy approach is a highly structured resource-intensive intervention that is being exploredin the UK421 but has not yet been used widely in UK settings and may reveal its limitations within aresource-constrained environment CenteringPregnancy provides group care to women at similar stages ofpregnancy with a health assessment and provision of education and peer support As a lsquowhole-systemrsquo

approach it seems to merit wider evaluation not simply against outcomes of relevance to PND but against abroad range of maternal and infant outcomes both short and medium term It may also offer support topartners considered an important aspect of an intervention by the literature and the expert group of serviceusers However such involvement is not unproblematic and may in fact exacerbate feelings of lackof support particularly in comparison to others within the group Although CenteringPregnancy has beenevaluated in a universal context its greater potential given the extensive requirement for training and individualfollow-up support seems to lie in it being a more appropriate approach for an indicated population

Clinical effectiveness of selective preventive interventions

In general the treatment effects for the selective preventive interventions were inconclusive Of the studiesincluded in the NMA the most beneficial treatments appeared to be CBT-based interventions158 IPT-basedinterventions163 and education on preparing for parenting The most promising interventions for a selectivepopulation of women are presented within the categories in which the universal preventive interventionswere presented

Psychological interventionsOne of the most beneficial selective preventive interventions appeared to be CBT-based intervention158 withIPT-based intervention estimated to provide the most QALYs IPT is a relatively newly studied specific form ofpsychological intervention which focuses on facilitating positive relationships The studies examining IPT-basedinterventions were mainly undertaken in the USA with two in China (one in Hong Kong) IPT has not beenas well adopted in the UK as CBT-based approaches Its use has been supported in a meta-analysis ofpsychological treatments for PND62422 and treatment for perinatal depression (including antenatal depression)250

These studies could be replicated in a selective preventive intervention population

Educational interventionsEducation on preparing for parenting appeared to be one of the more beneficial educational selectivepreventive interventions It was estimated to be the most cost-effective of the trials of educationalinterventions evaluated with a cost of approximately pound17000 per QALY The individual interventions weredissimilar One based in the UK examined the effectiveness of attendance at a twin clinic and provision ofadditional antenatal education information and support by a specialist midwife for women with twins191

The other based in the USA offered 10 classes during pregnancy and postpartum focusing on parentingand coping strategies with 44 women and was of unclear risk of bias189

Social supportThe trial conducted in the UK of 343 young women having their first baby and living in asocioeconomically disadvantaged area examined peer mentor support in pregnancy and postnatally201

The failure to demonstrate a difference in the social support peer mentor group was similar to results fromthe trial of postnatal social support provided for a universal population199 in which there appeared to be atrend for the intervention group scores to reflect poorer health than the scores for women in the controlgroup The authors recommended further rigorous evaluation of interventions to promote the health ofchildren in socially disadvantaged communities392 More attention should be paid to exploring the natureof the support women say they would like such as peer support rather than examining the effectivenessof interventions without a particular theoretical basis

Summary of qualitative findings for selective preventive interventionsFour qualitative studies presented data from those who had received a selective preventive interventionIncluded studies provide at least moderate certainty with regard to their findings CenteringPregnancy wascredited as offering support to partners as well as facilitating support from the wider family and mostimportantly the peer support the intervention offered IPT appears a well-received approach althoughconclusions on the appropriateness of IPT as a selective prevention intervention are based on findings froma single study and constrained by the lack of qualitative evidence on the other types of intervention

Clinical effectiveness of indicated preventive interventions

The NMA showed that in general the treatment effects for the indicated preventive interventions wereinconclusive and the CrIs were wide The most beneficial interventions appeared to be those promotingparentndashinfant interaction at 6 weeks and 3 months postnatally164 those providing peer support at3 months postnatally205 or educational information at 3 months postnatally168 CBT-based intervention at3ndash4 months postnatally173 IPT-based intervention at 7 months postnatally169170 PCA-based interventionat 6 and 12 months postnatally61 and CBT-based intervention at 6 and 12 months postnatally61

The economic analysis showed that the indicated preventive interventions strategies with a relatively highprobability of being optimal were midwifery continuous care and PCA-61 and IPT-based interventions

Indicated preventive interventions not included in the networkmeta-analysisSome interventions could not be compared in the NMA because trials did not provide the required dataApart from one large trial conducted in Pakistan148 most of those excluded were small trials or trialswithout a comparable usual-care control group Two small trials of women living in poverty178179 suggesteda positive benefit of an IPT-based intervention However these results could be a consequence of smallstudy effects and they should be confirmed in a RCT with up to 1 year of follow-up and adequatelypowered to detect clinically relevant treatment effects

DISCUSSION

Social supportAmong the trials not included in the NMA the UK-based trial examined Newpin volunteer peer support in65 women206 The prevalence of perinatal major depression measured by the SCAN was 27 (830) inthe Newpin befriender group and 54 (1935) in the control group This diagnostic instrument is morerobust than the EPDS and the findings should be taken seriously by replicating the trial with anappropriately large sample size

Pharmacological or supplementsThe findings demonstrating the effectiveness of sertraline216 have been incorporated into clinical practice

Complementary and alternative medicine or other interventionsThe small study of acupuncture control acupuncture and massage in 61 women at different points inpregnancy (11ndash28 weeks)229 was of unclear risk of bias and used the BDI at 10 weeks postnatallyAll of the trials within CAM or other were at unclear or high risk of bias

Summary of qualitative findings for indicated preventive interventionsThree qualitative studies presented data from those who had received an indicated preventive interventionand provided at least moderate certainty with regard to their findings For an indicated population thespecific attention to developing strategies for better management of interpersonal relationships as offeredby IPT approaches was important Although the experience of individual women is unique as affirmed bythe expert group of service users the facility for normalisation and creation of realistic expectations ofwhat to expect and of which strategies might help is key to intervention approaches However once againit must be recognised that conclusions on the appropriateness of IPT as an intervention are constrained bythe lack of qualitative evidence on the other types of intervention The good availability of a specialistperinatal and infant mental health service appeared to be an essential part of an indicated preventiveintervention although it should be noted that referral and discharge processes could cause anxiety andhow these are dealt with is of key importance

Economic analysis

This is the most up-to-date review of trials about the prevention or management of PND and provides thefirst estimate of the cost-effectiveness of preventing PND The review included economic evaluationsalongside trials decision models and a cost study In addition to the clinical outcomes the review wasable to combine the effectiveness data with the incremental costs for each intervention Data from thePoNDER trial61 were used to estimate a relationship between EPDS scores and SF-6D allowing the QALYsproduced by each intervention in the NMA of EPDS scores to be estimated The incremental costs andQALYs for each intervention compared with standard care were used to estimate the cost-effectiveness ofthe intervention against standard care In addition fully incremental analyses were conducted as werevalue of information analyses

These estimates do not take into account any effects on the infant and the potential for them to benefitfrom QALY gain throughout their life course

The universal preventive interventions with a relatively high probability of being optimal and hencecandidates for introduction within the NHS were redesigned midwifery-led community postnatal care264

PCA-based interventions61 and CBT-based interventions61173

Education on preparing for parenting was estimated to be the most cost-effective of the selectivepreventive interventions189191

Of the indicated preventive interventions a PCA-based intervention was estimated to be the mostcost-effective intervention with the probability of the IPT-based intervention being optimal increasing asthe willingness to pay per QALY increased

There is genuine uncertainty as to the most effective intervention within the three levels of preventiveintervention In addition the economic analysis has provided an analysis of the value of further research inthe area Assuming a willingness to pay of pound20000 per QALY the population analysis (EVPI) values arevery large in excess of pound150M for all analyses For the universal preventive interventions selectivepreventive interventions and indicated preventive interventions the EVPI was estimated to be pound1930Mpound205M and pound166M respectively These results were limited to those interventions for which an EPDSmean score was available Overall there was considerable uncertainty about the most cost-effectiveintervention in all populations as the cost estimations and estimations of the area under the curve weresimple and the absolute QALY gains were small for all interventions Expected value of informationanalyses quantify the expected gain from obtaining further information to inform decisions For furtherresearch to be worthwhile the EVPI must exceed the planned research costs No definitive answer can beprovided regarding the most cost-effective intervention because of the large uncertainty regarding therelative efficacies of the interventions Given the high EVPPI values which exceed the cost of trials futuretrials assessing the relative efficacies of promising interventions appear value for money

Limitations of the quantitative evidence base

Replication of interventionsOne limitation of the evidence base and therefore the evidence synthesis was the lack of replication ofinterventions other than of usual care as a control intervention The exceptions were lsquoeducation onpreparing for parentingrsquo189191 lsquopromoting parentndashinfant interactionrsquo164174 lsquoCBT-based interventionrsquo61165168173

and lsquoIPT-based interventionrsquo169170 Within the interventions there was variation in skills of the careprovider and the format timing and duration of the intervention provided

It was not possible for the review team to verify any potential benefits suggested by investigatorswho reported statistically significant effects on small trials of unclear risk of bias Similarly wheninvestigators reported statistically non-significant results in trials that were not adequately powered todetect clinically meaningful effects the results remain uncertain

Despite the number of interventions assessed for the prevention of PND and the large number of trialsconducted there was generally a lack of replication of trials to confirm intervention effects The lack ofreplication meant that there were insufficient sample data (ie trials) to estimate the between-trial SD fromthe data alone The reasons for the lack of replication concern the complexity of the aetiology of PNDand the additional skills required for interventions to be tested in addition to the novelty of the researchoverall in this generally neglected area of research

Moderators and mediatorsThe random (treatment)-effect models assumed that there was heterogeneity of treatment effects betweentrials The mean of the random-effects distribution represents the pooled mean across the population anddoes not relate to women with any specific characteristics Data were available from trials describing thestudy-level characteristics of the participants and the intervention provider as continuous or dichotomousoutcomes When there is heterogeneity between trials it is sometimes possible to use meta-regression toexplore whether or not study-level characteristics are treatment effect modifiers However it was notpossible to perform a meta-regression in this instance because there was insufficient replication of eachtreatment effect across trials

DISCUSSION

Limitations of the included trials

Quality of the trialsThe Cochrane risk-of-bias assessment allowed a robust assessment of the risk of bias by two reviewers forthe 86 RCTs The highest level of assessed risk was for allocation concealment followed by incompleteoutcome data then random sequence generation Rather than excluding trials on the basis of anassessment of high risk of bias all of the included trials were incorporated into the NMA irrespective of theassessment of risk of bias The trials for which there appeared to be the most beneficial treatments werenearly all assessed as being at low risk of bias Knowledge of the methodological weaknesses of the trialsthat were assessed as high risk of bias allows recommendations to be made about how to improve thegeneral standard of research in the field

Heterogeneity of trial participantsThe participantsrsquo characteristics reflected the heterogeneity of the individual trials country care systemseverity of depression risk factors age HIV serostatus thyroid status traumatic birth experience andintimate partner violence The mean age of participants ranged from 16 to 33 years The trials with youngparticipants were mainly the selective preventive intervention trials

Intervention providerMore than 30 different health-care professionals (doctors nurses and midwives) community volunteersand peer workers and specialists (acupuncture physiotherapy counselling massage psychology socialwork yoga) were involved in providing the interventions The training ranged from 4 hours for peersupport workers to master- and doctoral-level clinicians with supervision and the use of training manualsIt was not possible to determine whether or not a longer length of training was associated with greatereffectiveness although it is likely that the longer the length of training was associated with a greater cost

Variations in health-care practice are important and may be attributable to components related to practitionersas individuals and women as individuals and the interaction between them A highly skilled practitioner maybe able to develop a trusting relationship with many people a very much less skilled practitioner with onlysome people The skills are trainable but only to some extent In individual trials with access to individual-leveldata with many women and many practitioners it should be possible to carry out multilevel modelling thatwould enable an estimate of the practitioner effect When there are few participants and only one or twopractitioners providing the intervention it is not possible to disentangle the practitioner effect

Usual care in the UKThe reference treatment was usual care but we acknowledge that this varies between countries and withincountries We consulted a number of experts around the world to gain their views on the comparabilityof usual care in the UK with usual care in the other countries where trials were conducted Usual perinatalcare was defined as routine antenatal or postnatal care for healthy women with uncomplicatedpregnancies The consultation allowed us to conclude that care in Australia Canada Europe (France andNorway) and the USA was comparable for the network with usual care in the UK but that it would not bepossible to form a network with usual care provided in China (Hong Kong) Japan Mexico PakistanSouth Africa and Taiwan

Measures of depressionOver 100 different instruments had been used in the included trials reflecting the lack of focus onparticular outcomes or the lack of validated instruments used Trials using the EPDS were selected as thefocus for this review because this was the instrument most frequently used in the trials and because beinga continuous measure results were presented as mean (SD) values EPDS data are not normally distributedand methods of analysis should acknowledge the skewness of the data The EPDS can also be used as adichotomous measure for use in clinical practice but a score of below a certain threshold does not confirmthe absence of depression2 Further research might examine the outcomes of trials which used otherprimary outcome measures or diagnostic instruments when measuring depression

Treatment end pointsThe reason for the measuring outcomes at 6 weeks 10 weeks 12 weeks 16 weeks 4ndash5 months6 months 7 months 9 months and 12 months postnatally is not clear A reduction in some of the timepoints to 6 weeks 12 weeks 6 months and 12 months postnatally would allow monitoring of anyenduring effect to 12 months postnatally and allow a better comparison with the outcomes in other trials

Infant outcomesOne of the potential effects of PND is the impact on infant development An infant can be exposed to alsquocumulative dose of depressionrsquo by either severity or duration and infants may vary in their susceptibility tothe effects of PND Impact of interventions on infants is difficult to determine before the age of 12 monthsand is often assessed by parental reports or more objective researcher assessments in controlled situationsFew of the trials reported outcomes to 12 months or reported infant outcomes at all It would beimportant to use repeated measures analysis to 12 months postnatally or longer and explore if any effecton infant development varied over time and if infant development scores correlated with maternaldepression scores over time Infants of women who were depressed in pregnancy or postnatally have beenfollowed up to school age and beyond and there is evidence of lifelong effects on infantsrsquo mental healthHowever within the context of a RCT we are only aware of the PoNDER trial which followed up infants to18 months postnatally In the included studies which measured infant outcomes61149153168174201211 usingthe Ainsworth Strange Situation Assessment of Infant Attachment Bayley Scales of Infant DevelopmentBehaviour Screening Questionnaire Childrenrsquos Global Assessment Scale Infant CharacteristicsQuestionnaire and the Infant Toddler Social Emotional Assessment there was no clear benefit for infants inthe measures used It was not possible to perform a NMA The sample size for trials examining infantoutcomes should be appropriately large to determine differences where they exist The main reason for theexpansion of interest in PND in recent years is the recognition of the impact this usually self-limitingmaternal condition has on the mental health of the infant across the life course It is therefore a seriouslimitation of the review that the effects of intervention on this outcome could not be assessed

Strengths of the review

We undertook a rigorous systematic review and we believe that we identified all relevant trials evaluatingthe clinical effectiveness of interventions to prevent PND Although we appraised and summarised a verylarge number of trials much of the evidence was inconclusive because of inconsistency in determining anat-risk population for identifying the level of preventive intervention outcomes measured thresholds usedin the same outcome measure follow-up time points and timing duration and intensity of individualintervention provided

The analysis approach differs from that used in previous Cochrane reviews233417 and other reviews423 whichdid not distinguish between interventions within trials in terms of the control or comparator interventionsThe 2013 Cochrane review417 did not consider specific interventions separately but combined differentpsychosocial and psychological interventions In contrast our objective was to assess the clinicaleffectiveness and cost-effectiveness of individual interventions and the value of collecting additionalinformation These reviews were unable to make inferences about the relative effects of specificinterventions beyond class effects for psychological educational social and pharmacological interventionsThe assumptions that they made were that intervention effects within a class were identical rather thantreating them as related and exchangeable

Previous reviews used standardised effect sizes rather than EPDS scores Standardised effect sizes havebeen criticised on the basis that trials with identical results may spuriously appear to give different resultsThis can lead to estimates that were smaller in magnitude than other trials but appear greater and viceversa Working with standardised mean scores would also require a mapping to utility Previous reviewsalso tended to ignore the time at which assessments were made often taking the latest assessment time

DISCUSSION

this would be reasonable if the treatment effect was constant over time although little attempt has beenmade to test this assumption

A further strength was the development of a de novo model which allowed the cost-effectiveness of eachintervention compared with usual care to be estimated Furthermore fully incremental analyses and valueof information calculations were undertaken

Limitations of the review

The NMA offers an advance on previous reviews Nevertheless there are some limitations with thecurrent analysis

l Some trials were omitted because they did not provide EPDS scores and this may have introducedreporting or selection bias In principle a multivariate meta-analysis would allow correlation betweenoutcomes to be estimated in trials that provide multiple outcomes However this would involve amultivariate NMA of multiarm trials which is beyond the scope of this review

l No adjustment was made for the lack of quality associated with some trials Evidence was taken at facevalue and treatment effects may thus be overstated

l The analysis of EPDS scores assumes independence of outcomes within trials and independence ofpopulation intervention effects between trials The EPDS scores are longitudinal within trials(ie repeated measures) and EPDS mean scores are expected to be more similar within trials thanbetween trials We would also expect population mean intervention effects to be correlated betweentrials at different times and for the between study SD to be different at different times However thelack of replication of pairs of interventions means that these parameters would be difficult to estimatewithout external information which is beyond the scope of this review

l A limitation of the economic evaluation was that estimations of incremental costs and themethodology used in the area under the curve model were by necessity simplistic which may haveintroduced inaccuracy

l Infant outcomes were not examined in detail because of inconsistent published infant outcome datal Family outcomes were not examined in detail because of insufficient outcome data

Discussion of all qualitative findings

In addition to the 21 qualitative studies of interventions a further 23 studies reported qualitative data onperspectives and attitudes of women who had not experienced PND regarding PSSSs that they believehelped them to prevent the condition Included studies were generally of moderate to high quality andtherefore taken individually or collectively provide at least moderate certainty with regard to their findingsAlthough the hypothetical nature of suggested strategies must be acknowledged this body of evidenceclearly provides a useful counterpoint to interventions that are largely hypothesised by service providersGenerally this wider evidence base confirmed the presence of many features considered important bywomen within existing interventions However the teamrsquos ability to identify these components wasconstrained by the limited detail of reporting of each intervention Nevertheless we believe that eachintervention current or planned should be evaluated against the list of strategies considered helpful bywomen who avoided PND The findings of the qualitative review may therefore make a major contributionto design of future interventions

The implications of the main findings of this review

Findings associated with the evidence base methodological implicationsPrevious reviews have found no evidence to recommend any intervention for preventing PND because ofmethodological limitations

Many trials reviewed were pilot studies or had small or non-generalisable samples Overall the universalpreventive intervention trials were rated to have greater risks of bias than the selective and indicatedpreventive interventions this was most notable for selection bias and attrition bias This may be aninevitable consequence of research with women in this population Fundamental reporting of qualitycriteria applicable to all trials random sequence generation and allocation concealment would howeverimprove (when it occurred) the quality assessment of up to 25 of trials

Implications for future research in the prevention of postnataldepression

The implications of the findings are that a variety of different approaches may be valuable in theprevention of PND Identifying the single best approach for each level of preventive intervention may bewhat service commissioners require Future trials could investigate individual womenrsquos preferences forapproaches and the impact on effectiveness of offering women choice Rather than establish a newpractitioner role future trials could examine the effectiveness of the development of additional skills inpractitioners who already work with pregnant and postnatal women Examining the effectiveness oftraining in a PCA-based intervention a CBT-based intervention or an IPT-based intervention would requirea large enough sample to undertake practitioner-level analysis to explore practitioner variability

In future trials the data generation process for the EPDS should be better considered EPDS data areordered categorical data and calculating a sample mean and sample SD for the purpose of statisticalinference means appealing to the central limit theorem In general the sample sizes were not largeenough for the central limit theorem to apply Future estimates of treatment effect should be based onmethods of analysis using ordered categorical techniques It would still be possible to estimate populationEPDS mean scores rather than sample mean scores but based on the population proportion of womenUsing the current approach of using the sample mean can lead to negative estimates of absolute meanEPDS mean scores when it is assumed that the distribution of EPDS scores is normal

Edinburgh Postnatal Depression Scale scores may be dichotomised in clinical practice as an assessment ofrisk and therefore operate as a decision aid for individual women to have further intervention Withinclinical trials dichotomising EPDS scores according to a threshold for the purpose of making inferencesabout interventions is less appropriate It has been recommended that dichotomies should be abandonedso that people are not arbitrarily divided into groups by using thresholds on an underlying continuousscale Calculating sample sizes based on dichotomous measures is regarded as inefficient in unnecessarilyincreasing the size of clinical trials as well as contributing to overestimates of the extent to which differentwomen respond differently to the same treatment

Variation in the implementation of these interventions will manifest itself as heterogeneity between trialsin treatment effect (ie in the estimate of the between-trial SD) When the evidence suggests thatinterventions are beneficial and cost-effective relative to usual care then it would be necessary to dofurther research to identify under what circumstances the treatment is beneficial (and not beneficial)

DISCUSSION

The value of information analyses undertaken produced EVPPI values for the relative efficacy of treatmentin excess of pound150M for each population This is more than sufficient to fund research assessing the mosteffective intervention in each population Comparing interventions in such a way that feedback loopscould be created would create indirect as well as direct evidence (thereby strengthening inference)and would allow an assessment of inconsistency and adjustment for bias

Implications for individual interventionsThere are a number of hypothesised components for successful inclusion in an intervention presented infull in Chapter 8 and Table 55 specifically At a minimum an intervention should allow women to developtrusting relationships with the care provider feel supported access information have continuity of carehave individual-centred care and to have their partner involved For health-care providers there should besupport with appropriate training skills and resources for them to respond to cues about how a womanis feeling

Different psychological approaches (CBT-based PCA-based and IPT-based) all were possibly cost-effectivewithin the three levels of preventive interventions The role of non-specific factors such as congruencepositive regard and empathy in psychotherapeutic interventions has been recognised Skilled therapistsmay have multiple trainings and select the different approaches to suit clients at particular stages in theirintervention Skills to help women feel that they can trust their care provider and develop a continuingsupportive relationship for example with a midwife or health visitor would help address the needs ofpregnant and postnatal women

Chapter 11 Conclusion

Implications from this review for further research

The following recommendations are made for RCTs of preventive interventions for PND

l Trials should be designed appropriately powered to address important hypotheses of interest maternaland infant related

l Sample sizes should be based on clear statistical criteria and an understanding of a clinicallyimportant difference

l Trials should collect and report a battery of a few consistent outcome measuresl Outcomes should be measured at consistent time points ndash 6 weeks 12 weeks 6 months

12 months postnatallyl Outcomes should include anxietyl Trials should be in targeted populationsl There should be a clear justification for the interventions being trialledl Womenrsquos perspectives on what they might find helpful should precede a RCTl Attention should be paid to the needs of women for a trusting supportive ongoing relationship with a

care provider in the intervention development phasel Utility data should be collected for each interventionl Detailed costing data should be collected for each interventionl Womenrsquos and service providersrsquo perspectives should be gathered alongside an ongoing trial in properly

planned qualitative studiesl Trials should include multiple interventionsl Large data sets resulting from properly populated studies can be combined to allow multilevel

modelling to disentangle moderators and mediators and specifically practitioner- and service-level effects

Implications from this review for service provision

The activity represented by this volume of trials which aimed to prevent PND rather than treat PNDemphasises the importance of the condition and the potential benefit for perinatal women infants andpartners Of the trials included in the NMA the most beneficial treatments appeared to be midwiferyredesigned postnatal care146 PCA-based intervention61 and CBT-based intervention61 The effect of theinterventions appeared to be small Trials of parentndashinfant interaction including infant outcomes explicitlyand replication would be important to confirm these findings Although one intervention may not preventthe onset of depression it may reduce the severity of symptoms and extrapolated to a population levelthat would represent a large benefit

Suggestions for research priorities

Preventive interventions should be relatively simple and inexpensive particularly when they are to beapplied to a universal population Small trials are useful in assessing feasibility or generating hypothesesbut potential treatment effects need to be confirmed in properly designed and conducted RCTsSimilarly treatment effects based on small sample sizes from a limited number of trials should also beconfirmed in properly designed and conducted RCTs Specific interventions that are worthy of furtherevaluation include

l As a universal preventive intervention midwifery redesigned postnatal care PCA-based interventionsCBT-based interventions and preparing for parenting

l As a selective preventive intervention CenteringPregnancy IPT-based interventions and education onpreparing for parenting

l As an indicated preventive intervention PCA-based interventions CBT-based interventions IPT-basedinterventions promoting parentndashinfant interaction telephone-based peer support and Newpinvolunteer peer support

CONCLUSION

Acknowledgements

We acknowledge the help from Professor Christine MacArthur Professor Debra Bick ProfessorJeanette Milgrom Professor Julie Jomeen Professor Martin Knapp Professor Mike OrsquoHara

Professor Nine Glangeaud Dr Kari Glavin Dr Pauline Hall and Michelle Coghlan

Contributions of authors

All authors were involved in writing draft and final versions of the report

C Jane Morrell (Associate Professor in Health Research) co-ordinated the review wrote the backgroundsection of the report and conducted the clinical effectiveness systematic review (screening and retrievingpapers assessing against the inclusion criteria and appraising the quality of papers and abstractinginformation from papers for synthesis) wrote sections of the results and discussion and assembled thefinal report

Paul Sutcliffe (Associate Professor Deputy Director for Warwick Evidence) co-ordinated the review wrotethe abstract and scientific summary conducted the clinical effectiveness systematic review (screening andretrieving papers assessing against the inclusion criteria and appraising the quality of papers andabstracting information from papers for synthesis) and wrote sections of the results and discussion

Andrew Booth (Reader in Evidence-Based Information Practice) conducted the realist synthesis andcontributed to methodology data extraction and interpretation of the qualitative synthesis

John Stevens (Reader in Decision Science Director Centre for Bayesian Statistics in Health EconomicsHealth Economics and Decision Science) led on the quantitative synthesis co-ordinated the NMA andwrote sections of the results and discussion

Alison Scope (Research Fellow Health Economics and Decision Science) led on the qualitative synthesisand completed most of the data extraction and the initial analysis and interpretation

Matt Stevenson (Professor of HTA Health Economics and Decision Science) constructed the mathematicalmodel generated and interpreted the results and had overall responsibility for the modelling chapter

Rebecca Harvey (Research Associate in Medical Statistics Health Economics and Decision Science) carriedout the evidence synthesis assisted with drafting the statistical results and data extraction of the trialsincluded in the NMA

Alice Bessey (Research Associate Health Economics and Decision Science) undertook the economicevaluation literature review did the costing of interventions for economic evaluation and contributed tothe health economic chapter

Anna Cantrell (Information Specialist Information Resources Group Health Economics and DecisionScience) led on the literature searching for the quantitative qualitative and economic components of thereview managed the reference management database and performed the update procedures

Cindy-Lee Dennis (Professor in Nursing and Medicine Department of Psychiatry Canada Research Chairin Perinatal Community Health) assisted in screening studies and selecting eligible trials for inclusioncontributed to data extraction assessment of risk of bias edited chapters and commented on thefinal draft

Shijie Ren (Statistician Health Economics and Decision Science) wrote sections of the background editedchapters and commented on the final draft

Margherita Ragonesi (Visiting Clinical Psychology Academic University of Bologna) developed the dataextraction tool and conducted the data extraction

Michael Barkham (Professor in Clinical Psychology Department of Psychology) contributed to the originalproposal wrote sections of the background and discussion edited chapters and commented on final draft

Dick Churchill (Clinical Associate ProfessorDirector of Clinical Skills) commented on drafts chapters andwrote sections of the final report

Carol Henshaw (Psychiatrist Division of Psychiatry) assisted with the grey literature search assessing riskof bias of pharmacological interventions and commenting on drafts of the final report

Jo Newstead (EP Group Co-ordinator) contributed to the research proposal led the PPI inputco-ordinated the EP group wrote the sections for the report from a service user perspective providedcomments on all report chapters and drafted the Plain English summary

Pauline Slade (Professor of Clinical Psychology Consultant Clinical Psychologist) contributed to theoriginal proposal and commented on drafts of the final report through perinatal clinicalpsychology expertise

Helen Spiby (Professor of Midwifery) provided a midwifery perspective contributed to the design of theresearch filtering of the results of the searches and interpretation of the data wrote sections for the finalreport provided critical review of drafts of the report and commented on the final version

Sarah Stewart-Brown (Professor of Public Health Statistics and Epidemiology) advised on design ofsearches and the selection of trials for inclusion with regard to complementary and alternative approachesadvised on classification of preventive interventions and interpretation of findings and contributed to thefinal report

Data sharing statement

Data can be obtained from the corresponding author

ACKNOWLEDGEMENTS

References

1 OrsquoHara MW McCabe JE Postpartum depression current status and future directions Annu RevClin Psychol 20139379ndash407 httpdxdoiorg101146annurev-clinpsy-050212-185612

2 Cox J Holden J Henshaw C Perinatal Mental Health The Edinburgh Postnatal Depression Scale(EPDS) Manual Glasgow RCPsych Publications 2014

3 American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders-FifthEdition (DSM-5) Arlington VA American Psychiatric Association 2013

4 World Health Organization (WHO) Maternal Mental Health and Child Health and DevelopmentImproving Maternal Mental Health Millennium Development Goal 5 ndash Improving Maternal HealthGeneva WHO 2010

5 World Health Organization (WHO) International Statistical Classification of Diseases and RelatedHealth Problems 10th revision Geneva WHO 2010 URL wwwwhointclassificationsicden(accessed 4 March 2016)

6 Almond P Postnatal depression a global public health perspective Perspect Public Health2009129221ndash7 httpdxdoiorg1011771757913909343882

7 Oates MR Cox JL Neema S Asten P Glangeaud-Freudenthal N Figueiredo B et al Postnataldepression across countries and cultures a qualitative study Br J Psychiatry 200446s10ndash16httpdxdoiorg101192bjp18446s10

8 Rahman A Fisher J Bower P Luchters S Tran T Yasamy MT et al Interventions for commonperinatal mental disorders in women in low-and middle-income countries a systematic reviewand meta-analysis Bull World Health Organ 201391593ndash601I httpdxdoiorg102471BLT12109819

9 Gaynes BN Gavin N Meltzer BS Lohr KN Swinson T Gartlehner G et al Perinatal DepressionPrevalence Screening Accuracy and Screening Outcomes Evidence ReportTechnologyAssessment No 119 (Prepared by the RTI-University of North Carolina Evidence-based PracticeCenter under Contract No 290-02-0016) AHRQ Publication No 05-E006-2 Rockville MDAgency for Healthcare Research and Quality 2005

10 Cox J Holden JM Sagovsky R Detection of postnatal depression Development of the 10-itemEdinburgh Postnatal Depression Scale Br J Psychiatry 1987150782ndash6 httpdxdoiorg101192bjp1506782

11 Akman C Uguz F Kaya N Postpartum-onset major depression is associated with personalitydisorders Compr Psychiatry 200748343ndash7 httpdxdoiorg101016jcomppsych200703005

12 Kumar R Robson KM A prospective study of emotional disorders in childbearing womenBr J Psychiatry 198414435ndash47 httpdxdoiorg101192bjp144135

13 Cooper PJ Murray L Postnatal depression BMJ 19983161884ndash6 httpdxdoiorg101136bmj31671481884

14 Heron J OrsquoConnor TG Evans J Golding J Glover V the ALSPAC Study Team The course ofanxiety and depression through pregnancy and the postpartum in a community sample J AffectDisord 20048065ndash73 httpdxdoiorg101016jjad200308004

15 Evans J Heron J Francomb H Oke S Golding J Cohort study of depressed mood duringpregnancy and after childbirth BMJ 2001323257ndash60 httpdxdoiorg101136bmj3237307257

16 Pearson RM Evans J Kounali D Lewis G Heron J Ramchandani PG et al Maternal depressionduring pregnancy and the postnatal period risks and possible mechanisms for offspringdepression at age 18 years JAMA Psychiatry 2013701312ndash19 httpdxdoiorg101001jamapsychiatry20132163

17 Gavin NI Gaynes BN Lohr KN Meltzer-Brody S Gartlehner G Swinson T Perinatal depressiona systematic review of prevalence and incidence Obstet Gynecol 20051061071ndash83httpdxdoiorg10109701AOG000018359731630db

18 Lee AM Lam SK Lau SM Chong CS Chui HW Fong DY Prevalence course and risk factors forantenatal anxiety and depression Obstet Gynecol 20071101102ndash12 httpdxdoiorg10109701AOG00002870655949170

19 Engineer N Darwin L Nishigandh D Ngianga-Bakwin K Smith SC Grammatopoulos DKAssociation of glucocorticoid and type 1 corticotropin-releasing hormone receptors gene variantsand risk for depression during pregnancy and post-partum J Psychiatr Res 2013471166ndash73httpdxdoiorg101016jjpsychires201305003

20 Robertson E Grace S Wallington T Stewart DE Antenatal risk factors for postpartum depressiona synthesis of recent literature Gen Hosp Psychiatry 200426289ndash95 httpdxdoiorg101016jgenhosppsych200402006

21 Lancaster CA Gold KJ Flynn HA Yoo H Marcus SM Davis MM Risk factors for depressivesymptoms during pregnancy a systematic review Am J Obstet Gynecol 20102025ndash14httpdxdoiorg101016jajog200909007

22 Russell S Lang B Perinatal Mental Health Experiences of Women and Health ProfessionalsThe Boots Family Trust October 2013 URL wwwbftalliancecoukwp-contentuploads201402boots-perinatal-mental-health-09-10-13-webpdf (accessed July 2014)

23 Oates MR Perinatal psychiatric syndromes clinical features Psychiatry 200981ndash6httpdxdoiorg101016jmppsy200810014

24 Murray L Halligan S Cooper P Effects of postnatal depression on motherndashinfant interactions andchild development In Bremner JG T D Wachs TD editors The Wiley-Blackwell Handbook ofInfant Development Volume 2 2nd ed Hoboken NJ Wiley-Blackwell 2010 pp 192ndash220httpdxdoiorg1010029781444327588ch8

25 Murray L Arteche A Fearon P Halligan S Goodyer I Cooper P Maternal postnatal depressionand the development of depression in offspring up to 16 years of age J Am Acad Child AdolescPsychiatry 201150460ndash70 httpdxdoiorg101016jjaac201102001

26 Brand SR Brennan PA Impact of antenatal and postpartum maternal mental illness how are thechildren Clin Obstet Gynecol 200952441ndash55 httpdxdoiorg101097GRF0b013e3181b52930

27 Murray L Marwick H Arteche A Sadness in mothersrsquo lsquobaby-talkrsquo predicts affective disorder inadolescent offspring Infant Behav Dev 201033361ndash4 httpdxdoiorg101016jinfbeh201003009

28 Hay DF Pawlby S Sharp D Asten P Mills A Kumar R Intellectual problems shown by 11-year-oldchildren whose mothers had postnatal depression J Child Psychol Psychiatry 200142871ndash89httpdxdoiorg1011111469-761000784

29 Murray L Arteche A Fearon P Halligan S Croudace T Cooper P The effects of maternalpostnatal depression and child sex on academic performance at age 16 years a developmentalapproach J Child Psychol Psychiatry 2010511150ndash9 httpdxdoiorg101111j1469-7610201002259x

REFERENCES

30 Sinclair D Murray L Effects of postnatal depression on childrenrsquos adjustment to schoolTeacherrsquos reports Br J Psychiatry 199817258ndash63 httpdxdoiorg101192bjp172158

31 Morrell J Murray L Parenting and the development of conduct disorder and hyperactivesymptoms in childhood a prospective longitudinal study from 2 months to 8 years J Child PsycholPsychiatry 200344489ndash508 httpdxdoiorg1011111469-7610t01-1-00139

32 Hammen C Brennan PA Severity chronicity and timing of maternal depression and risk foradolescent offspring diagnoses in a community sample Arch Gen Psychiatry 200360253ndash8httpdxdoiorg101001archpsyc603253

33 Hay DF Pawlby S Waters CS Sharp D Antepartum and postpartum exposure to maternaldepression different effects on different adolescent outcomes J Child Psychol Psychiatry2008491079ndash88 httpdxdoiorg101111j1469-7610200801959x

34 Grote NK Bridge JA Gavin AR Melville JL Iyengar S Katon WJ A meta-analysis of depressionduring pregnancy and the risk of preterm birth low birth weight and intrauterine growthrestriction Arch Gen Psychiatry 2010671012ndash24 httpdxdoiorg101001archgenpsychiatry2010111

35 Huot RL Brennan PA Stowe ZN Plotsky PM Walker EF Negative affect in offspring of depressedmothers is predicted by infant cortisol levels at 6 months and maternal depression duringpregnancy but not postpartum Ann N Y Acad Sci 20041032234ndash6 httpdxdoiorg101196annals1314028

36 Pawlby S Hay DF Sharp D Waters CS OrsquoKeane V Antenatal depression predicts depression inadolescent offspring prospective longitudinal community-based study J Affect Disord2009113236ndash43 httpdxdoiorg101016jjad200805018

37 Paulson JF Bazemore SD Prenatal and postpartum depression in fathers and its association withmaternal depression a meta-analysis JAMA 20103031961ndash9 httpdxdoiorg101001jama2010605

38 National Collaborating Centre for Mental Health Antenatal and Postnatal Mental Health TheNICE Guideline on Clinical Management and Service Guidance NICE Clinical Guidelines (CG45)London NICE 2007

39 National Collaborating Centre for Womenrsquos and Childrenrsquos Health Antenatal Care forUncomplicated Pregnancies NICE Clinical Guidelines (CG62) London NICE 2008

40 Office for National Statistics Births in England and Wales by Characteristics of Birth 2 2012London Office for National Statistics 2013

41 Department of Health Maternal Mental Health Pathways 2012 URL wwwgovukgovernmentpublicationsmaternal-mental-health-pathway (accessed July 2014)

42 Gaudion A Bick D Menka Y Demilew J Walton C Yiannouzis K et al Adapting theCenteringPregnancyreg model for a UK feasibility study Br J Midwifery 201119433ndash8httpdxdoiorg1012968bjom2011197433

43 Gaudion A Menka Y Demilew J Walton C Yiannouzis K Robbins J et al Findings from a UKfeasibility study of the CenteringPregnancyreg model Br J Midwifery 201119796ndash802httpdxdoiorg1012968bjom20111912796

44 Rising SS Centering pregnancy an interdisciplinary model of empowerment J Nurse Midwifery19984346ndash54 httpdxdoiorg101016S0091-2182(97)00117-1

45 Hewitt CE Gilbody SM Brealey S Paulden M Palmer S Mann R et al Methods to identifypostnatal depression in primary care an integrated evidence synthesis and value of informationanalysis Health Technol Assess 200913(36) httpdxdoiorg103310hta13360

46 Morrell CJ Review of interventions to prevent or treat postnatal depression Clin Eff Nurs20069e135ndash61 httpdxdoiorg101016jcein200611006

47 Hearn G Iliff A Jones I Kirby A Ormiston P Parr P et al Postnatal depression in the communityBr J Gen Pract 1998481064ndash6

48 Whooley MA Avins AL Miranda J Browner WS Case-finding instruments for depressionJ Gen Intern Med 199712439ndash45 httpdxdoiorg101046j1525-1497199700076x

49 Spitzer RL Kroenke K Williams JB The development and validation of a version of PRIME-MDthe PHQ primary care study JAMA 19992821737ndash44 httpdxdoiorg101001jama282181737

50 Zigmund AS Snaith RP The Hospital Anxiety and Depression Scale Acta Psychiatr Scand198367361ndash70 httpdxdoiorg101111j1600-04471983tb09716x

51 Brealey SD Hewitt C Green JM Morrell J Gilbody S Screening for postnatal depression is itacceptable to women and healthcare professionals A systematic review and meta-synthesisReprod Infant Psychol 201028328ndash44 httpdxdoiorg101080026468382010513045

52 Shakespeare J An Evaluation of Screening for Postnatal Depression Against the NSC HandbookCriteria Oxford National Screening Committee 2001

53 Petrou S Cooper P Murray L Davidson LL Economic costs of post-natal depression in a high-riskBritish cohort Br J Psychiatry 2002181505ndash12 httpdxdoiorg101192bjp1816505

54 Bauer A Pawlby S Plant D King D Pariante C Knapp M Perinatal depression and childdevelopment exploring the economic consequences from a South London cohort Psychol Med20144551ndash61 httpdxdoiorg101017S0033291714001044

55 Edoka IP Petrou S Ramchandani PG Healthcare costs of paternal depression in the postnatalperiod J Affect Disord 2011133356ndash60 httpdxdoiorg101016jjad201104005

56 Campbell S Norris S Standfield L Suebwongpat A Screening for Postnatal Depression Withinthe Well Child Tamariki Ora Framework HSAC Report 1(2) Christchurch Health ServicesAssessment Collaboration (HSAC) 2008

57 Paulden M Palmer S Hewitt C Gilbody S Screening for postnatal depression in primary carecost effectiveness analysis BMJ 2009339b5203 httpdxdoiorg101136bmjb5203

58 Petrou S Morrell CJ Knapp M An Overview of Economic Aspects of Perinatal DepressionIn Milgrom J Gemmill AW editors Identifying Perinatal Depression and Anxiety Evidence-BasedPractice in Screening Psychosocial Assessment and Management Oxford Wiley 2015httpdxdoiorg1010029781118509722ch14

59 Knapp M King D Healey A Thomas C Economic outcomes in adulthood and their associationswith antisocial conduct attention deficit and anxiety problems in childhood J Ment Health PolicyEcon 201114137ndash47

60 Appleby L Warner R Whitton A Faragher B A controlled study of fluoxetine andcognitivendashbehavioural counselling in the treatment of postnatal depression BMJ 1997314932ndash6httpdxdoiorg101136bmj3147085932

61 Morrell CJ Warner R Slade P Dixon S Walters S Paley G et al Psychological interventions forpostnatal depression cluster randomised trial and economic evaluation The PoNDER trialHealth Technol Assess 200913(30) httpdxdoiorg103310hta13300

62 Cuijpers P Brannmark JG Straten A Psychological treatment of postpartum depressiona meta-analysis J Clin Psychol 200864103ndash18 httpdxdoiorg101002jclp20432

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63 Dimidjian S Goodman S Nonpharmacologic intervention and prevention strategies for depressionduring pregnancy and the postpartum Clin Obstet Gynecol 200952498ndash515 httpdxdoiorg101097GRF0b013e3181b52da6

64 Munoz RF Beardslee WR Leykin Y Major depression can be prevented Am Psychol201267285 httpdxdoiorg101037a0027666

65 England NHS A Call to Action Commissioning for Prevention 2013 URL wwwenglandnhsukwp-contentuploads201311call-to-action-com-prevpdf (accessed July 2014)

66 Marmot MG Allen J Goldblatt P Boyce T McNeish D Grady M et al Fair Society Healthy LivesStrategic Review of Health Inequalities in England Post-2010 London The Marmot Review 2010

67 Mrazek PJ Haggerty RJ Reducing Risks for Mental Disorders Frontiers for Preventive InterventionResearch Washington DC National Academies Press 1994

68 Cuijpers P Straten A Smit F Preventing the incidence of new cases of mental disordersa meta-analytic review J Nerv Ment Dis 2005193119ndash25 httpdxdoiorg10109701nmd000015281076190a6

69 Barker ED Jaffee SR Uher R Maughan B The contribution of prenatal and postnatal maternalanxiety and depression to child maladjustment Depress Anxiety 201128696ndash702httpdxdoiorg101002da20856

70 Jane-Llopis EVA Hosman C Jenkins R Anderson P Predictors of efficacy in depression preventionprogrammes meta-analysis Br J Psychiatry 2003183384ndash97 httpdxdoiorg101192bjp1835384

71 Hollon SD Thase ME Markowitz JC Treatment and prevention of depression Psychol Sci PublicInterest 2002339ndash77 httpdxdoiorg1011111529-100600008

72 Khan A Faucett J Lichtenberg P Kirsch I Brown WA A systematic review of comparative efficacyof treatments and controls for depression PLOS ONE 20127e41778 httpdxdoiorg101371journalpone0041778

73 Hollon SD Ponniah K A review of empirically supported psychological therapies for mooddisorders in adults Depress Anxiety 201027891ndash932 httpdxdoiorg101002da20741

74 Robinson LA Berman JS Neimeyer RA Psychotherapy for the treatment of depressiona comprehensive review of controlled outcome research Psychol Bull 199010830ndash49httpdxdoiorg1010370033-2909108130

75 Cuijpers P Van Straten A Andersson G van Oppen P Psychotherapy for depression in adultsa meta-analysis of comparative outcome studies J Consult Clin Psychol 200876909httpdxdoiorg101037a0013075

76 Munder T Brutsch O Leonhart R Gerger H Barth J Researcher allegiance in psychotherapyoutcome research an overview of reviews Clin Psychol Rev 201333501ndash11 httpdxdoiorg101016jcpr201302002

77 Leykin Y DeRubeis RJ Allegiance in psychotherapy outcome research Separating associationfrom bias Clin Psychol (New York) 20091654ndash65 httpdxdoiorg101111j1468-2850200901143x

78 Lambert MJ The Efficacy and Effectiveness of Psychotherapy In Lambert MJ editor Bergin andGarfieldrsquos Handbook of Psychotherapy and Behavior Change London John Wiley amp Sons 2013pp 169ndash218

79 Lambert MJ Pyschotherapy Outcome Research Implication for Integrative and Eclectic TherapistsIn Norcoss JC Goldfried MR editors Handbook of Psychotherapy Integration New York NYBasic Books 1992 pp 94ndash129

80 Cuijpers P Driessen E Hollon SD van Oppen P Barth J Andersson G The efficacy ofnon-directive supportive therapy for adult depression a meta-analysis Clin Psychol Rev201232280ndash91 httpdxdoiorg101016jcpr201201003

81 Horvath AO Greenberg LS Development and validation of the Working Alliance InventoryJ Couns Psychol 198936223 httpdxdoiorg1010370022-0167362223

82 Martin DJ Garske JP Davis MK Relation of the therapeutic alliance with outcome and othervariables a meta-analytic review J Consult Clin Psychol 200068438ndash50 httpdxdoiorg1010370022-006X683438

83 Rosenzweig S Some implicit common factors in diverse methods of psychotherapyAm J Orthopsychiatry 19366412 httpdxdoiorg101111j1939-00251936tb05248x

84 Frank JD Persuasion and Healing A Comparative Study of Psychotherapy Baltimore MDJohns Hopkins University Press 1993

85 Stiles WB Shapiro DA Elliott R Are all psychotherapies equivalent Am Psychol 198641165ndash80httpdxdoiorg1010370003-066X412165

86 Kazdin AE Treatment outcomes common factors and continued neglect of mechanisms ofchange Clin Psychol (New York) 200512184ndash8 httpdxdoiorg101093clipsybpi023

87 Petch J Halford WK Psycho-education to enhance couplesrsquo transition to parenthood Clin PsycholRev 2008281125ndash37 httpdxdoiorg101016jcpr200803005

88 Billingham K Preparing for parenthood the role of antenatal education CommunityPract 20118436ndash8

89 Nolan ML Information giving and education in pregnancy a review of qualitative studiesJ Perinat Educ 20091821ndash30 httpdxdoiorg101624105812409X474681

90 Mitnick DM Heyman RE Smith Slep AM Changes in relationship satisfaction across the transitionto parenthood a meta-analysis J Fam Psychol 200923848ndash52 httpdxdoiorg101037a0017004

91 Shapiro AF Gottman JM Carrere S The baby and the marriage identifying factors that bufferagainst decline in marital satisfaction after the first baby arrives J Fam Psychol 20001459ndash70httpdxdoiorg1010370893-320014159

92 Cowan CP Cowan PA Interventions to ease the transition to parenthood Why they are neededand what they can do Fam Relat 199544412ndash23 httpdxdoiorg102307584997

93 OrsquoHara MW Swain AM Rates and risk of postpartum degression ndash a meta-analysisInt Rev Psychiatry 1996837ndash54 httpdxdoiorg10310909540269609037816

94 Deave T Johnson D Ingram J Transition to parenthood the needs of parents in pregnancy andearly parenthood BMC Pregnancy Childbirth 2008830ndash44 httpdxdoiorg1011861471-2393-8-30

95 Petch J Halford WK Creedy DK Gamble J Couple relationship education at the transition toparenthood a window of opportunity to reach high risk couples Fam Process 201251498ndash511httpdxdoiorg101111j1545-5300201201420x

96 Cobb S Social support as a moderator of life stress Psychosom Med 197638300ndash14httpdxdoiorg10109700006842-197609000-00003

97 Dennis CL Peer support within a health care context a concept analysis Int J Nurs Stud200340321ndash32 httpdxdoiorg101016S0020-7489(02)00092-5

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98 Cohen S Underwood L Gottlieb BH Social Support Measurement and Intervention A Guide ForHealth and Social Scientists Oxford Oxford University Press 2000 httpdxdoiorg101093medpsych97801951267090010001

99 Lin N Ye X Ensel WM Social support and depressed mood a structural analysis J Health SocBehav 199940344ndash59 httpdxdoiorg1023072676330

100 Berkman LF Glass T Social Integration Social Networks Social Support and Health In Berkman LFKawachi I editors Social Epidemiology New York NY Oxford University Press 2000 pp 137ndash73

101 Thoits PA Social support as coping assistance J Consult Clin Psychol 198654416 httpdxdoiorg1010370022-006X544416

102 Dalton K Progesterone prophylaxis used successfully in postnatal depression Practitioner1985229507ndash8

103 Dalton K Successful prophylactic progesterone for idiopathic postnatal depression Int J PrenatPerinat Studies 19891323ndash7

104 Dalton K Progesterone prophylaxis for postnatal depression Int J Prenat Perinat Psychol Med19957447ndash50

105 Turner KM Sharp D Folkes L Hew-Graham C Womenrsquos views and experiences ofantidepressants as a treatment for postnatal depression a qualitative study Fam Pract200825450ndash5 httpdxdoiorg101093fampracmn056

106 Browne JC Scott KM Silvers KM Fish consumption in pregnancy and omega-3 status after birthare not associated with postnatal depression J Affect Disord 200690131ndash9 httpdxdoiorg101016jjad200510009

107 Freeman MP Davis M Sinha P Wisner KL Hibbeln JR Gelenberg AJ Omega-3 fatty acids andsupportive psychotherapy for perinatal depression a randomized placebo-controlled studyJ Affect Disord 2008110142ndash8 httpdxdoiorg101016jjad200712228

108 Barnes PM Bloom B Nahin R Complementary and alternative medicine use among adults andchildren United States 2007 Natl Health Stat Report 2008101ndash23

109 Pallivalappila AR Stewart D Shetty A Pande B McLay JS Complementary and alternativemedicines use during pregnancy a systematic review of pregnant women and healthcareprofessional views and experiences Evid Based Complement Alternat Med 2013205639httpdxdoiorg1011552013205639

110 Beddoe AE Lee KA Mindndashbody interventions during pregnancy J Obstet Gynecol Neonatal Nurs200837165ndash75 httpdxdoiorg101111j1552-6909200800218x

111 Bishop FL Lewith GT Who uses CAM A narrative review of demographic characteristics andhealth factors associated with CAM use Evid Based Complement Alternat Med 2010711ndash28httpdxdoiorg101093ecamnen023

112 Xue CCL Zhang AL Lin V Da Costa C Story DF Complementary and alternative medicine use inAustralia a national population-based survey J Altern Complement Med 200713643ndash50httpdxdoiorg101089acm20066355

113 Field T Figueiredo B Hernandez RM Diego M Deeds O Ascencio A Massage therapy reducespain in pregnant women alleviates prenatal depression in both parents and improves theirrelationships J Bodyw Mov Ther 200812146ndash50 httpdxdoiorg101016jjbmt200706003

114 Field T Deeds O Diego M Hernandez RM Gauler A Sullivan S et al Benefits of combiningmassage therapy with group interpersonal psychotherapy in prenatally depressed womenJ Bodyw Mov Ther 200913297ndash303 httpdxdoiorg101016jjbmt200810002

115 Field T Diego MA Hernandez RM Schanberg S Kuhn C Massage therapy effects on depressedpregnant women J Psychosom Obstet Gynaecol 200425115ndash22 httpdxdoiorg10108001674820412331282231

116 Mantle F The role of alternative medicine in treating postnatal depression Complement TherNurs Midwifery 20028197ndash203 httpdxdoiorg101054ctnm20020647

117 Zhang ZJ Chen HY Yip Kc Ng R Wong VT The effectiveness and safety of acupuncture therapyin depressive disorders systematic review and meta-analysis J Affect Disord 20101249ndash21httpdxdoiorg101016jjad200907005

118 Dennis CL Allen K Interventions (other than pharmacological psychosocial or psychological) fortreating antenatal depression Cochrane Database Syst Rev 20084CD006795 httpdxdoiorg10100214651858cd006795pub2

119 Field T Diego M Hernandez RM Medina L Delgado J Hernandez A Yoga and massage therapyreduce prenatal depression and prematurity J Bodyw Mov Ther 201216204ndash9 httpdxdoiorg101016jjbmt201108002

120 DrsquoSilva S Poscablo C Habousha R Kogan M Kligler B Mindndashbody medicine therapies for arange of depression severity a systematic review Psychosomatics 201253407ndash23httpdxdoiorg101016jpsym201204006

121 Vieten C Astin J Effects of a mindfulness-based intervention during pregnancy on prenatal stressand mood results of a pilot study Arch Womens Ment Health 20081167ndash74 httpdxdoiorg101007s00737-008-0214-3

122 Hofmann SG Sawyer AT Witt AA Oh D The effect of mindfulness-based therapy on anxiety anddepression A meta-analytic review J Consult Clin Psychol 201078169ndash83 httpdxdoiorg101037a0018555

123 Norman E Sherburn M Osborne RH Galea MP An exercise and education program improveswell-being of new mothers a randomized controlled trial Phys Ther 201090348ndash55httpdxdoiorg102522ptj20090139

124 Whitaker R Hendry M Booth A Carter B Charles J Craine N et al Intervention Now ToEliminate Repeat Unintended Pregnancy in Teenagers (INTERUPT) a systematic review ofintervention effectiveness and cost-effectiveness qualitative and realist synthesis ofimplementation factors and user engagement BMJ Open 20144e004733 httpdxdoiorg101136bmjopen-2013-004733

125 Cochrane Community Cochrane Central Register of Controlled Trials (CENTRAL) URLhttpcommunitycochraneorgeditorial-and-publishing-policy-resourcecochrane-central-register-controlled-trials-central (accessed July 2014)

126 Higgins J Altman DG Gotzsche PC Juni P Moher D Oxman AD et al The CochraneCollaborationrsquos tool for assessing risk of bias in randomised trials BMJ 2011343d5928httpdxdoiorg101136bmjd5928

127 MacKinnon DP Integrating mediators and moderators in research design Res Soc Work Pract201121675ndash81 httpdxdoiorg1011771049731511414148

128 Dias S Sutton AJ Ades AE Welton NJ Evidence synthesis for decision making 2A generalizedlinear modeling framework for pairwise and network meta-analysis of randomized controlledtrials Med Decis Making 201333607ndash17 httpdxdoiorg1011770272989X12458724

129 Songoslashygard KM Stafne SN Evensen KA Salvesen K Vik T Moslashrkved S Does exercise duringpregnancy prevent postnatal depression A randomized controlled trial Acta Obstet GynecolScand 20129162ndash7 httpdxdoiorg101111j1600-0412201101262x

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130 Lunn DJ Thomas A Best N Spiegelhalter D WinBUGS-a Bayesian modelling frameworkconcepts structure and extensibility Stat Comput 200010325ndash37 httpdxdoiorg101023A1008929526011

131 Brooks SP Gelman A Alternative methods for monitoring convergence of iterative simulationsJ Comput Graph Stat 19887434ndash55

132 Dakin HA Welton NJ Ades AE Collins S Orme M Kelly S Mixed treatment comparison ofrepeated measurements of a continuous endpoint an example using topical treatments forprimary open angle glaucoma and ocular hypertension Stat Med 2011302511ndash35httpdxdoiorg101002sim4284

133 Wei Y Higgins J Bayesian multivariate meta-analysis with multiple outcomes Stat Med2013322911ndash34 httpdxdoiorg101002sim5745

134 Riley RD Multivariate meta-analysis the effect of ignoring within-study correlation J R Stat SocSer A 2009172789ndash98 httpdxdoiorg101111j1467-985X200800593x

135 Glenton C Colvin CJ Carlsen B Swartz A Lewin S Noyes J et al Barriers and facilitators to theimplementation of lay health worker programmes to improve access to maternal and child healthqualitative evidence synthesis Cochrane Database Syst Rev 201310D010414 httpdxdoiorg10100214651858cd010414

136 Critical Appraisal Skills Programme (CASP) 10 Questions to Help you Make Sense of QualitativeResearch Oxford CASP 2011

137 Noyes J Lewin S Chapter 5 Extracting Qualitative Evidence In Noyes J Booth A Hannes KHarden A Harris J Lewin S Lockwood C editors Supplementary Guidance for Inclusion ofQualitative Research in Cochrane Systematic Reviews of Interventions Version 1 (updatedAugust 2011) Cochrane Collaboration Qualitative Methods Group 2011 URL httpcqrmgcochraneorgsupplemental-handbook-guidance (accessed July 2014)

138 Thomas J Harden A Methods for the thematic synthesis of qualitative research in systematicreviews BMC Med Res Methodol 2008845 httpdxdoiorg1011861471-2288-8-45

139 Bates MJ The design of browsing and berrypicking techniques for the online search interfaceOnline Info Rev 198913407ndash24 httpdxdoiorg101108eb024320

140 Jagosh J Macaulay AC Pluye P Salsberg J Bush PL Henderson J et al Uncovering the benefitsof participatory research implications of a realist review for health research and practiceMilbank Q 201290311ndash46 httpdxdoiorg101111j1468-0009201200665x

141 Booth A Harris J Croot E Springett J Campbell F Wilkins E Towards a methodology for clustersearching to provide conceptual and contextual BMC Med Res Methodol 201313118httpdxdoiorg1011861471-2288-13-118

142 Beck CT Postpartum depression a metasynthesis Qual Health Res 200212453ndash72httpdxdoiorg101177104973202129120016

143 Marsh J A middle range theory of postpartum depression analysis and application Int JChildbirth Educ 20132850

144 Guise JM Chang C Viswanathan M Glick S Treadwell J Umscheid C Whitlock E Fu RBerliner E Paynter R Anderson J Motursquoapuaka M Trikalinos T Systematic Reviews of ComplexMulticomponent Health Care Interventions Research White Paper AHRQ Publication No14-EHC003-EF Rockville MD Agency for Healthcare Research and Quality March 2014URL wwweffectivehealthcareahrqgovreportsfinalcfm (accessed July 2014)

145 Noyes J Popay J Pearson A Hannes K Booth A Chapter 20 Qualitative Research and CochraneReviews In Higgins JPT Green S editors Cochrane Handbook for Systematic Reviews ofInterventions Version 501 [updated September 2008] The Cochrane Collaboration 2008URL wwwcochrane-handbookorg (accessed July 2014) httpdxdoiorg1010029780470712184ch20

146 MacArthur C Winter HR Bick DE Knowles H Lilford R Henderson C et al Effects of redesignedcommunity postnatal care on womensrsquo health 4 months after birth a cluster randomisedcontrolled trial Lancet 2002359378ndash85 httpdxdoiorg101016S0140-6736(02)07596-7

147 Lumley J Watson L Small R Brown S Mitchell C Gunn J PRISM (Program of ResourcesInformation and Support for Mothers) a community-randomised trial to reduce depression andimprove womenrsquos physical health six months after birth [ISRCTN03464021] BMC Public Health2006637 httpdxdoiorg1011861471-2458-6-37

148 Rahman A Malik A Sikander S Roberts C Creed F Cognitive behaviour therapy-basedintervention by community health workers for mothers with depression and their infants in ruralPakistan a cluster-randomised controlled trial Lancet 2008372902ndash9 httpdxdoiorg101016S0140-6736(08)61400-2

149 Barnes J Senior R MacPherson K The utility of volunteer home-visiting support to preventmaternal depression in the first year of life Child Care Health Dev 200935807ndash16httpdxdoiorg101111j1365-2214200901007x

150 Christie J Bunting B The effect of health visitorsrsquo postpartum home visit frequency on first-timemothers cluster randomised trial Int J Nurs Stud 201148689ndash702 httpdxdoiorg101016jijnurstu201010011

151 Morrell CJ Slade P Warner R Paley G Dixon S Walters SJ et al Clinical effectiveness of healthvisitor training in psychologically informed approaches for depression in postnatal womenpragmatic cluster randomised trial in primary care BMJ 2009338a3045 httpdxdoiorg101136bmja3045

152 Brugha TS Morrell CJ Slade P Walters SJ Universal prevention of depression in womenpostnatally cluster randomized trial evidence in primary care Psycho Med 201141739ndash48httpdxdoiorg101017S0033291710001467

153 Cooper PJ Tomlinson M Swartz L Landman M Molteno C Stein A et al Improving quality ofmotherndashinfant relationship and infant attachment in socioeconomically deprived community inSouth Africa randomised controlled trial BMJ 2009338b974 httpdxdoiorg101136bmjb974

154 Gao LL Chan SW Li X Chen S Hao Y Evaluation of an interpersonal-psychotherapy-orientedchildbirth education programme for Chinese first-time childbearing women a randomisedcontrolled trial Int J Nurs Stud 2010471208ndash16 httpdxdoiorg101016jijnurstu201003002

155 Kozinszky Z Dudas RB Devosa I Csatordai S Toth E Szabo D et al Can a brief antepartumpreventive group intervention help reduce postpartum depressive symptomatology PsychotherPsychosom 20128198ndash107 httpdxdoiorg101159000330035

156 Leung S Lam TH Group antenatal intervention to reduce perinatal stress and depressivesymptoms related to intergenerational conflicts a randomized controlled trial Int J Nurs Stud2012491391ndash402 httpdxdoiorg101016jijnurstu201206014

157 Mao HJ Li HJ Chiu H Chan WC Chen SL Effectiveness of antenatal emotionalself-management training program in prevention of postnatal depression in Chinese womenPerspect Psychiatr Care 201248218ndash24 httpdxdoiorg101111j1744-6163201200331x

REFERENCES

158 Chabrol H Teissedre F Saint JM Teisseyre N Rog B Mullet E Prevention and treatment ofpost-partum depression a controlled randomized study on women at risk Psycho Med2002321039ndash47 httpdxdoiorg101017S0033291702006062

159 Hagan R Evans SF Pope S Preventing postnatal depression in mothers of very preterm infantsa randomised controlled trial BJOG 2004111641ndash7 httpdxdoiorg101111j1471-0528200400165x

160 Phipps MG Raker CA Ware CF Zlotnick C Randomized controlled trial to prevent postpartumdepression in adolescent mothers Am J Obstet Gynecol 2013208192ndash1e1 httpdxdoiorg101016jajog201212036

161 Silverstein M Feinberg E Cabral H Sauder S Egbert L Schainker E et al Problem-solvingeducation to prevent depression among low-income mothers of preterm infants a randomizedcontrolled pilot trial Arch Womens Ment Health 201114317ndash24 httpdxdoiorg101007s00737-011-0222-6

162 Tam WH Lee DT Chiu HF Ma KC Lee A Chung TK A randomised controlled trial ofeducational counselling on the management of women who have suffered suboptimal outcomesin pregnancy BJOG 2003110853ndash9 httpdxdoiorg101111j1471-0528200302412x

163 Zlotnick C Capezza NM Parker D An interpersonally based intervention for low-incomepregnant women with intimate partner violence a pilot study Arch Womens Ment Health20111455ndash65 httpdxdoiorg101007s00737-010-0195-x

164 Armstrong KL Fraser JA Dadds MR Morris J A randomized controlled trial of nurse homevisiting to vulnerable families with newborns J Paediatr Child Health 199935237ndash44httpdxdoiorg101046j1440-1754199900348x

165 Austin MP Frilingos M Lumley J Hadzi PD Roncolato W Acland S et al Brief antenatalcognitive behaviour therapy group intervention for the prevention of postnatal depression andanxiety a randomised controlled trial J Affect Disord 200810535ndash44 httpdxdoiorg101016jjad200704001

166 Crockett K Zlotnick C Davis M Payne N Washington R A depression preventive interventionfor rural low-income African-American pregnant women at risk for postpartum depressionArch Womens Ment Health 200811319ndash25 httpdxdoiorg101007s00737-008-0036-3

167 El-Mohandes AA Kiely M Joseph JG Subramanian S Johnson AA Blake SM et al Anintervention to improve postpartum outcomes in African-American mothers a randomizedcontrolled trial Obstet Gynecol 2008112611ndash20 httpdxdoiorg101097AOG0b013e3181834b10

168 Ginsburg GS Barlow A Goklish N Hastings R Baker EV Mullany B et al Postpartum depressionprevention for reservation-based American Indians results from a pilot randomized controlledtrial Child Youth Care Forum 201241229ndash45 httpdxdoiorg101007s10566-011-9161-7

169 Gorman L Prevention of Postpartum Difficulties in a High Risk Sample Doctoral dissertation IowaCity IA University of Iowa 1997

170 Grote NK Swartz HA Geibel SL Zuckoff A Houck PR Frank E A randomized controlled trial ofculturally relevant brief interpersonal psychotherapy for perinatal depression Psychiatr Serv200960313ndash21 httpdxdoiorg101176ps2009603313

171 Le HN Perry DF Stuart EA Randomized controlled trial of a preventive intervention for perinataldepression in high-risk Latinas J Consult Clin Psychol 201179135ndash41 httpdxdoiorg101037a0022492

172 McKee MD Zayas LH Fletcher J Boyd RC Nam SH Results of an intervention to reduce perinataldepression among low-income minority women in community primary care J Soc Serv Res20063263ndash81 httpdxdoiorg101300J079v32n04_04

173 Munoz RF Le HN Ippen CG Diaz MA Urizar GG Soto J et al Prevention of postpartumdepression in low-income women development of the Mamas y BebesMothers and BabiesCourse Cogn Behav Pract 20071470ndash83 httpdxdoiorg101016jcbpra200604021

174 Petrou S Cooper P Murray L Davidson LL Cost-effectiveness of a preventive counseling andsupport package for postnatal depression Int J Technol Assess Health Care 200622443ndash53httpdxdoiorg101017S0266462306051361

175 Tiwari A Leung WC Leung TW Humphreys J Parker B Ho PC A randomised controlledtrial of empowerment training for Chinese abused pregnant women in Hong Kong BJOG20051121249ndash56 httpdxdoiorg101111j1471-0528200500709x

176 Weidner K Bittner A Junge HJ Zimmermann K Siedentopf F Richter J et al A psychosomaticintervention in pregnant in-patient women with prenatal somatic risks J Psychosom ObstetGynaecol 201031188ndash98 httpdxdoiorg1031090167482X2010497233

177 Wilson P Puckering C Thompson L Clarke A MacBeth A McAlees S Henderson M AntenatalParenting Support for Women Vulnerable in Pregnancy An Exploratory Randomised ControlledTrial of Mellow Bumps Edinburgh Scottish Collaboration for Public Health Research andPolicy 2013

178 Zlotnick C Johnson SL Miller IW Pearlstein T Howard M Postpartum depression in womenreceiving public assistance pilot study of an interpersonal-therapy-oriented group interventionAm J Psychiatry 2001158638ndash40 httpdxdoiorg101176appiajp1584638

179 Zlotnick C Miller IW Pearlstein T Howard M Sweeney P A preventive intervention for pregnantwomen on public assistance at risk for postpartum depression Am J Psychiatry 20061631443ndash5httpdxdoiorg101176ajp200616381443

180 Feinberg ME Kan ML Establishing family foundations Intervention effects on coparentingparentinfant well-being and parentndashchild relations J Fam Psychol 200822253 httpdxdoiorg1010370893-3200222253

181 Gjerdingen DK Center B A randomized controlled trial testing the impact of a supportwork-planning intervention on first-time parentsrsquo health partner relationship and work responsibilitiesBehav Med 20022884ndash91 httpdxdoiorg10108008964280209596045

182 Hayes BA Muller R Bradley BS Perinatal depression a randomized controlled trial of anantenatal education intervention for primiparas Birth 20012828ndash35 httpdxdoiorg101046j1523-536x200100028x

183 Ho SM Heh SS Jevitt CM Huang LH Fu YY Wang LL Effectiveness of a discharge educationprogram in reducing the severity of postpartum depression a randomized controlled evaluationstudy Patient Educ Couns 20097768ndash71 httpdxdoiorg101016jpec200901009

184 Matthey S Kavanagh DJ Howie P Barnett B Charles M Prevention of postnatal distress ordepression an evaluation of an intervention at preparation for parenthood classes J Affect Disord200479113ndash26 httpdxdoiorg101016S0165-0327(02)00362-2

185 Milgrom J Schembri C Ericksen J Rossb J Gemmill AW Towards parenthood An antenatalintervention to reduce depression anxiety and parenting difficulties [ACTRN012606000263594]J Affect Disord 2011130385ndash94 httpdxdoiorg101016jjad201010045

186 Sealy PA Simpson JP Evans MK The effect of a pamphlet on womenrsquos experiences ofpostpartum depression Can J Commun Ment Health 200928113ndash22 httpdxdoiorg107870cjcmh-2009-0009

REFERENCES

187 Shapiro AF Gottman JM Effects on marriage of a psycho-communicative-educationalintervention with couples undergoing the transition to parenthood evaluation at 1-year postintervention J Fam Commun 200551ndash24 httpdxdoiorg101207s15327698jfc0501_1

188 Brugha TS Wheatley S Taub NA Culverwell A Friedman T Kirwan P et al Pragmaticrandomized trial of antenatal intervention to prevent post-natal depression by reducingpsychosocial risk factors Psycho Med 2000301273ndash81 httpdxdoiorg101017S0033291799002937

189 Buist A Westley D Hill C Antenatal prevention of postnatal depression Arch Womens MentHealth 19991167ndash73 httpdxdoiorg101007s007370050024

190 Howell EA Balbierz A Wang J Parides M Zlotnick C Leventhal H Reducing postpartumdepressive symptoms among black and Latina mothers a randomized controlled trialObstet Gynecol 2012119942ndash9 httpdxdoiorg101097AOG0b013e318250ba48

191 Sen DM A Randomised Controlled Trial of a Midwife-Led Twin Antenatal Programme TheNewcastle Twin Study PhD thesis Newcastle upon Tyne University of Newcastle 2006

192 Walkup JT Barlow A Mullany BC Pan W Goklish N Hasting R et al Randomized controlled trialof a paraprofessional-delivered in-home intervention for young reservation-based American Indianmothers J Am Acad Child Adolesc Psychiatry 200948591ndash601 httpdxdoiorg101097CHI0b013e3181a0ab86

193 Heh SS Fu YY Effectiveness of informational support in reducing the severity of postnatal depressionin Taiwan J Adv Nurs 20034230ndash6 httpdxdoiorg101046j1365-2648200302576x

194 Lara MA Navarro C Navarrete L Outcome results of a psycho-educational intervention inpregnancy to prevent PPD a randomized control trial J Affect Disord 2010122109ndash17httpdxdoiorg101016jjad200906024

195 Stamp GE Williams AS Crowther CA Evaluation of antenatal and postnatal support to overcomepostnatal depression a randomized controlled trial Birth 199522138ndash43 httpdxdoiorg101111j1523-536X1995tb00689x

196 Webster J Linnane J Roberts J Starrenburg S Hinson J Dibley L IDentify Educate and Alert(IDEA) trial an intervention to reduce postnatal depression BJOG 2003110842ndash6httpdxdoiorg101111j1471-0528200302377x

197 Hodnett ED Lowe NK Hannah ME Willan AR Stevens B Weston JA et al Effectiveness ofnurses as providers of birth labor support in North American hospitals a randomized controlledtrial JAMA 20022881373ndash81 httpdxdoiorg101001jama288111373

198 Kieffer EC Caldwell CH Welmerink DB Welch KB Sinco BR Guzman JR Effect of the healthyMOMs lifestyle intervention on reducing depressive symptoms among pregnant latinasAm J Community Psychol 20135176ndash89 httpdxdoiorg101007s10464-012-9523-9

199 Morrell CJ Spiby H Stewart P Walters S Morgan A Costs and effectiveness of communitypostnatal support workers randomised controlled trial BMJ 2000321593ndash8 httpdxdoiorg101136bmj3217261593

200 Reid M Glazener C Murray GD Taylor GS A two-centred pragmatic randomised controlled trialof two interventions of postnatal support BJOG 20021091164ndash70 httpdxdoiorg101111j1471-0528200201306x

201 Cupples ME Stewart MC Percy A Hepper P Murphy C Halliday HL A RCT of peer-mentoringfor first-time mothers in socially disadvantaged areas (The MOMENTS Study) Arch Dis Child201196252ndash8 httpdxdoiorg101136adc2009167387

202 Logsdon MC Birkimer JC Simpson T Looney S Postpartum depression and social support inadolescents J Obstet Gynecol Neonatal Nurs 20053446ndash54 httpdxdoiorg1011770884217504272802

203 Richter L Rotheram-Borus MJ Heerden AV Stein A Tomlinson M Harwood JM et al PregnantWomen Living with HIV (WLH) supported at clinics by peer wlh a cluster randomized controlledtrial AIDS Behav 201418706ndash15 httpdxdoiorg101007s10461-014-0694-2

204 Wolman WL Chalmers B Hofmeyr GJ Nikodem VC Postpartum depression and companionshipin the clinical birth environment a randomized controlled study Am J Obstet Gynecol19931681388ndash93 httpdxdoiorg101016S0002-9378(11)90770-4

205 Dennis CL Hodnett E Kenton L Weston J Zupancic J Stewart DE et al Effect of peer supporton prevention of postnatal depression among high risk women multisite randomised controlledtrial BMJ 2009338a3064 httpdxdoiorg101136bmja3064

206 Harris T Brown GW Hamilton V Hodson S Craig TKJ The Newpin Antenatal and PostnatalProject A Randomised Controlled Trial of an Intervention for Perinatal Depression In Mondy LMondy S editors Newpin Courage to Change Together 2008 North Parramatta NSWUnitingCare Burnside 2008 pp 137ndash45

207 Doornbos B Goor SA Dijck-Brouwer DA Schaafsma A Korf J Muskiet FA Supplementation of alow dose of DHA or DHA+AA does not prevent peripartum depressive symptoms in a smallpopulation based sample Prog Neuropsychopharmacol Biol Psychiatry 20093349ndash52httpdxdoiorg101016jpnpbp200810003

208 Harrison-Hohner J Coste S Dorato V Curet LB McCarron D Hatton D Prenatal calciumsupplementation and postpartum depression an ancillary study to a randomized trial of calciumfor prevention of preeclampsia Arch Womens Ment Health 20013141ndash6 httpdxdoiorg101007s007370170011

209 Lawrie TA Hofmeyr GJ Jager M Berk M Paiker J Viljoen E A double-blind randomised placebocontrolled trial of postnatal norethisterone enanthate the effect on postnatal depression andserum hormones Br J Obstet Gynaecol 19981051082ndash90 httpdxdoiorg101111j1471-05281998tb09940x

210 Llorente AM Jensen CL Voigt RG Fraley JK Berretta MC Heird WC Effect of maternaldocosahexaenoic acid supplementation on postpartum depression and information processingAm J Obstet Gynecol 20031881348ndash53 httpdxdoiorg101067mob2003275

211 Makrides M Gibson RA McPhee AJ Yelland L Quinlivan J Ryan P Effect of DHAsupplementation during pregnancy on maternal depression and neurodevelopment of youngchildren a randomized controlled trial JAMA 20103041675ndash83 httpdxdoiorg101001jama20101507

212 Mokhber N Namjoo M Tara F Boskabadi H Rayman MP Ghayour MM et al Effect ofsupplementation with selenium on postpartum depression a randomized double-blind placebo-controlled trial J Matern Fetal Neonatal Med 201124104ndash8 httpdxdoiorg103109147670582010482598

213 Harris B Oretti R Lazarus J Parkes A John R Richards C et al Randomised trial of thyroxineto prevent postnatal depression in thyroid-antibody-positive women Br J Psychiatry 2002180327ndash30httpdxdoiorg101192bjp1804327

214 Mozurkewich EL Clinton CM Chilimigras J et al The Mothers Omega-3 and Mental HealthStudy a double-blind randomized controlled trial Am J Obstet Gynecol 2013208313ndash15httpdxdoiorg101016jajog201301038

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215 Wisner KL Perel JM Peindl KS Hanusa BH Findling RL Rapport D Prevention of recurrentpostpartum depression a randomized clinical trial J Clin Psychiatry 20016282ndash6httpdxdoiorg104088JCPv62n0202

216 Wisner KL Perel JM Peindl KS Hanusa BH Piontek CM Findling RL Prevention of postpartumdepression a pilot randomized clinical trial Am J Psychiatry 20041611290ndash2 httpdxdoiorg101176appiajp16171290

217 Priest SR Henderson J Evans SF Hagan R Stress debriefing after childbirth a randomisedcontrolled trial Med J Aust 2003178542ndash5

218 Selkirk R McLaren S Ollerenshaw A McLachlan AJ Moten J The longitudinal effects ofmidwife-led postnatal debriefing on the psychological health of mothers J Reprod Infant Psychol200624133ndash47 httpdxdoiorg10108002646830600643916

219 Shields N Reid M Cheyne H Holmes A McGinley M Turnbull D et al Impact ofmidwife-managed care in the postnatal period an exploration of psychosocial outcomesJ Reprod Infant Psychol 19971591ndash108 httpdxdoiorg10108002646839708404537

220 Waldenstrom U Brown S McLachlan H Forster D Brennecke S Does team midwife care increasesatisfaction with antenatal intrapartum and postpartum care A randomized controlled trialBirth 200027156ndash67 httpdxdoiorg101046j1523-536x200000156x

221 Gamble J Creedy D Moyle W Webster J McAllister M Dickson P Effectiveness of a counselingintervention after a traumatic childbirth a randomized controlled trial Birth 20053211ndash19httpdxdoiorg101111j0730-7659200500340x

222 Ickovics JR Reed E Magriples U Westdahl C Schindler RS Kershaw TS Effects of group prenatalcare on psychosocial risk in pregnancy results from a randomised controlled trial Psychol Health201126235ndash50 httpdxdoiorg101080088704462011531577

223 Small R Lumley J Donohue L Potter A Waldenstroumlm U Randomised controlled trial of midwifeled debriefing to reduce maternal depression after operative childbirth BMJ 20003211043ndash7httpdxdoiorg101136bmj32172681043

224 Marks MN Siddle K Warwick C Can we prevent postnatal depression A randomized controlledtrial to assess the effect of continuity of midwifery care on rates of postnatal depression inhigh-risk women Prog Neuropsychopharmacol Biol Psychiatry 200313119ndash27 httpdxdoiorg101080jmf132119127

225 Gunn J Lumley J Chondros P Young D Does an early postnatal check-up improve maternalhealth results from a randomised trial in Australian general practice Br J Obstet Gynaecol1998105991ndash7 httpdxdoiorg101111j1471-05281998tb10263x

226 Rotheram-Borus MJ le Roux IM Tomlinson M Mbewu N Comulada WS le Roux K et al PhilaniPlus (+) a mentor mother community health worker home visiting program to improve maternaland infantsrsquo outcomes Prev Sci 201112372ndash88 httpdxdoiorg101007s11121-011-0238-1

227 Serwint JR Wilson MH Duggan AK Mellits ED Baumgardner RA DeAngelis C Do postpartumnursery visits by the primary care provider make a difference Pediatrics 199188444ndash9

228 Fujita M Endoh Y Saimon N Yamaguchi S Effect of massaging babies on mothers pilot studyon the changes in mood states and salivary cortisol level Complement Ther Clin Pract200612181ndash5 httpdxdoiorg101016jctcp200601003

229 Manber R Schnyer RN Allen JJ Rush AJ Blasey CM Acupuncture a promising treatment fordepression during pregnancy J Affect Disord 20048389ndash95 httpdxdoiorg101016jjad200405009

230 Austin MP Priest SR Sullivan EA Antenatal psychosocial assessment for reducing perinatalmental health morbidity Cochrane Database Syst Rev 20088CD005124 httpdxdoiorg10100214651858cd005124pub2

231 Bennett C Macdonald GM Dennis J Coren E Patterson J Astin M et al Home-based supportfor disadvantaged adult mothers Cochrane Database Syst Rev 20073CD003759httpdxdoiorg10100214651858cd003759pub2

232 Dale J Caramlau IO Lindenmeyer A Williams SM Peer support telephone calls for improvinghealth Cochrane Database Syst Rev 20084CD006903 httpdxdoiorg10100214651858cd006903pub2

233 Dennis CL Creedy D Psychosocial and psychological interventions for preventing postpartumdepression Cochrane Database Syst Rev 20044CD001134 httpdxdoiorg10100214651858cd001134pub2

234 Dennis CL Psychosocial and psychological interventions for prevention of postnatal depressionsystematic review BMJ 200533115ndash21 httpdxdoiorg101136bmj331750715

235 Dennis CL Preventing postpartum depression part I a review of biological interventionsCan J Psychiatry 200449467ndash75

236 Dennis CL Kingston D A systematic review of telephone support for women during pregnancyand the early postpartum period J Obstet Gynecol Neonatal Nurs 200837301ndash14httpdxdoiorg101111j1552-6909200800235x

237 Dennis CL Ross LE Herxheimer A Oestrogens and progestins for preventing and treatingpostpartum depression Cochrane Database Syst Rev 20084CD001690 httpdxdoiorg10100214651858cd001690pub2

238 Dennis CL Preventing postpartum depression part II a critical review of nonbiologicalinterventions Can J Psychiatry 200449526ndash38

239 Dodd JM Crowther CA Specialised antenatal clinics for women with a multiple pregnancy forimproving maternal and infant outcomes Cochrane Database Syst Rev 20128CD005300httpdxdoiorg10100214651858cd005300pub3

240 Fontein-Kuipers YJ Nieuwenhuijze MJ Ausems M Bude L Vries R Antenatal interventions toreduce maternal distress a systematic review and meta-analysis of randomised trials BJOG2014121389ndash97 httpdxdoiorg1011111471-052812500

241 Howard LM Hoffbrand S Henshaw C Boath L Bradley E Antidepressant prevention of postnataldepression Cochrane Database Syst Rev 20052CD004363 httpdxdoiorg10100214651858cd004363pub2

242 Jans LA Giltay EJ Does AJ The efficacy of n-3 fatty acids DHA and EPA (fish oil) for perinataldepression Br J Nutr 20101041577ndash85 httpdxdoiorg101017S0007114510004125

243 Lawrie TA Herxheimer A Dalton K Oestrogens and progestogens for preventing and treatingpostnatal depression Cochrane Database Syst Rev 20082CD001690

244 Leis JA Mendelson T Tandon SD Perry DF A systematic review of home-based interventions toprevent and treat postpartum depression Arch Womens Ment Health 2009123ndash13httpdxdoiorg101007s00737-008-0039-0

245 Lumley J Austin MP Mitchell C Intervening to reduce depression after birth a systematic reviewof the randomized trials Int J Technol Assess Health Care 200420128ndash44 httpdxdoiorg101017S0266462304000911

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246 Marc I Toureche N Ernst E Hodnett ED Blanchet C Dodin S et al Mindndashbody interventionsduring pregnancy for preventing or treating womenrsquos anxiety Cochrane Database Syst Rev20117CD007559 httpdxdoiorg10100214651858cd007559pub2

247 Miller BJ Murray L Beckmann MM Kent T Macfarlane B Dietary supplements for preventingpostnatal depression Cochrane Database Syst Rev 201310CD009104 httpdxdoiorg10100214651858cd009104pub2

248 Sado M Ota E Stickley A Mori R Hypnosis during pregnancy childbirth and the postnatalperiod for preventing postnatal depression Cochrane Database Syst Rev 20126CD009062httpdxdoiorg10100214651858cd009062pub2

249 Shaw E Levitt C Wong S Kaczorowski J McMaster University Postpartum Research GSystematic review of the literature on postpartum care effectiveness of postpartum supportto improve maternal parenting mental health quality of life and physical health Birth200633210ndash20 httpdxdoiorg101111j1523-536X200600106x

250 Sockol LE Epperson CN Barber JP A meta-analysis of treatments for perinatal depressionClin Psychol Rev 201131839ndash49 httpdxdoiorg101016jcpr201103009

251 Armstrong KL Fraser JA Dadds MR Morris J Promoting secure attachment maternal mood andchild health in a vulnerable population a randomized controlled trial J Paediatr Child Health200036555ndash62 httpdxdoiorg101046j1440-1754200000591x

252 Fraser JA Armstrong KL Morris JP Dadds MR Home visiting intervention for vulnerable familieswith newborns follow-up results of a randomized controlled trial Child Abuse Negl2000241399ndash429 httpdxdoiorg101016S0145-2134(00)00193-9

253 Wheatley SL Brugha TS lsquoJust because I like it doesnrsquot mean it has to workrsquo personal experiencesof an antenatal psychosocial intervention designed to prevent postnatal depression Int J MentHealth Promot 1999126ndash31 httpdxdoiorg10110817465729199900006

254 Wheatley SL Brugha TS Shapiro DA Exploring and enhancing engagement to the psychosocialintervention lsquoPreparing for Parenthoodrsquo Arch Womens Ment Health 20034275ndash85httpdxdoiorg101007s00737-003-0025-5

255 Chabrol H Teissedre F Saint JM Teisseyre N Roge B Prevention and treatment of post partumdepression A controlled study Devenir 2003155ndash25 httpdxdoiorg103917dev0310005

256 Chabrol H Coroner N Rusibane S Seacutejourneacute N Preacutevention du blues du post-partum eacutetude pilote(pilot study of prevention of postpartum blues) Gynecol Obstet Fertil 2007351242ndash4httpdxdoiorg101016jgyobfe200710014

257 Cooper PJ Landman M Tomlinson M Molteno C Swartz L Murray L Impact of a mother-infantintervention in an indigent peri-urban South African context pilot study Br J Psychiatry200218076ndash81 httpdxdoiorg101192bjp180176

258 Dukhovny D Dennis CL Hodnett E Kenton L Weston J Stewart DE et al Prospective economicevaluation of a peer support intervention for prevention of postpartum depression amongst highrisk women in Ontario Canada Am J Perinatol 201330631ndash42 httpdxdoiorg101055s-0032-1331029

259 Creedy D Reducing Postpartum Emotional Distress A Randomised Controlled Trial 10thInternational Conference of Maternity Care Researchers Lund Sweden 13ndash16 June 2004

260 Gamble J Creedy D Reducing Postpartum Emotional Distress A Randomised Controlled TrialPerinatal Society of Australia and New Zealand 7th Annual Congress Hobart Tasmania9ndash12 March 2003 A29

261 Levine RJ Hauth JC Curet LB Sibai BM Catalano PM Morris CD et al Trial of calcium toprevent preeclampsia N Engl J Med 199733769ndash77 httpdxdoiorg101056NEJM199707103370201

262 Ickovics JR Kershaw TS Westdahl C Magriples U Massey Z Reynolds H et al Group prenatalcare and perinatal outcomes a randomized controlled trial Obstet Gynecol 2007110330httpdxdoiorg10109701AOG00002752842429823

263 Lumley J Small R Brown S Watson L Gunn J Mitchell C et al PRISM (Program of ResourcesInformation and Support for Mothers) Protocol for a community-randomised trial[ISRCTN03464021] BMC Public Health 2003336 httpdxdoiorg1011861471-2458-3-36

264 MacArthur C Winter HR Bick DE Lilford RJ Lancashire RJ Knowles H et al Redesigningpostnatal care a randomised controlled trial of protocol-based midwifery-led care focused onindividual womenrsquos physical and psychological health needs Health Technol Assess 20037(37)httpdxdoiorg103310hta7370

265 Ryan P Griffith E McDermott B Makrides M Gibson R Data management tools in theDOMINO trial DHA in pregnancy to prevent postnatal depressive symptoms and enhanceneurodevelopment in children Clinical Trials 20074426

266 Morrell C Spiby H Stewart P Walters S Morgan A Costs and benefits of community postnatalsupport workers a randomised controlled trial Health Technol Assess 20004(6)

267 Cooper P De Pascalis L Woolgar M Romaniuk H Murray L Attempting to prevent postnataldepression by targeting the motherndashinfant relationship a randomised controlled trial Prim HealthCare Res Dev 201416 384ndash97 httpdxdoiorg101017S1463423614000401

268 Reid M Glazener C Connery L Mackenzie J Ismail D Prigg A et al Two interventions forpostnatal support Br J Midwifery 200311294ndash8 httpdxdoiorg1012968bjom200311511226

269 Rotheram-Borus MJ Richter L Rooyen HV Tomlinson M Harwood JM Tang Z et al A clusterrandomized controlled trial evaluating the efficacy of peer mentors to support South Africanwomen living with HIV and their infants PLOS ONE 20149e84867 httpdxdoiorg101371journalpone0084867

270 le Roux IM Tomlinson M Harwood JM OrsquoConnor MJ Worthman CM Mbewu N et alOutcomes of home visits for pregnant mothers and their infants a cluster randomized controlledtrial AIDS 2013271461ndash71 httpdxdoiorg101097QAD0b013e3283601b53

271 Sen DM Robson SC Bond S Peripartum depression and anxiety in mothers expectinguncomplicated twin infants-an antenatal model of care in the North East of England J ReprodInfant Psychol 200422238

272 Stamp GE Williams AS Crowther CA Predicting postnatal depression among pregnant womenBirth 199623218ndash23 httpdxdoiorg101111j1523-536X1996tb00498x

273 Peindl KS The use of nortriptyline for prevention of postpartum depression in a high-risk group ofwomen 152nd Annual Meeting of the American Psychiatric Association Washington DC USA15ndash20 May 1999

274 Wisner KL Peindl KS Perel JM Hanusa BH Plontek CM Findling RL Sertraline preventspostpartum depression 156th Annual Meeting of the American Psychiatric Association SanFrancisco CA USA 17ndash22 May 2003 httpdxdoiorg101016s0009-9236(03)90455-3

275 Nikodem VC Nolte AG Wolman W Guumllmezoglu AM Hofmeyr GJ Companionship by a laylabour supporter to modify the clinical birth environment long-term effects on mother and childCurationis 1998218ndash12 httpdxdoiorg104102curationisv21i1596

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276 Trotter C Wolman WL Hofmeyr J Nikodem C Turton R The effect of social support duringlabour on postpartum depression S Afr J Psychol 199222134ndash9 httpdxdoiorg101177008124639202200304

277 Andersson E Christensson K Hildingsson I Parentsrsquo experiences and perceptions of group-basedantenatal care in four clinics in Sweden Midwifery 201228502ndash8 httpdxdoiorg101016jmidw201107006

278 Carolan M Barry M Gamble M Turner K Mascarenas O Experiences of pregnant womenattending a lullaby programme in Limerick Ireland a qualitative study Midwifery 201228321ndash8httpdxdoiorg101016jmidw201104009

279 Carolan M Barry M Gamble M Turner K Mascarenas O The Limerick Lullaby project anintervention to relieve prenatal stress Midwifery 201228173ndash80 httpdxdoiorg101016jmidw201012006

280 Doran F Hornibrook J Womenrsquos experiences of participation in a pregnancy and postnatal groupincorporating yoga and facilitated group discussion a qualitative evaluation Women Birth20132682ndash6 httpdxdoiorg101016jwombi201206001

281 Evans M Donelle L Hume-Loveland L Social support and online postpartum depressiondiscussion groups a content analysis Patient Educ Couns 201287405ndash10 httpdxdoiorg101016jpec201109011

282 Gao LL Luo SY Chan SWC Interpersonal psychotherapy-oriented program for Chinese pregnantwomen delivery content and personal impact Nurs Health Sci 201214318ndash24httpdxdoiorg101111j1442-2018201200722x

283 Kennedy HP Farrell T Paden R Hill S Jolivet R Willetts J et al lsquoI wasnrsquot alonersquo ndash a study of groupprenatal care in the military J Midwifery Womens Health 200954176ndash83 httpdxdoiorg101016jjmwh200811004

284 Klima C Norr K Vonderheid S Handler A Introduction of CenteringPregnancy in a public healthclinic J Midwifery Womens Health 20095427ndash34 httpdxdoiorg101016jjmwh200805008

285 McNeil DA Vekved M Dolan SM Siever J Horn S Tough SC Getting more than they realizedthey needed a qualitative study of womenrsquos experience of group prenatal care BMC PregnancyChildbirth 20121217 httpdxdoiorg1011861471-2393-12-17

286 Migl KS The Lived Experiences of Prenatal Stress and Mindndashbody Exercises Reflections ofPost-Partum Women PhD thesis Texas University of Texas Medical Branch Graduate School ofBiomedical Sciences 2009

287 Morrell C Postnatal Support Who Wants it What is its Benefit and How Much Does it CostPhD thesis Sheffield University of Sheffield 2002

288 Scott D Maternal and child health nurse role in post-partum depression Aust J Adv Nurs1987528ndash37

289 Teate A Leap N Rising SS Homer CS Womenrsquos experiences of group antenatal care inAustralia ndash the CenteringPregnancy Pilot StudyMidwifery 201127138ndash45 httpdxdoiorg101016jmidw200903001

290 McNeil DA Vekved MF Dolan SM Siever J Siever JF Horn S et al A qualitative study of theexperience of CenteringPregnancy group prenatal care for physicians BMC Pregnancy Childbirth201313(Suppl 1)6 httpdxdoiorg1011861471-2393-13-S1-S6

291 Tanner-Smith EE Steinka-Fry KT Lipsey MW A Multi-site Evaluation of the Centering Pregnancyreg

Programs in Tennessee Nashville TN Peabody Research Institute Vanderbilt University 2012URL httpsmyvanderbilteduemilytannersmithfiles201202Contract19199-GR1030830-Final-Reportpdf (accessed August 2014)

292 Lehman E Centering pregnancy A Combined Quantitative and Qualitative Appraisal of WomenrsquosExperiences of Depression and Anxiety During Group Prenatal Care Wheaton IL WheatonCollege 2012

293 Novick G Sadler LS Knafl KA Groce NE Kennedy HP The intersection of everyday life and groupprenatal care for women in two urban clinics J Health Care Poor Underserved 201223589ndash603httpdxdoiorg101353hpu20120060

294 Novick G Reid A Lewis J Kershaw TS Rising SS Ickovics J Group prenatal care model fidelityand outcomes Am J Obstet Gynecol 2013209112e1ndashe6 httpdxdoiorg101016jajog201303026

295 Novick G Sadler LS Knafl KA Groce NE Kennedy HP In a hard spot providing group prenatalcare in two urban clinics Midwifery 201329690ndash7 httpdxdoiorg101016jmidw201206013

296 Shanok AF Miller L Stepping up to motherhood among inner-city teens Psychol Women Q200731252ndash61 httpdxdoiorg101111j1471-6402200700368x

297 Shanok AF Miller L Depression and treatment with inner city pregnant and parenting teensArch Womens Ment Health 200710199ndash210 httpdxdoiorg101007s00737-007-0194-8

298 Shanok AF Experiences of Pregnancy and Parenting Among Inner City Teens Attending anAlternative Public School PhD thesis New York NY Columbia University 2007

299 Dennis CL Postpartum depression peer support maternal perceptions from a randomizedcontrolled trial Int J Nurs Stud 201047560ndash8 httpdxdoiorg101016jijnurstu200910015

300 Myors KA Schmied V Johnson M Cleary M lsquoMy special timersquo Australian womenrsquos experiencesof accessing a specialist perinatal and infant mental health service Health Soc Care Community201422268ndash77 httpdxdoiorg101111hsc12079

301 Dennis CL Peer support for postpartum depression volunteersrsquo perceptions recruitmentstrategies and training from a randomized controlled trial Health Promot Int 201328187ndash96httpdxdoiorg101093heaprodas003

302 Corrigan LB Postpartum Depressive Symptomatology in First-time Mothers Relationship toExpectations and Postpartum Perceptions PhD thesis Malibu CA Pepperdine University 1997

303 Curtis R Robertson P Forst A Bradford C Postpartum mood disorders results of an onlinesurvey Counsel Psychother Res 20077203ndash10 httpdxdoiorg10108014733140701706060

304 Hanley J The emotional wellbeing of Bangladeshi mothers during the postnatal periodCommunity Pract 20078034ndash7

305 Leung SSK Postpartum Depression Perceived Social Support and Stress among Hong KongChinese Women PhD thesis Peoplersquos Republic of China Hong Kong Polytechnic 2001

306 Edge D lsquoWe donrsquot see black women herersquo an exploration of the absence of black Caribbeanwomen from clinical and epidemiological data on perinatal depression in the UK Midwifery200824379ndash89 httpdxdoiorg101016jmidw200701007

307 Edge D Perinatal depression its absence among black Caribbean women Br J Midwifery200614646 httpdxdoiorg1012968bjom2006141122251

REFERENCES

308 Edge D Baker D Rogers A Perinatal depression among black Caribbean women Health Soc CareCommunity 200412430ndash8 httpdxdoiorg101111j1365-2524200400513x

309 Edge D MacKian SC Ethnicity and mental health encounters in primary care help-seeking andhelp-giving for perinatal depression among black Caribbean women in the UK Ethn Health20101593ndash111 httpdxdoiorg10108013557850903418836

310 Edge D Rogers A Dealing with it black Caribbean womenrsquos response to adversity andpsychological distress associated with pregnancy childbirth and early motherhood Soc Sci Med20056115ndash25 httpdxdoiorg101016jsocscimed200411047

311 Edge D lsquoItrsquos leaflet leaflet leaflet then lsquosee you laterrsquorsquo black Caribbean womenrsquos perceptions ofperinatal mental health care Br J Gen Pract 201161256ndash62 httpdxdoiorg103399bjgp11X567063

312 Lewis SE Nicolson P Talking about early motherhood recognizing loss and reconstructingdepression J Reprod Infant Psychol 199816177ndash97 httpdxdoiorg10108002646839808404567

313 Nicolson P Loss happiness and postpartum depression the ultimate paradox Can Psychol19992162ndash78 httpdxdoiorg101037h0086834

314 Parvin A Jones CE Hull SA Experiences and understandings of social and emotional distressin the postnatal period among Bangladeshi women living in Tower Hamlets Fam Pract200421254ndash60 httpdxdoiorg101093fampracmh307

315 Raymond JE lsquoCreating a safety netrsquo womenrsquos experiences of antenatal depression and theiridentification of helpful community support and services during pregnancy Midwifery20092539ndash49 httpdxdoiorg101016jmidw200701005

316 Razurel C Bruchon-Schweitzer M Dupanloup A Irion O Epiney M Stressful events socialsupport and coping strategies of primiparous women during the postpartum period a qualitativestudy Midwifery 201127237ndash42 httpdxdoiorg101016jmidw200906005

317 Sword W Clark AM Hegadoren K Brooks S Kingston D The complexity of postpartum mentalhealth and illness a critical realist study Nurs Inq 20121951ndash62 httpdxdoiorg101111j1440-1800201100560x

318 Taniguchi H Baruffi G Childbirth overseas the experience of Japanese women in HawaiiNurs Health Sci 2007990ndash5 httpdxdoiorg101111j1442-2018200700307x

319 Thurtle V First time mothersrsquo perceptions of motherhood and PND Community Pract200376261ndash5

320 Ugarriza DN Brown SE Chang-Martinez C Anglo-American mothers and the prevention ofpostpartum depression Issues Ment Health Nurs 200728781ndash98 httpdxdoiorg10108001612840701413624

321 Choi P Henshaw C Baker S Tree J Supermum superwife supereverything performingfemininity in the transition to motherhood J Reprod Infant Psychol 200523167ndash80httpdxdoiorg10108002646830500129487

322 Furber CM Garrod D Maloney E Lovell K McGowan L A qualitative study of mild to moderatepsychological distress during pregnancy Int J Nurs Stud 200946669ndash77 httpdxdoiorg101016jijnurstu200812003

323 Haga SM Lynne A Slinning K Kraft P A qualitative study of depressive symptoms and well-beingamong first-time mothers Scand J Caring Sci 201226458ndash66 httpdxdoiorg101111j1471-6712201100950x

324 Mauthner NS Re-assessing the importance and role of the marital relationship in postnataldepression methodological and theoretical implications J Reprod Infant Psychol 1998161998httpdxdoiorg10108002646839808404566

325 Rodrigues M Patel V Jaswal S de SN Listening to mothers qualitative studies on motherhoodand depression from Goa India Soc Sci Med 2003571797ndash806 httpdxdoiorg101016S0277-9536(03)00062-5

326 Morrell CJ Ricketts T Tudor K Williams C Curran J Barkham M Training health visitors incognitive behavioural and person-centred approaches for depression in postnatal women as partof a cluster randomised trial and economic evaluation in primary care the PoNDER trial PrimHealth Care Res Dev 20111211ndash20 httpdxdoiorg101017S1463423610000344

327 Gao Ll Chan SW-c Sun K Effects of an interpersonal-psychotherapy-oriented childbirtheducation programme for Chinese first-time childbearing women at 3-month follow uprandomised controlled trial Int J Nurs Stud 20123274ndash81 httpdxdoiorg101016jijnurstu201109010

328 Ware JE Kosinski M Gandek B SF-12 How to Score the SF-12 Physical and Mental HealthSummary Scales Boston MA The Health Institute New England Medical Centre 1995

329 Hayes BA Muller R Prenatal depression a randomized controlled trial in the emotional health ofprimiparous women Res Theory Nurs Pract 200418165ndash83 httpdxdoiorg101891rtnp18216561277

330 Henderson J Sharp J Priest SR Hagan R Evans SF Postnatal debriefing what do women feelabout it 14th Annual Congress of the Perinatal Society of Australia and New Zealand AliceSprings Australia381998

331 Wheatley SL Culverwell A Brugha TS Shapiro DA Preparing for parenthood background anddevelopment of a risk modifying intervention to prevent postnatal depression Arch WomensMental Health 2000381ndash90 httpdxdoiorg101007s007370070001

332 Lavender T Walkinshaw SA Can midwives reduce postpartum psychological morbidity Arandomized trial Birth 199825215ndash19 httpdxdoiorg101046j1523-536X199800215x

333 Smith J An integrated approach to perinatal support by Family Action J Health Visiting20131272ndash6 httpdxdoiorg1012968johv201315272

334 Lara MA Navarro C Navarrete L Le HN Retention rates and potential predictors in a longitudinalrandomized control trial to prevent postpartum depression Salud Mental 201033429ndash36

335 Howell EA Bodnar-Deren S Balbierz A Loudon H Mora PA Zlotnick C et al An intervention toreduce postpartum depressive symptoms a randomized controlled trial Arch Womens MentHealth 20141757ndash63 httpdxdoiorg101007s00737-013-0381-8

336 Martin A Negron R Balbierz A Bickell N Howell EA Recruitment of black and Latina women to arandomized controlled trial J Health Care Poor Underserved 2013241102ndash14 httpdxdoiorg101353hpu20130125

337 Shields N Turnbull D Reid M Holmes A McGinley M Smith LN Satisfaction with midwife-managed care in different time periods a randomised controlled trial of 1299 women Midwifery19981485ndash93 httpdxdoiorg101016S0266-6138(98)90003-1

338 Tumbull D Holmes A Shields N Cheyne H Twaddle S Gilmour WH et al Randomisedcontrolled trial of efficacy of midwife-managed care Lancet 1996348213ndash18 httpdxdoiorg101016S0140-6736(95)11207-3

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339 Young D Shields N Holmes A Turnbull D Twaddle S A new style of midwife-managedantenatal care costs and satisfaction Br J Midwifery 19975540ndash5 httpdxdoiorg1012968bjom199759540

340 Beynon R Wafula S One charityrsquos approach to perinatal depression and social inclusion MentHealth Soc Inclusion 201216206ndash10 httpdxdoiorg10110820428301211281078

341 Schroter S Glasziou P Heneghan C Quality of descriptions of treatments a review of publishedrandomised controlled trials BMJ Open 201226 httpdxdoiorg101136bmjopen-2012-001978

342 Hoffmann TC Glasziou PP Boutron I Milne R Perera R Moher D et al Better reporting ofinterventions template for intervention description and replication (TIDieR) checklist and guideBMJ 2014348g1687 httpdxdoiorg101136bmjg1687

343 Quinones AR Richardson J Freeman M Fu R OrsquoNeil ME Kansagara D Group Visits Focusing onEducation for the Management of Chronic Conditions in Adults A Systematic Review VA-ESPProject 05-225 2012

344 Quinones AR Richardson J Freeman M Fu R OrsquoNeil ME Motursquoapuaka M et al Educationalgroup visits for the management of chronic health conditions a systematic review Patient EducCouns 2014953ndash29 httpdxdoiorg101016jpec201312021

345 Carroll C Booth A Cooper K A worked example of rsquobest fitrsquo framework synthesis a systematicreview of views concerning the taking of some potential chemopreventive agents BMC Med ResMethodol 2011111ndash9 httpdxdoiorg1011861471-2288-11-29

346 Carroll C Booth A Leaviss J Rick J lsquoBest fitrsquo framework synthesis refining the method BMC MedRes Methodol 20131337 httpdxdoiorg1011861471-2288-13-37

347 Clark DME Fairburn CG Science and Practice of Cognitive Behaviour Therapy Oxford OxfordUniversity Press 1997

348 Sanders P Mapping person-centred approaches to counselling and psychotherapy Person-CentredPractice 2000862ndash74

349 Greenberg MT Speltz ML DeKlyen M The role of attachment in the early development ofdisruptive behavior problems Dev Psychopathol 19935191ndash213 httpdxdoiorg101017S095457940000434X

350 Fonagy P Target M Playing with reality I Theory of mind and the normal development ofpsychic reality Int J Psychoanal 199677217ndash33

351 Fonagy P Steele M Steele H Higgitt A Target M The Emanuel Miller Memorial Lecture 1992The Theory and Practice of Resilience J Child Psychol Psychiatry 199435231ndash57 httpdxdoiorg101111j1469-76101994tb01160x

352 Gilligan R Enhancing the resilience of children and young people in public care by mentoringtheir talents and interests Child Fam Soc Work 19994187ndash96 httpdxdoiorg101046j1365-2206199900121x

353 Klerman GL Weissman MM Rounsaville B Chevron ES Interpersonal Psychotherapy forDepression New York NY University Press 1996

354 Sullivan HS The Interpersonal Theory of Psychiatry New York NY Routledge 2013

355 Bowlby J Attachment Vol 1 of Attachment and Loss New York NY Basic Books 1969

356 Finkelhor D The trauma of child sexual abuse two models J Interpers Violence 19872348ndash66httpdxdoiorg101177088626058700200402

357 Littlewood J McHugh N Maternal Distress and Postnatal Depression The Myth of MadonnaLondon Palgrave Macmillan Limited 1997 httpdxdoiorg101007978-1-349-13755-8

358 Brown GW Harris T Social Origins of Depression A Study of Psychiatric Disorder in WomenNew York NY Routledge 2012

359 Lazarus RS Folkman S Stress Appraisal and Coping New York NY Springer 1984

360 Bandura A Social Learning Theory Englewood Cliffs NJ Prentice-Hall 1977

361 Bandura A Social Foundations of Thought and Action A Social Cognitive Theory EnglewoodCliffs NJ Prentice-Hall 1986

362 Rahman A Surkan PJ Cayetano CE Rwagatare P Dickson KE Grand challenges integratingmaternal mental health into maternal and child health programmes PLOS Med 201310e1001442httpdxdoiorg101371journalpmed1001442

363 Novick G Sadler LS Kennedy HP Cohen SS Groce NE Knafl KA Womenrsquos experience of groupprenatal care Qual Health Res 20112197ndash116 httpdxdoiorg1011771049732310378655

364 Teng L Robertson BE Stewart DE Healthcare workerrsquos perceptions of barriers to care byimmigrant women with postpartum depression an exploratory qualitative study Arch WomensMent Health 20071093ndash101 httpdxdoiorg101007s00737-007-0176-x

365 Holopainen D The experience of seeking help for postnatal depression Aust J Adv Nurs20021939ndash44

366 Dennis CL Chung-Lee L Postpartum depression help-seeking barriers and maternal treatmentpreferences a qualitative systematic review Birth 200633323ndash31 httpdxdoiorg101111j1523-536X200600130x

367 Heneghan AM Morton S DeLeone NL Paediatriciansrsquo attitudes about discussing maternaldepression during a paediatric primary care visit Child Care Health Dev 200733333ndash9httpdxdoiorg101111j1365-2214200600648x

368 Herrman JW Rogers S Ehrenthal DB Womenrsquos perceptions of CenteringPregnancy a focusgroup study MCN Am J Matern Child Nurs 20123719ndash28 httpdxdoiorg101097NMC0b013e3182385204

369 Sword W Busser D Ganann R McMillan T Swinton M Womenrsquos care-seeking experiences afterreferral for postpartum depression Qual Health Res 2008181161ndash73 httpdxdoiorg1011771049732308321736

370 Buultjens M Liamputtong P When giving life starts to take the life out of you womenrsquosexperiences of depression after childbirth Midwifery 20072377ndash91 httpdxdoiorg101016jmidw200604002

371 Williamson VH A Hermeneutic Phenomenological Study of Womenrsquos Experiences of PostnatalDepression and Health Professional Intervention PhD thesis Adelaide SA University of Adelaide 2005

372 Everingham CR Heading G Connor L Couplesrsquo experiences of postnatal depression a framinganalysis of cultural identity gender and communication Soc Sci Med 2006621745ndash56httpdxdoiorg101016jsocscimed200508039

373 Barkin JL Bloch JR Hawkins KC Thomas TS Barriers to optimal social support in the postpartumperiod J Obstet Gynecol Neonatal Nurs 201443445ndash54 httpdxdoiorg1011111552-690912463

374 Blau PM Exchange and Power in Social Life Piscataway NJ Transaction Publishers 1964

375 Homans GC Social Behavior Its Elementary Forms New York NY Harcourt Brace amp WorldInc 1961

REFERENCES

376 Scrandis DA Normalizing postpartum depressive symptoms with social support J Am PsychiatrNurses Assoc 200511223ndash30 httpdxdoiorg1011771078390305280940

377 Bandura A Self-Efficacy In Ramachaudran VS editor Encyclopedia of Human BehaviourNew York NY Academic Press pp 71ndash81

378 Champion LA Power MJ Social and cognitive approaches to depression towards a newsynthesis Br J Clin Psychol 199534485ndash503 httpdxdoiorg101111j2044-82601995tb01484x

379 Leahy-Warren P McCarthy G Corcoran P First-time mothers social support maternal parentalself-efficacy and postnatal depression J Clin Nurs 201221388ndash97 httpdxdoiorg101111j1365-2702201103701x

380 Berg M Genuine Caring in Caring for the Genuine Childbearing and High Risk as Experienced byWomen and Midwives PhD thesis Uppsala Uppsala University Disciplinary Domain of Medicineand Pharmacy Faculty of Medicine Department of Womenrsquos and Childrenrsquos Health 2002

381 Beck CT Postpartum depression it isnrsquot just the blues Am J Nurs 200610640ndash50httpdxdoiorg10109700000446-200605000-00020

383 Rising SS Kennedy HP Klima CS Redesigning prenatal care through CenteringPregnancyJ Midwifery Womens Health 200449398ndash404 httpdxdoiorg101111j1542-20112004tb04433x

384 Dennis CL Ross LE Grigoriadis S Psychosocial and psychological interventions for treatingantenatal depression Cochrane Database Syst Rev 20073CD006309

385 Pennington A The Student Guide to Counselling and Psycotherapy Approaches LondonSAGE 2012

386 Dennis CL The effect of peer support on postpartum depression a pilot randomized controlledtrial Can J Psychiatry 200348115ndash24

387 Harris T Brown G Hamilton V Hodson S Craig TKJ The Newpin Antenatal and Postnatal Projecta randomised controlled trial of an intervention for Perinatal Depression Poster prepared for theHSR Open Day Institute of Psychiatry Kingrsquos College London London 6 July 2006

388 Rojas G Fritsch R Solis J Jadresic E Castillo C Gonzalez M et al Treatment of postnataldepression in low-income mothers in primary-care clinics in Santiago Chile a randomisedcontrolled trial Lancet 20073701629ndash37 httpdxdoiorg101016S0140-6736(07)61685-7

389 Chowdhary N Sikander S Atif N Singh N Ahmad I Fuhr DC et al The content and delivery ofpsychological interventions for perinatal depression by non-specialist health workers in lowand middle income countries a systematic review Best Pract Res Clin Obstet Gynaecol201428113ndash33 httpdxdoiorg101016jbpobgyn201308013

390 Hanley J Long B A study of Welsh mothersrsquo experiences of postnatal depression Midwifery200622147ndash57 httpdxdoiorg101016jmidw200508004

391 Dunstan P Calm the Crying The Secret Baby Language that Reveals the Hidden Meaning Behindan Infantrsquos Cry London Penguin 2012

392 Stevenson MD Scope A Sutcliffe PA Booth A Slade P Parry G et al Group cognitivebehavioural therapy for postnatal depression a systematic review of clinical effectivenesscost-effectiveness and value of information analyses Health Technol Assess 201014(44)httpdxdoiorg103310hta14440

393 Stevenson MD Scope A Sutcliffe PA The cost-effectiveness of group cognitive behavioraltherapy compared with routine primary care for women with postnatal depression in the UKValue Health 201013580ndash4 httpdxdoiorg101111j1524-4733201000720x

394 Buist AE Barnett BE Milgrom J Pope S Condon JT Ellwood DA et al To screen or not toscreen ndash that is the question in perinatal depression Med J Aust 200217S101ndashS5

395 Darcy JM Grzywacz JG Stephens RL Leng I Clinch CR Arcury TA Maternal depressivesymptomatology 16-month follow-up of infant and maternal health-related quality of lifeJ Am Board Fam Med 201124249ndash57 httpdxdoiorg103122jabfm201103100201

396 Dukhovny D Dennis CL Hodnett E Weston J Stewart DE Mao W et al Prospective economicevaluation of a peer support intervention for prevention of postpartum depression amonghigh-risk women in Ontario Canada Am J Perinatol 201330631ndash42 httpdxdoiorg101055s-0032-1331029

397 Gold L Shiell A Hawe P Riley T Rankin B Smithers P The costs of a community-basedintervention to promote maternal health Health Educ Res 200722648ndash57 httpdxdoiorg101093hercyl127

398 Appleby L Hirst E Marshall S Keeling F Brind J Butterworth T et al The treatment of postnataldepression by health visitors impact of brief training on skills and clinical practice J Affect Disord200377261ndash6 httpdxdoiorg101016S0165-0327(02)00145-3

399 Boath E Major K Cox J When the cradle falls II the cost-effectiveness of treating postnataldepression in a psychiatric day hospital compared with routine primary care J Affect Disord200374159ndash66 httpdxdoiorg101016S0165-0327(02)00007-1

400 Dagher RK McGovern PM Dowd BE Gjerdingen DK Postpartum depression and health servicesexpenditures among employed women J Occup Environ Med 201254210ndash15 httpdxdoiorg101097JOM0b013e31823fdf85

401 Cooper PJ Murray L Hooper R West A The development and validation of a predictive index forpostpartum depression Psycho Med 199626627ndash34 httpdxdoiorg101017S0033291700035698

402 Revicki DA Wood M Patient-assigned health state utilities for depression-related outcomesdifferences by depression severity and antidepressant medications J Affect Disord 19984825ndash36httpdxdoiorg101016S0165-0327(97)00117-1

403 National Institute for Health and Care Excellence (NICE) Guide to the Methods of TechnologyAppraisal London NICE 2013

404 Curtis L Unit Costs of Health and Social Care 2013 Canterbury PSSRU University of Kent 2013

405 Statistics Canada Consumer Price Index Health and Personal Care by Province (Canada) CanadaGovernment of Canada 2014

406 Executive Office of the President of the United States Council of Economic Advisers Trends inHealth Care Cost Growth and the Role of the Affordable Care Act Washington DC ExecutiveOffice of the President of the United States 2013

407 Australian Institute of Health and Welfare Health Expenditure Australia 201112 Health andwelfare expenditure series 50 Canberra Australian Institute of Health and Welfare 2013

408 Honey KL Bennett P Morgan M A brief psycho-educational group intervention for postnataldepression British J Clin Psychol 200241405ndash9 httpdxdoiorg101348014466502760387515

409 Netten A Dennet J Knight J Unit Costs of Health and Social Care Canterbury PSSRU Universityof Kent 1998

REFERENCES

410 Joint Formulary Committee British National Formulary 67 ed London BMJ Group andPharmaceutical Press 2014

411 XE XE Currency Converter URL wwwxecomcurrencyconverter (accessed August 2014)

412 Fenwick E Claxton K Sculpher M Representing uncertainty the role of cost-effectivenessacceptability curves Health Econ 200110779ndash87 httpdxdoiorg101002hec635

413 Claxton K Posnett J An economic approach to clinical trial design and research priority-settingHealth Econ 19965513ndash24 httpdxdoiorg101002(SICI)1099-1050(199611)56lt513AID-HEC237gt30CO2-9

414 Stinnett A Mullahy J Net health benefits a new framework for the analysis of uncertainty incost-effectiveness analyses Med Decis Making 199818S68ndash80 httpdxdoiorg1011770272989X9801800209

415 Felli JC Hazen GB Sensitivity analysis and the expected value of perfect information MedicalDecision Making 19981895ndash109 httpdxdoiorg1011770272989X9801800117

416 Office for National Statistics Birth Summary Tables England and Wales 2012 London Office forNational Statistics 2013

417 Dennis CL Dowswell T Psychosocial and psychological interventions for preventing postpartumdepression Cochrane Database Syst Rev 20132CD001134 httpdxdoiorg10100214651858CD001134pub3

418 Smith A Dixon A Shakespeare J The Role of GPS in Maternity Care ndash What Does The FutureHold An Inquiry Into the Quality of General Practice in England London The Kingrsquos Fund 2010

419 Department of Health Department for Education and Skills National Service Framework forChildren Young People and Maternity Services (England) London Department of Health 2004

420 National Institute for Health and Care Excellence (NICE) Routine Postnatal Care of Women andTheir Babies London NICE 2006

421 Barnes J Aistrop D Allen E Barlow J Elbourne D Macdonald G et al First steps study protocolfor a randomized controlled trial of the effectiveness of the Group Family Nurse Partnership(gFNP) program compared to routine care in improving outcomes for high-risk mothers and theirchildren and preventing abuse Trials 201314285 httpdxdoiorg1011861745-6215-14-285

422 Miniati M Callari A Calugi S Rucci P Savino M Mauri M et al Interpersonal psychotherapy forpostpartum depression a systematic review Arch Womens Ment Health 201417257ndash68httpdxdoiorg101007s00737-014-0442-7

423 Sockol LE Epperson CN Barber JP Preventing postpartum depression a meta-analytic reviewClin Psychol Rev 2013331205ndash17 httpdxdoiorg101016jcpr201310004

424 Hoffenaar PJ van Balen F Hermanns J The impact of having a baby on the level and contentof womenrsquos well-being Soc Indic Res 201097279ndash95 httpdxdoiorg101007s11205-009-9503-0

425 Bennett C Macdonald GM Dennis J Coren E Patterson J Astin M et al Home-based supportfor disadvantaged adult mothers Cochrane Database Syst Rev 20081CD003759 [Update ofCochrane Database Syst Rev 20073CD003759] httpdxdoiorg10100214651858cd003759pub3

426 Baldwin KA Comparison of selected outcomes of CenteringPregnancy versus traditional prenatalcare J Midwifery Womens Health 200651266ndash72 httpdxdoiorg101016jjmwh200511011

427 Baldwin K Phillips G Voices along the journey midwivesrsquo perceptions of implementing thecentering pregnancy model of prenatal care J Perinat Educ 201120210 httpdxdoiorg1018911058-1243204210

428 Shakespear K Waite PJ Gast J A comparison of health behaviors of women in centeringpregnancy and traditional prenatal care Matern Child Health J 201014202ndash8 httpdxdoiorg101007s10995-009-0448-3

429 Shakespear K Centering Pregnancy and Traditional Prenatal Care A Comparison of HealthPractices MSc thesis Logan UT Utah State University 2008

430 Xaverius PK Grady MA Centering pregnancy in Missouri a system level analysis Sci World J2014285386 httpdxdoiorg1011552014285386

431 Gaudion A Menka Y lsquoNo decision about me without mersquo centering pregnancy Pract Midwife20101315ndash17

432 Teate A Leap N Homer CSE Midwives experiences of becoming CenteringPregnancy facilitatorsa pilot study in Sydney Australia Women Birth 201326e31ndash6 httpdxdoiorg101016jwombi201208002

433 Robertson B Aycock DM Darnell LA Comparison of centering pregnancy to traditional care inHispanic mothers Matern Child Health J 200913407ndash14 httpdxdoiorg101007s10995-008-0353-1

434 Sheeder J Yorga KW Kabir-Greher K A review of prenatal group care literature the need for astructured theoretical framework and systematic evaluation Matern Child Health J 201216177ndash87httpdxdoiorg101007s10995-010-0709-1

435 Slade P Morrell CJ Rigby A Ricci K Spittlehouse J Brugha TS Postnatal womenrsquos experiences ofmanagement of depressive symptoms a qualitative study Br J Gen Pract 201060e440ndash8httpdxdoiorg103399bjgp10X532611

436 Morrell CJ Nurse-led postpartum discharge education programme including information onpostnatal depression reduces risk of high depression scores at 3-month follow-up Evid BasedNurs 20101348ndash9 httpdxdoiorg101136ebn13248

437 Gao Ll Sun K Chan SW-c Social support and parenting self-efficacy among Chinese women inthe perinatal period Midwifery 201430532ndash8 httpdxdoiorg101016jmidw201306007

438 Ngai FW Chan S Psychosocial factors and maternal wellbeing an exploratory path analysisInt J Nurs Stud 201148725ndash31 httpdxdoiorg101016jijnurstu201011002

439 Grote NK Zuckoff A Swartz H Bledsoe SE Geibel S Engaging women who are depressed andeconomically disadvantaged in mental health treatment Soc Work 200752295ndash308httpdxdoiorg101093sw524295

440 Grote NK Swartz HA Zuckoff A Enhancing interpersonal psychotherapy for mothers andexpectant mothers on low incomes adaptations and additions J Contemp Psychother20083823ndash33 httpdxdoiorg101007s10879-007-9065-x

441 Grote NK Bledsoe SE Swartz HA Frank E Feasibility of providing culturally relevant briefinterpersonal psychotherapy for antenatal depression in an obstetrics clinic a pilot study Res SocWork Pract 200414397ndash407 httpdxdoiorg1011771049731504265835

442 Grote NK Bledsoe SE Swartz HA Frank E Culturally relevant psychotherapy for perinataldepression in low-income obgyn patients Clin Soc Work J 20043327ndash47 httpdxdoiorg101023BCSOW0000035111812055b

REFERENCES

443 Grote NK Spieker SJ Lohr MJ Geibel SL Swartz HA Frank E et al Impact of childhood traumaon the outcomes of a perinatal depression trial Depress Anxiety 201229563ndash73httpdxdoiorg101002da21929

444 Dennis CL Ravitz P Grigoriadis S Jovellanos M Hodnett E Ross L et al The effect of telephone-based interpersonal psychotherapy for the treatment of postpartum depression study protocol fora randomized controlled trial Trials 20121338 httpdxdoiorg1011861745-6215-13-38

445 Fenwick J Gamble J Creedy D Barclay L Buist A Ryding EL Womenrsquos perceptions of emotionalsupport following childbirth a qualitative investigation Midwifery 201329217ndash24httpdxdoiorg101016jmidw201112008

446 Fenwick J Gamble J Creedy DK Buist A Turkstra E Sneddon A et al Study protocol forreducing childbirth fear a midwife-led psycho-education intervention BMC Pregnancy Childbirth201313190 httpdxdoiorg1011861471-2393-13-190

447 Gamble J Creedy DK A counselling model for postpartum women after distressing birthexperiences Midwifery 200925e21ndash30 httpdxdoiorg101016jmidw200704004

448 Reed M Fenwick J Hauck Y Gamble J Creedy DK Australian midwivesrsquo experience of deliveringa counselling intervention for women reporting a traumatic birth Midwifery 201430269ndash75httpdxdoiorg101016jmidw201307009

449 Turkstra E Gamble J Creedy DK Fenwick J Barclay L Buist A et al PRIME impact of previousmental health problems on health-related quality of life in women with childbirth traumaArch Womens Ment Health 201316561ndash4 httpdxdoiorg101007s00737-013-0384-5

450 Turnbull D Shields N McGinley M Holmes A Cheyne H Reid M et al Can midwife-managedunits improve continuity of care Br J Midwifery 19997499ndash503 httpdxdoiorg1012968bjom1999788285

451 Shields N Holmes A Cheyne H McGinley M Young D Gilmour WH et al Knowing yourmidwife during labour Br J Midwifery 19997504ndash10 httpdxdoiorg1012968bjom1999788286

452 Young D Lees A Twaddle S The costs to the NHS of maternity care midwife-managed vsshared Br J Midwifery 19975465ndash72 httpdxdoiorg1012968bjom199758465

453 Ferguson L Beating the baby blues Pract Midwife 20121517ndash19

454 Lederer J Family Action Southwark Newpin Prenatal Support Project Evaluation Report LondonFamily Action 2009

455 Barlow J Coe C Family Action Perinatal Support Project Warwick University of WarwickWarwick Medical School 2012

456 Bick D MacArthur C Winter H Fortune H Henderson C Lilford R et al Redesigning postnatalcare physical and psychological needs Br J Midwifery 19975621ndash2 httpdxdoiorg1012968bjom1997510621

457 Morrow J McLachlan H Forster D Davey MA Newton M Redesigning postnatal care exploringthe views and experiences of midwives Midwifery 201329159ndash66 httpdxdoiorg101016jmidw201111006

458 MacArthur C Winter H Bick D Henderson C Knowles H Re-designed community postnatal caretrial Br J Midwifery 200513319ndash23 httpdxdoiorg1012968bjom200513518096

459 Glavin K Smith L Sorum R Ellefsen B Redesigned community postpartum care to prevent andtreat postpartum depression in women ndash a one-year follow-up study J Clin Nurs 2010193051ndash62httpdxdoiorg101111j1365-2702201003332x

460 Furuta M Sandall J Bick D Womenrsquos perceptions and experiences of severe maternal morbiditylsquoA synthesis of qualitative studies using a meta-ethnographic approach Midwifery 201430158ndash69httpdxdoiorg101016jmidw201309001

461 Bick D MacArthur C Winter H Postnatal Care London Elsevier Health Sciences UK 2008

462 Lavender T Richens Y Milan SJ Smyth R Dowswell T Telephone support for women duringpregnancy and the first six weeks postpartum Cochrane Database Syst Rev 20137CD009338httpdxdoiorg10100214651858cd009338pub2

463 Rahman A Challenges and opportunities in developing a psychological intervention for perinataldepression in rural Pakistan ndash a multi-method study Arch Womens Ment Health 200710211ndash19httpdxdoiorg101007s00737-007-0193-9

464 Simon GE CBT improves maternal perinatal depression in rural Pakistan Evid Based Ment Health20091245 httpdxdoiorg101136ebmh12245

465 Rahman A Sikander S Malik A Ahmed I Tomenson B Creed F Effective treatment of perinataldepression for women in debt and lacking financial empowerment in a low-income countryBr J Psychiatry 2012201451ndash7 httpdxdoiorg101192bjpbp112109207

466 Martin A Horowitz C Balbierz A Howell EA Views of women and clinicians on postpartumpreparation and recovery Matern Child Health J 201318707ndash13 httpdxdoiorg101007s10995-013-1297-7

467 Negron R Martin A Almog M Balbierz A Howell EA Social support during the postpartumperiod mothersrsquo views on needs expectations and mobilization of support Matern ChildHealth J 201317616ndash23 httpdxdoiorg101007s10995-012-1037-4

468 Novick G CenteringPregnancy and the current state of prenatal care J Midwifery Womens Health200449405ndash11 httpdxdoiorg101111j1542-20112004tb04434x

469 Fu YY Heh SS Effectiveness of informational support in reducing the severity of postnataldepression in Taiwan J Adv Nurs 20034230ndash6 httpdxdoiorg101046j1365-2648200302576x

470 Mills EP Finchilescu G Lea SJ Postnatal depression ndash an examination of psychosocial factorsS Afr Med J 19958599ndash105

471 Mason WA Rice MJ Records K The lived experience of postpartum depression in a psychiatricpopulation Perspect Psychiatr Care 20054152ndash61 httpdxdoiorg101111j1744-6163200500011x

472 Knaak S lsquoHaving a tough timersquo towards an understanding of the psycho-social causes ofpostpartum emotional stress JMI 20091180ndash94

473 Guedeney A Marchand-Martin L Cote SJ Larroque B Perinatal risk factors and social withdrawalbehaviour Eur Child Adolesc Psychiatry 201221185ndash91 httpdxdoiorg101007s00787-012-0250-4

474 Saligheh M Physical Activity in Postpartum Women and its Relationship to Postnatal DepressionPhD thesis Bentley WA Curtin University 2011

475 Frank E Kupfer DJ Cornes C Morris SM Maintenance Interpersonal Psychotherapy for RecurrentDepression In Klerman G Weissman MM editors New Applications of InterpersonalPsychotherapy Washington DC American Psychiatric Press 1993 pp 75ndash102

476 Zuckoff A Swartz HA Grote NK Motivational Interviewing as a Prelude to Psychotherapy ofDepression In Arkowitz H Westra HA Miller WR Rollnick S editors Motivational Interviewing inthe Treatment of Psychological Problems New York NY Guilford 2008

REFERENCES

477 Bernal G Saez-Santiago E Culturally centered psychosocial interventions J Community Psychol200634121ndash32 httpdxdoiorg101002jcop20096

478 Human Development Research F Thinking Healthy Cognitive Behavioural Training for HealthyMothers and Infants Training Manual Draft 01-11-2004 (English Version) Islamabad HumanDevelopment Research Foundation 2007

479 Ritter C Social Supports Social Networks and Health Behaviors In Gochman DS editor HealthBehavior New York NY Springer 1998 pp 149ndash61

480 Collins NL Dunkel-Schetter C Lobel M Scrimshaw SC Social support in pregnancy psychosocialcorrelates of birth outcomes and postpartum depression J Pers Soc Psychol 1993651243httpdxdoiorg1010370022-35146561243

481 McGinley M Turnbull D Fyvie H Johnstone I MacLennan B Midwifery development unit atGlasgow Royal Maternity Hospital Br J Midwifery 19953362ndash71

482 Turnbull D McGinley M Fyvie H Johnstone I Holmes A Shields N et al Implementation andevaluation of a midwifery development unit Br J Midwifery 19953465ndash8

Appendix 1 Literature search strategies

Electronic bibliographic databases searched for clinicaleffectiveness evidence

l The Cochrane Library including the Cochrane Systematic Reviews Database Cochrane Controlled TrialsRegister DARE HTA and NHS EED databases 1991 (searched on 28 November 2012)

l MEDLINE (via Ovid) 1946 ndash November week 3 2012 (searched on 30 November 2012)l PreMEDLINE (via Ovid) 4 December 2012 (searched on 5 December 2012)l EMBASE (via Ovid) 1974 ndash 4 December 2012 (searched on 5 December 2012)l CINAHL (via EBSCOhost) 1982 (searched on 11 December 2012)l PsycINFO (via Ovid) 1806 ndash November week 4 2012 (searched on 5 December 2012)l Science Citation Index (via ISI Web of Science) 1899 ndash date (searched on 5 December 2012)l Social Science Citation Index (via ISI Web of Science) 1956 (searched on 5 December 2012)l ASSIA (via ProQuest) 1987 (searched on 19 December 2012)l AMED (via Ovid) 1985 ndash 4 December 2012 (searched on 5 December 2012)l CPCI-S (via ISI Web of Science) 1990 (searched on 5 December 2012)l MIDIRS reference database 1991 (searched 24 July 2013)

Additional resources used for clinical effectiveness evidence

1 UK Clinical Research Network (searched on 30 January 2013)2 Current Controlled Trials (searched on 30 January 2013)3 Clinical Trialsgov (searched on 30 January 2013)4 PROSPERO (searched on 19 February 2013)5 Social Care online (searched on 19 February 2013)6 ProQuest Dissertation and Theses (searched on 26 March 2013)7 HSRProj (Health Services Research Projects in Progress) (searched on 19 February 2013)8 Index to Theses (searched on 19 February 2013)9 OpenGrey (searched on 19 February 2013)

10 relevant websites (searched on 26 March 2013)11 general internet search using the search engine Google (searched on 19 February 2013)

Search strategy for randomised controlled trials

1 MeSH descriptor [Depression Postpartum] explode all trees2 pndtiabkw (Word variations have been searched)3 MeSH descriptor [Depression] explode all trees4 depresstiabkw (Word variations have been searched)5 stresstiabkw (Word variations have been searched)6 anxitiabkw (Word variations have been searched)7 MeSH descriptor [Anxiety Disorders] explode all trees8 MeSH descriptor [Anxiety] explode all trees9 MeSH descriptor [Affective Disorders Psychotic] explode all trees

10 affectivetiabkw (Word variations have been searched)11 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10

12 postpartum or post partum or postpartumtiabkw (Word variations have been searched)13 MeSH descriptor [Postpartum Period] explode all trees14 postnatal or post natal or postnataltiabkw (Word variations have been searched)15 post-pregnan or post pregnan or postpregnantiabkw (Word variations have been searched)16 ante-natal or ante natal or antenataltiabkw (Word variations have been searched)17 pre-natal or pre natal or prenataltiabkw (Word variations have been searched)18 peri-natal or peri natal or perinataltiabkw (Word variations have been searched)19 12 or 13 or 14 or 15 or 16 or 17 or 1820 11 and 1921 1 or 2 or 2022 MeSH descriptor [Primary Prevention] explode all trees23 preventtiabkw (Word variations have been searched)24 Any MeSH descriptor with qualifier(s) [Prevention amp control - PC]25 prophylatiabkw (Word variations have been searched)26 decreas or reduc or lower or overcom or improv or avoidtiabkw (Word variations have

been searched)27 wellbeing or well-being or well beingtiabkw (Word variations have been searched)28 enhanc or improv or increastiabkw (Word variations have been searched)29 27 and 2830 22 or 23 or 24 or 25 or 26 or 2931 21 and 3032 MeSH descriptor [Risk Factors] explode all trees33 MeSH descriptor [Risk] explode all trees34 risk or indicat or predict or predispostiabkw (Word variations have been searched)35 MeSH descriptor [Social Support] explode all trees36 social supporttiabkw (Word variations have been searched)37 MeSH descriptor [Socioeconomic Factors] explode all trees38 MeSH descriptor [Social Class] explode all trees39 MeSH descriptor [Life Change Events] explode all trees40 history of depressiontiabkw (Word variations have been searched)41 MeSH descriptor [Marriage] explode all trees42 dyadic adjustment or parental adjustmenttiabkw (Word variations have been searched)43 MeSH descriptor [Pregnancy Complications] explode all trees44 MeSH descriptor [Obstetric Labor Complications] explode all trees45 complicationtiabkw (Word variations have been searched)46 MeSH descriptor [Parturition] explode all trees47 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45

or 4648 21 and 4749 interven or program or target or educat or strattiabkw (Word variations have been searched)50 21 and 4951 31 or 48 or 50

APPENDIX 1

Search strategy used on The Cochrane Library

The Cochrane Library including the Cochrane Systematic Reviews Database Cochrane Controlled TrialsRegister DARE HTA and NHS EED databases 1991ndash date (searched on 28 November 2012)

10 affectivetiabkw (Word variations have been searched)11 3 or 4 or 5 or 6 or 7 or 8 or 9 or 1012 postpartum or post partum or postpartumtiabkw (Word variations have been searched)13 postnatal or post natal or postnataltiabkw (Word variations have been searched)14 post-pregnan or post pregnan or postpregnantiabkw (Word variations have been searched)15 ante-natal or ante natal or antenataltiabkw (Word variations have been searched)16 pre-natal or pre natal or prenataltiabkw (Word variations have been searched)17 peri-natal or peri natal or perinataltiabkw (Word variations have been searched)18 12 or 13 or 14 or 15 or 16 or 1719 11 and 1820 1 or 2 or 19

Search steps 1ndash20 are for the population PND

21 MeSH descriptor [Primary Prevention] explode all trees22 preventtiabkw (Word variations have been searched)23 Any MeSH descriptor with qualifier(s) [Prevention amp control - PC]24 prophylatiabkw (Word variations have been searched)25 decreas or reduc or lower or overcome or improvetiabkw (Word variations have

been searched)26 21 or 22 or 23 or 24 or 25

Search steps 21ndash26 are terms for prevention

27 20 and 26

Search step 27 combines the population and prevention terms to find literature on prevention of PND

28 MeSH descriptor [Risk Factors] explode all trees29 MeSH descriptor [Risk] explode all trees30 risk or indicat or predict or predispostiabkw (Word variations have been searched)31 MeSH descriptor [Social Support] explode all trees32 social supporttiabkw (Word variations have been searched)33 MeSH descriptor [Socioeconomic Factors] explode all trees34 MeSH descriptor [Social Class] explode all trees35 MeSH descriptor [Life Change Events] explode all trees36 history of depressiontiabkw (Word variations have been searched)

37 MeSH descriptor [Marriage] explode all trees38 dyadic adjustment or parental adjustmenttiabkw (Word variations have been searched)39 MeSH descriptor [Pregnancy Complications] explode all trees40 MeSH descriptor [Obstetric Labor Complications] explode all trees41 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40

Search steps 28ndash30 are terms for risk and 31ndash40 are terms for known risk factors for PND

42 20 and 41

Search step 20 and 41 combines the population and risk terms to find papers about risk factors and PNDto find trials that are focused at risk factors

43 interven or program or target or educat or strattiabkw (Word variations have been searched)

Search step 43 are different terms around interventions

44 20 and 43

Search step 44 combines PND and intervention terms to find trials of PND interventions

45 27 or 42 or 44

Search step 45 uses OR to combine the different subsets and try to find all PND trials

The search retrieved 883 records 60 systematic reviews 38 other reviews from DARE 759 trials eighttechnology assessments and nine economic evaluations

Search strategy used on PreMEDLINE (via Ovid)

MEDLINE (Ovid) 1946 ndash week 3 November 2012 (searched on 30 November 2012) and PreMEDLINE (Ovid)4 December 2012 (searched on 5 December 2012)

1 exp Depression Postpartum 2 pndtw3 exp Depression 4 depress$tw5 stress$tw6 anxi$tw7 exp Anxiety Disorders 8 exp Anxiety 9 exp Affective Disorders Psychotic

10 affectivetw11 3 or 4 or 5 or 6 or 7 or 8 or 9 or 1012 12(postpartum or post partum or postpartum)tw13 exp Postpartum Period 14 (postnatal$ or post natal$ or postnatal$)tw15 (post-pregnan$ or post pregnan$ or postpregnan$)tw16 (ante-natal$ or ante natal$ or antenatal$)tw17 (pre-natal$ or pre natal$ or prenatal$)tw

APPENDIX 1

18 (peri-natal$ or peri natal$ or perinatal$)tw19 12 or 13 or 14 or 15 or 16 or 17 or 1820 11 and 1921 1 or 2 or 20

Search steps 1ndash21 are terms for the population PND

22 exp Primary Prevention 23 prevent$tw24 pcfs25 prophyla$tw26 (decreas$ or reduc$ or lower$ or overcom$ or improv$ or avoid$)tw27 (wellbeing or well-being or well being)tw28 (enhanc$ or improv$ or increas$)tw29 27 and 2830 or 22-2629

31 21 and 30

32 exp Risk Factors 33 Risk 34 (risk$ or indicat$ or predict$ or predispos$)tw35 exp Social Support 36 social support$tw37 exp Socioeconomic Factors 38 exp Social Class 39 exp Life Change Events 40 history of depression$tw41 exp Marriage 42 (dyadic adjustment$ or parental adjustment$)tw43 exp Pregnancy Complications 44 Obstetric Labor Complications 45 complication$tw46 exp Parturition 47 or 32-46

48 21 and 47

Search step 48 combines 21 and 47 combining the population and risk terms to find papers about riskfactors and PND to find trials that are focused at risk factors

49 (interven$ or program$ or target$ or educat$ or strat$)tw

50 21 and 49

51 31 or 48 or 50

52 Meta-Analysis as Topic 53 meta analy$tw54 metaanaly$tw55 Meta-Analysis 56 (systematic adj (review$1 or overview$1))tw57 exp Review Literature as Topic 58 52 or 53 or 54 or 55 or 56 or 5759 cochraneab60 embaseab61 (psychlit or psyclit)ab62 (cinahl or cinhal)ab63 science citation indexab64 bidsab65 cancerlitab66 59 or 60 or 61 or 62 or 63 or 64 or 6567 reference list$ab68 bibliograph$ab69 hand-search$ab70 relevant journalsab71 manual search$ab72 67 or 68 or 69 or 70 or 7173 selection criteriaab74 data extractionab75 73 or 7476 Review 77 75 and 7678 Comment 79 Letter 80 Editorial 81 animal 82 human 83 81 not (81 and 82)84 78 or 79 or 80 or 8385 58 or 66 or 72 or 7786 85 not 84

Search steps 52ndash86 are the systematic reviews filter for MEDLINE

87 51 and 86

Search step 87 combines the search with the systematic reviews filter to retrieve systematic reviews

APPENDIX 1

88 limit 87 to (English language and humans)89 exp ldquocosts and cost analysisrdquo 90 economics 91 exp economics hospital 92 exp economics medical 93 exp economics nursing 94 economics pharmaceutical 95 exp ldquofees and chargesrdquo 96 exp budgets 97 budget$tw98 cost$ti99 (cost$ adj2 (effective$ or utilit$ or benefit$ or minim$))ab

100 (economic$ or pharmacoeconomic$ or pharmaco-economic$)ti101 (price or pricing$)tw102 (financial or finance or finances or finanaced)tw103 (fee or fees)tw104 or 89-103

Search steps 89ndash104 is the economic evaluations filter for MEDLINE

105 51 and 104

Search step 105 combines the search with the economic evaluations filter to retrieve economic evaluations

106 limit 105 to (english language and humans)107 from 106 keep 1-266108 mixed methodtw109 mixed methodstw110 mixed studytw111 multi methodtw112 multiple sources of datatw113 triangulation designtw114 (qualitative adj99 quantitative)tw115 108 or 109 or 110 or 111 or 112 or 113 or 114

Search steps 108ndash115 are terms for mixed-methods research

116 51 and 115

Search step 116 combines the search with the mixed-methods filter to mixed-methods papers

117 limit 116 to (english language and humans)118 findingstw119 interviewtw120 qualitativetw121 118 or 119 or 120

Search steps 108ndash115 are the qualitative filter for MEDLINE

122 51 and 121

Search step 122 combines the search with the qualitative filter to retrieve qualitative studies

123 limit 122 to (english language and humans)124 Depression Postpartum 125 123 and 124

Search step 125 further refines the search to retrieve qualitative research with Depression Postpartum as a major subject heading

Search strategy used on EMBASE

EMBASE (Ovid) 1974 ndash 4 December 2012 (searched on 5 December 2012)

1 puerperal depression 2 pndtw3 exp depression 4 depress$tw5 stress$tw6 anxi$tw7 exp anxiety disorder 8 exp anxiety 9 mood disorder

10 affectivetw11 or 3-1012 (postpartum or post partum or postpartum)tw13 exp puerperium 14 (postnatal$ or post natal$ or postnatal$)tw15 (post-pregnan$ or post pregnan$ or postpregnan$)tw16 (ante-natal$ or ante natal$ or antenatal$)tw17 (pre-natal$ or pre natal$ or prenatal$)tw18 (peri-natal$ or peri natal$ or perinatal$)tw19 or 12-1820 11 and 1921 1 or 2 or 20

22 exp primary prevention 23 prevent$tw24 pcfs25 prophyla$tw26 (decreas$ or reduc$ or lower$ or overcom$ or improv$ or avoid$)tw27 (wellbeing or well-being or well being)tw28 (enhanc$ or improv$ or increas$)tw29 27 and 2830 or 22-2629

31 21 and 30

APPENDIX 1

32 exp risk factor 33 risk 34 (risk$ or indicat$ or predict$ or predispos$)tw35 exp social support 36 social support$tw37 exp socioeconomics 38 exp social class 39 exp life event 40 history of depression$tw41 marriage 42 (dyadic adjustment$ or parental adjustment$)tw43 exp pregnancy complication 44 exp labor complication 45 complication$tw46 exp birth 47 or 32-46

48 21 and 47

50 21 and 49

51 21 or 48 or 50

52 Meta Analysis 53 ((meta adj analy$) or metaanalys$)tw54 (systematic adj (review$1 or overview$1))tw55 or 51-5356 cancerlitab57 cochraneab58 embaseab59 (psychlit or psyclit)ab60 (psychinfo or psycinfo)ab61 (cinal or cinahl)ab62 science citation indexab63 bidsab64 or 55-6265 reference listsab

66 bibliograph$ab67 hand-search$ab68 manual search$ab69 relevant journalsab70 or 64-6871 data extractionab72 selection criteriaab73 70 or 7174 reviewpt75 72 and 7376 letterpt77 editorialpt78 animal 79 human 80 77 not (77 and 78)81 or 75-767982 54 or 63 or 69 or 7483 81 not 80

Search steps 52ndash83 is the systematic reviews filter for EMBASE

84 51 and 83

85 exp SOCIOECONOMICS 86 exp ldquoCost Benefit Analysisrdquo 87 exp ldquoCost Effectiveness Analysisrdquo 88 exp ldquoCost of Illnessrdquo 89 exp ldquoCost Controlrdquo 90 exp Economic Aspect 91 exp Financial Management 92 exp ldquoHealth Care Costrdquo 93 exp Health Care Financing 94 exp Health Economics 95 exp ldquoHospital Costrdquo 96 (financial or fiscal or finance or funding)tw97 exp ldquoCost Minimization Analysisrdquo 98 (cost adj estimate$)mp99 (cost adj variable$)mp

100 (unit adj cost$)mp101 or 83-100

Search steps 85ndash101 is a economic evaluations filter for EMBASE

102 51 and 101

Search step 102 combines the search with the economic filter to retrieve economic evaluations

103 mixed methodtw104 mixed methodstw105 mixed studytw106 multi methodtw

APPENDIX 1

107 multiple sources of datatw108 triangulation designtw109 (qualitative adj99 quantitative)tw110 or 103-109

Search steps 103ndash110 are terms for mixed methods

111 51 and 110

Search step 111 combines the search with the terms for mixed-methods to retrievemixed-methods research

112 findingstw113 interviewtw114 qualitativetw115 or 112-114

Search steps 112ndash115 are a qualitative filter for EMBASE

116 51 and 115

Search step 116 combines the search with the qualitative filter to retrieve qualitative research

117 puerperal depression 118 116 and 117

Search step 118 further refines the search to retrieve qualitative research with puerperal depression as amajor subject heading

Search strategy used on Cumulative Index to Nursing andAllied Health Literature

CINAHL (EBSCOhost) 1982 (searched on 11 December 2012)

S53 S51 and S52

S52 (MM ldquoDepression Postpartumrdquo)

S51 S41 AND S50

S50 TI (findings OR interview OR qualitative) OR AB (findings OR interview OR qualitative)

S49 S41 AND S48

S48 TI (ldquomixed methodrdquo OR ldquomixed methodsrdquo OR ldquomixed studyrdquo OR ldquomulti methodrdquo OR ldquomultiplesources of datardquo OR ldquotriangulation designrdquo OR (qualitative AND quantitative)) OR AB (ldquomixed methodrdquo ORldquomixed methodsrdquo OR ldquomixed studyrdquo OR ldquomulti methodrdquo OR ldquomultiple sources of datardquo OR ldquotriangulationdesignrdquo OR (qualitative AND quantitative))

S47 S41 AND S46

S46 TI (economic OR cost OR fee OR charge OR budget OR pharmacoeconomic or price or pricing)OR AB (economic OR cost OR fee OR charge OR budget OR pharmacoeconomic or price or pricing)

S45 S41 AND S44

S44 TI (meta analy OR metaanaly OR meta-analysis OR systematic review OR overview OR revie) ORAB (meta analy OR metaanaly OR meta-analysis OR systematic review OR overview OR revie)

S43 S41 AND S42

S42 TI (randomised controlled trial OR randomized controlled trial OR random OR blind OR maskOR clinical trial OR placebo) OR AB (randomised controlled trial OR randomized controlled trial ORrandom OR blind OR mask OR clinical trial OR placebo)

S41 S25 OR S38 OR S40

S40 S17 AND S39

S39 TI (interven or program or target or educat or strat) OR AB (interven or program or targetor educat or strat)

S38 S17 AND S37

S37 S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37

S37 (MH ldquoChildbirth+rdquo)

S36 TI complication OR AB complication

S35 (MH ldquoLabor Complications+rdquo)

S34 (MH ldquoPregnancy Complications+rdquo)

S33 TI (dyadic adjustment or parental adjustment) OR AB (dyadic adjustment orparental adjustment)

S32 (MH ldquoMarriagerdquo)

S31 TI history of depression OR AB history of depression

S30 (MH ldquoLife Change Events+rdquo)

S29 (MH ldquoSocioeconomic Factors+rdquo)

S28 TI social support OR AB social support

S27 (MH ldquoSupport Psychosocial+rdquo)

S26 TI (risk or indicat or predict or predispos) OR AB (risk or indicat or predict or predispos)

S25 S17 AND S24

S24 S18 OR S19 OR S20 OR S23

APPENDIX 1

S23 S21 AND S22

S22 TI (enhanc or improv or increas) OR AB (enhanc or improv or increas)

S21 TI (wellbeing or well-being or well being) OR AU (wellbeing or well-being or well being)

S20 TI (decreas or reduc or lower or overcom or improv or avoid) OR AB (decreas or reduc orlower or overcom or improv or avoid)

S19 TI prophyla OR AB prophyla

S18 TI prevent OR AB prevent

S17 S1 OR S2 OR S1

S16 (S8 AND S15)

S15 S9 OR S10 OR S11 OR S12 OR S13 OR S14

S14 TI (peri-natal or peri natal or perinatal) OR AB (peri-natal or peri natal or perinatal)

S13 TI (pre-natal or pre natal or prenatal) OR AB (pre-natal or pre natal or prenatal)

S12 TI (ante-natal or ante natal or antenatal) OR AB (ante-natal or ante natal or antenatal)

S11 TI (post-pregnan or post pregnan or postpregnan) OR AB (post-pregnan or post pregnanor postpregnan)

S10 TI (postnatal or post natal or postnatal) OR AB (postnatal or post natal or postnatal)

S9 TI (postpartum or post partum or postpartum) OR AB (postpartum or post partum or postpartum)

S8 S3 OR S4 OR S5 OR S6 OR S7

S7 TI affective OR AB affective

S6 (MH ldquoAnxiety+rdquo)

S5 (MH ldquoAffective Disorders Psychotic+rdquo)

S4 (MH ldquoAnxiety Disorders+rdquo)

S3 TI (depress OR stress OR anxi) OR AB (depress OR stress OR anxi)

S2 TI pnd OR AB pnd

S1 (MH ldquoDepression Postpartumrdquo)

Results from search line 43 were saved for RCTs 45 for systematic reviews 47 for economic evaluations49 for mixed-methods research and 53 for qualitative research

Search strategy used on PsycINFO

PsycINFO (via Ovid) was searched from 1806 to week 4 November 2012 (searched on 5 December 2012)

1 postpartum depression 2 pndabti3 (depress$ or stress$ or anxi)abti4 anxiety 5 anxiety disorders 6 or 3-57 postnatal period 8 (postpartum or post partum or postpartum or postnatal$ or post natal$ or postnatal$ or post-pregnan

$ or post pregnan$ or postpregnan$ or ante-natal$ or ante natal$ or antenatal$ or pre-natal$ or prenatal$ or prenatal$ or peri-natal$ or peri natal$ or perinatal$)abti

9 7 or 810 6 and 911 1 or 2 or 10

12 exp Primary Mental Health Prevention 13 (prevent$ or prophyla$ or decreas$ or reduc$ or lower$ or overcom$ or improv$ or avoid$)abti14 (wellbeing or well-being or well being)abti15 (enhanc$ or improv$ or increas$)abti16 14 and 1517 12 or 13 or 16

18 11 and 17

19 risk factors 20 (risk$ or indicat$ or predict$ or predispos$)abti21 social support 22 social support$abti23 exp socioeconomic status 24 life changes 25 history of depression$abti26 marriage 27 (dyadic adjustment$ or parental adjustment$)abti28 exp obstetrical complications 29 complication$abti30 birth 31 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30

32 11 and 31

APPENDIX 1

Search step 32 combines 11 and 31 combining the population and risk terms to find papers about riskfactors and PND to find trials that are focused on risk factors

33 (interven$ or program$ or target$ or educat$ or strat$)abti

Search step 33 is synonymous for the term intervention

34 11 and 33

35 18 or 32 or 34

36 limit 35 to (human and english language)

Search steps 36 limits the results of the search to studies about human in English

37 (double-blind or random assigned or control)tw

Search step 37 is a one-line RCT filter for PsycINFO

38 36 and 37

Search step 38 combines the search with the RCT filter to retrieve RCTs of PND prevention trials

39 (meta-analysis or search)tw

Search step 39 is a one-line systematic reviews filter for PsycINFO

40 36 and 39

Search strategy used for cost-effectiveness studies witheconomic evaluations filter for MEDLINE

Search step 38 combines the search with the systematic reviews filter to retrieve systematic reviews onPND prevention

41 exp ldquocosts and cost analysisrdquo42 economics 43 exp economics hospital 44 exp economics medical 45 exp economics nursing 46 economics pharmaceutical 47 exp ldquofees and chargesrdquo48 exp budgets 49 budget$tw50 cost$ti

51 (cost$ adj2 (effective$ or utilit$ or benefit$ or minim$))ab52 (economic$ or pharmacoeconomic$ or pharmaco-economic$)ti53 (price or pricing$)tw54 (financial or finance or finances or finanaced)tw55 (fee or fees)tw56 or 41-55

Step 56 is an economic evaluation filter for PsycINFO

57 36 and 56

Step 57 combines the search with the economic evaluation filter to retrieve economic evaluations

58 mixed methodtw59 mixed methodstw60 mixed studytw61 multi methodtw62 multiple sources of datatw63 triangulation designtw64 (qualitative adj99 quantitative)tw65 or 58-64

Search step 65 are terms for mixed-methods research

66 36 and 65

Search step 66 combined the search with the mixed-methods terms to retrieve research that utilisesmixed methods

Search step 70 is a qualitative filter for PsycINFO

71 36 and 70

72 Depression Postpartum 73 71 and 72

Search step 73 further refines the search to retrieve qualitative research with Depression Postpartum asa major subject heading

APPENDIX 1

Search strategy used on Conference Proceedings Citation Indexand Social Science Citation Index Search and ScienceCitation Index

Science Citation Index (via ISI Web of Science) 1899ndashdate Social Science Citation Index (via ISI Web ofScience) 1956ndashdate and CPCI-S (via ISI Web of Science) 1990ndashdate (searched on 5 December 2012)

29 15 AND 28

Indexes = SCI-EXPANDED SSCI CPCI-S CPCI-SSH Timespan =All years

28 (TS= (randomised controlled trial OR randomized controlled trial OR random OR blind ORmask OR clinical trial OR placebo)) AND LANGUAGE(English)

27 15 AND 26

26 (TS= (findings OR interview OR qualitative)) AND LANGUAGE (English)

25 15 AND 34

24 22 OR 23

23 (TS= (ldquomixed methodrdquo OR ldquomixed methodsrdquo OR ldquomixed studyrdquo OR ldquomulti methodrdquo OR ldquomultiplesources of datardquo OR ldquotriangulation designrdquo)) AND LANGUAGE (English)

22 (TS= (qualitative AND quantitative)) AND LANGUAGE (English)

21 15 AND 20

20 (TS= (ldquomixed methodrdquo OR ldquomixed methodsrdquo OR ldquomixed studyrdquo OR ldquomulti methodrdquo OR ldquomultiplesources of datardquo OR ldquotriangulation designrdquo OR ldquoqualitative quantitativerdquo)) AND LANGUAGE (English)

19 15 AND 18

18 (TS= (economic OR cost OR fee OR charge OR budget OR pharmacoeconomic or price orpricing)) AND LANGUAGE (English)

17 (16) AND LANGUAGE(English)

16 12 AND 15

15 13 AND 14

14 10 OR 11

13 3 OR 4

12 TI= (meta analy OR metaanaly OR meta-analysis OR systematic review OR overview OR review)

11 TI= (interven OR program OR target OR educat OR strat)

10 7 OR 8 OR 9

9 TI= (prevent OR prophyla OR decreas OR reduc OR lower OR overcom OR improvOR avoid)

8 TI= (risk OR indicat OR predict OR predispos OR social support OR socioeconomic factor ORsocial class OR life change event OR history of depression OR marriage OR dyadic adjustment ORparental adjustment OR complication OR birth OR parturition)

7 6 AND 5

APPENDIX 1

6 TS= (wellbeing OR well-being OR well being)

5 TI= (decreas OR reduc OR lower OR overcom OR improv or avoid)

4 TS= pnd

3 2 AND 1

2 TI= (postpartum OR post partum OR postpartum OR postnatal OR post natal OR postnatal ORpost-pregnan OR post pregnan OR postpregnan OR ante-natal OR ante natal OR antenatal OR pre-natal OR pre natal OR prenatal OR peri-natal OR peri natal OR perinatal)

1 TI= (depress OR stress OR anxi OR affective)

Search strategy used on Applied Social Sciences Index andAbstracts (via ProQuest)

Applied Social Sciences Index and Abstracts (via ProQuest) 1987 ndash (searchedon 19 December 2012)

1 ((((SUEXACTEXPLODE(ldquoPostnatal depressionrdquo) OR pnd) OR ((SUEXACT(ldquoDepressionrdquo) OR (depressOR stress OR anxi) OR SUEXACT(ldquoAnxietyrdquo) OR SUEXACT(ldquoAnxiety disordersrdquo) OR SUEXACT(ldquoAffective disordersrdquo) OR affective) AND (SUEXACTEXPLODE(ldquoPostpartum womenrdquo) OR all(postpartum OR post partum OR postpartum) OR (postnatal OR post natal OR postnatal)OR (post-pregnan OR post pregnan OR postpregnan) OR (ante-natal OR ante natal ORantenatal) OR all(peri-natal OR peri natal OR perinatal) OR all(pre-natal) OR all(prenatal)))) AND(SUEXACTEXPLODE(ldquoPrimary prevention trialsrdquo) OR (prevent OR prophyla OR decreas OR reducOR lower OR overcom OR improv OR avoid) OR ((wellbeing OR well-being OR well being) AND(enhanc OR improv OR increas)))) OR (((SUEXACTEXPLODE(ldquoPostnatal depressionrdquo) OR pnd) OR((SUEXACT(ldquoDepressionrdquo) OR (depress OR stress OR anxi) OR SUEXACT(ldquoAnxietyrdquo) OR SUEXACT(ldquoAnxiety disordersrdquo) OR SUEXACT(ldquoAffective disordersrdquo) OR affective) AND (SUEXACTEXPLODE(ldquoPostpartum womenrdquo) OR all(postpartum OR post partum OR postpartum) OR (postnatal OR postnatal OR postnatal) OR (post-pregnan OR post pregnan OR postpregnan) OR (ante-natalOR ante natal OR antenatal) OR all(peri-natal OR peri natal OR perinatal) OR all(pre-natal)OR all(prenatal))))

2 (((risk OR indicat OR predict OR predispos) OR (SUEXACT ldquoRisk factorsrdquo) OR SUEXACT(ldquoRiskfactorsrdquo) OR SUEXACTEXPLODE(ldquoComputer based social supportrdquo OR ldquoPerceived social supportrdquoOR ldquoSocial supportrdquo) OR (social support) OR SUEXACTEXPLODE(ldquoAristocracyrdquo OR ldquoElitesrdquo ORldquoGentrificationrdquo OR ldquoLumpenproletariatrdquo OR ldquoMiddle class peoplerdquo OR ldquoPeeragesrdquo OR ldquoProletariatrdquoOR ldquoRuling classesrdquo OR ldquoSocial classrdquo OR ldquoUnderclassesrdquo OR ldquoUpper class peoplerdquo OR ldquoUpper classwomenrdquo OR ldquoUpper middle class peoplerdquo OR ldquoWorking class peoplerdquo) OR all(history of depress) ORSUEXACTEXPLODE(ldquoArranged marriagesrdquo OR ldquoBridesrdquo OR ldquoConjugal contractsrdquo OR ldquoConsanguineousmarriagesrdquo OR ldquoCustody after divorcerdquo OR ldquoDivorcerdquo OR ldquoEndogamyrdquo OR ldquoEngaged couplesrdquoOR ldquoExogamyrdquo OR ldquoExtramarital affairsrdquo OR ldquoHomogamyrdquo OR ldquoIntermarriagerdquo OR ldquoJoint custodyrdquoOR ldquoMarital qualityrdquo OR ldquoMarital structurerdquo OR ldquoMarriagerdquo OR ldquoMonogamyrdquo OR ldquoParental divorcerdquoOR ldquoPolyandryrdquo OR ldquoPolygamyrdquo OR ldquoPolygynyrdquo OR ldquoPrenuptial contractsrdquo OR ldquoRacial intermarriagerdquoOR ldquoRemarriagesrdquo OR ldquoSerial monogamyrdquo OR ldquoSinglenessrdquo OR ldquoTahlil marriagerdquo OR ldquoTemporarymarriagesrdquo OR ldquoTransnational divorcerdquo OR ldquoWeddingsrdquo) OR (dyadic adjustment OR parentaladjustment OR complication) OR SUEXACTEXPLODE(ldquoBirth centresrdquo OR ldquoCaesarean sectionrdquoOR ldquoChildbirthrdquo OR ldquoDystociardquo OR ldquoHome birthrdquo OR ldquoLabourrdquo OR ldquoNatural childbirthrdquo OR ldquoPlacentardquoOR ldquoPremature labourrdquo OR ldquoShoulder dystociardquo OR ldquoVacuum extractionrdquo OR ldquoVaginal birthrdquoOR ldquoWaterbirthrdquo)))

3 (interven OR program OR target OR educat OR strat)4 (random control OR blind OR trial singl OR doubl OR trebl OR tripl OR mask OR placebo)

Searches 1 2 3 and 4 were combined to find RCTs on prevention of PND

5 (meta-analy OR meta analy OR metaanaly OR review OR overview)

Searches 1 2 3 and 5 were combined to find systematic reviews on prevention of PND

6 (economic OR cost OR fee OR charge OR budget OR pharmacoeconomic or price or pricing)

Searches 1 2 3 and 6 were combined to find economic evaluations

7 (ldquomixed methodrdquo OR ldquomixed methodsrdquo OR ldquomixed studyrdquo OR ldquomulti methodrdquo OR ldquomultiple sources ofdatardquo OR ldquotriangulation designrdquo OR ldquoqualitative quantitativerdquo)

Searches 1 2 3 and 7 were combined to find mixed-methods research

8 (findings OR interview OR qualitative)

Searches 1 2 3 and 8 were combined to find qualitative research

Search strategy used on Allied and Complementary MedicineDatabase (via Ovid)

Allied and Complementary Medicine Database (via Ovid) was searched from 1985 to 4 December 2012and EconLit (via Ovid) was searched from 1961 to November 2012 (searched on 5 December 2012)

1 pndtw2 depress$tw3 stress$tw4 anxi$tw5 affectivetw6 or 2-57 (postpartum or post partum or postpartum)tw

APPENDIX 1

8 (postnatal$ or post natal$ or postnatal$)tw9 (post-pregnan$ or post pregnan$ or postpregnan$)tw

10 (ante-natal$ or ante natal$ or antenatal$)tw11 (pre-natal$ or pre natal$ or prenatal$)tw12 (peri-natal$ or peri natal$ or perinatal$)tw13 or 7-1214 6 and 1315 1 or 1416 prevent$tw17 pcfs18 prophyla$tw19 (decreas$ or reduc$ or lower$ or overcom$ or improv$ or avoid$)tw20 (wellbeing or well-being or well being)tw21 (enhanc$ or improv$ or increas$)tw22 20 and 2123 or 16-192224 15 and 2325 (risk$ or indicat$ or predict$ or predispos$)tw26 social support$tw27 social class$tw28 life change event$tw29 history of depression$tw30 marriagetw31 (dyadic adjustment$ or parental adjustment$)tw32 complication$tw33 parturitiontw34 or 25-3335 15 and 3436 (interven$ or program$ or target$ or educat$ or strat$)tw37 15 and 3638 24 or 35 or 37

No filters were used for AMED or EconLit due to the small size of the databases

Search strategy used on Midwives Information andResource Service

Midwives Information and Resource Service Reference Database 1991 ndash

(searched 24 July 2013)Owing to the small size of the database searches were conducted for the population terms only and thenreviewed for relevance

Electronic databases searched for the cost-effectiveness literature

The following electronic databases were searched

l MEDLINE (via Ovid) 1946 ndash November week 3 2012 (searched on 30 November 2012)l PreMEDLINE (via Ovid) (searched on 5 December 2012)l EMBASE (via Ovid) 1974 ndash 4 December 2012 (searched on 5 December 2012)l CINAHL (via EBSCOhost) 1982 ndash (searched on 11 December 2012)l NHS EED (via Wiley) 1991 ndash (searched on 28 November 2012)

l EconLit (via Ovid) 1961 ndash November 2012 (searched on 5 December 2012)l PsycINFO (via Ovid) 1806 ndash week 4 November 2012 (searched on 5 December 2012)l Science Citation Index (via ISI Web of Science) 1899 ndash (searched on 5 December 2012)l Social Science Citation Index (via ISI Web of Science) 1956 ndash (searched on 5 December 2012)l AMED (via Ovid) 1985 ndash 4 December 2012 (searched on 5 December 2012)l ASSIA (via ProQuest) 1987 ndash (searched on 19 December 2012)l MIDIRS reference database 1991 ndash (searched 24 July 2013)

APPENDIX 1

Appendix 2 Randomised controlled trials andsystematic reviews number retrieved

Database searchedNumberof RCTs

Number ofsystematic reviews

Cochrane Systematic Reviews Database NA 60

Cochrane Controlled Trials Register 767 0

DARE NA 38

HTA NA 8

MEDLINE NA 268

PreMEDLINE NA 27

EMBASE NA 393

CINAHL 408 124

PsycINFO 575 126

Citation Indexes (Science and Social Sciences) Science Citation Index expanded(1899 to date) Social Sciences Citation Index (1956 to date) CPCI-S (1990 to date)Conference Proceedings Citation Index ndash Social Science amp Humanities (1990 to date)

ASSIA 107 132

AMED 3 3

MIDIRS reference database 2 0

NA not applicable

Appendix 3 Key journals hand-searched viaelectronic alerts

Acta Psychiatrica Scandinavica

American Journal of Obstetrics amp Gynecology

American Journal of Psychiatry

American Journal of Family Therapy

Archives of General Psychiatry

Archives of Womenrsquos Mental Health

BJOG An International Journal of Obstetrics and Gynaecology

BMC Public Health

British Journal of General Practice

British Journal of Clinical Psychology

British Journal of Psychiatry

British Medical Journal

Canadian Journal of Psychiatry

International Journal of Methods in Psychiatric Research

International Journal of Nursing Studies

Journal of Advanced Nursing

Journal of Affective Disorders

Journal of Clinical Psychiatry

Journal of Mental Health

Journal of Midwifery and Womenrsquos Health

Journal of Paediatrics and Child Health

Journal of Psychiatry

Journal of Psychopharmacology

Journal of Psychosomatic Research

Medical Journal of Australia

Midwifery

Nursing Research

Obstetrics and Gynaecology

Psychological Medicine

Psychology and Health

Therapeutic Research

Therapy

APPENDIX 3

Appendix 4 Qualitative studies andmixed-methods studies number retrieved

Database searched

Number of results

QualitativeMixedmethods

MEDLINE 581 58

PreMEDLINE 0 3

EMBASE 691 78

CINAHL 304 53

PsycINFO 517 69

Citation Indexes (Science and Social Sciences) Science Citation Index expanded (1899 to date)Social Sciences Citation Index (1956 to date) CPCI-S (1990 to date) Conference ProceedingsCitation Index ndash Social Science amp Humanities (1990 to date)

ASSIA 0 21

AMED 16 0

Cochrane Systematic Reviews Database Cochrane Controlled Trials Register DARE HTA NA NA

NA not applicable

Appendix 5 Reason for exclusion ofquantitative studies

Reference Reason for exclusion

Abel KM Review psychosocial and psychological interventions reduce postpartumdepressive symptoms Evid Based Mental Health 20081179

Commentary or clinicaloverview

Armstrong K Edwards H The effectiveness of a pram-walking exercise programme inreducing depressive symptomatology for postnatal women Int J Nurs practice200410177ndash94

PND treatment trial

Armstrong K Edwards H The effects of exercise and social support on mothers reportingdepressive symptoms a pilot randomized controlled trial Int J Ment Health Nursing200312130ndash8

PND treatment trial

Austin MP Lumley J Antenatal screening for postnatal depression a systematic reviewActa Psychiatr Scand 200310710ndash17

Systematic review notabout prevention of PND

Austin MP Priest SR Clinical issues in perinatal mental health new developments in thedetection and treatment of perinatal mood and anxiety disorders Acta Psychiatr Scand200511297ndash104

Austin MP Targeted group antenatal prevention of postnatal depression a reviewActa Psychiatr Scand 2003107244ndash50

Non-systematic review

Beddoe AE Lee KA Mindndashbody interventions during pregnancy JOGNN 200837165ndash75 Outcome measurementsbefore 6 weeks postnatally

Bennett S Alpert M Kubulins V Hansler RL Use of modified spectacles and light bulbs toblock blue light at night may prevent postpartum depression Med Hypotheses200973251ndash3

PND treatment trial

Bergstroumlm M Kieler H Waldenstroumlm U Effects of natural childbirth preparation versusstandard antenatal education on epidural rates experience of childbirth and parental stressin mothers and fathers a randomised controlled multicentre trial BJOG 20091161167ndash76

Bernard RS Williams SE Storfer-Isser A Rhine W Horwitz SM Koopman C et al Briefcognitive-behavioral intervention for maternal depression and trauma in the neonatalintensive care unit a pilot study J Trauma Stress 201124230ndash4

Outcome measurementsbefore 6 weeks postnatally

Beucher G Viaris de LB Dreyfus M Maternal outcome of gestational diabetes mellitusDiabetes Metab 201036522ndash37

Review not aboutprevention of PND

Bhutta ZA Lassi ZS Blanc A Donnay F Linkages among reproductive health maternalhealth and perinatal outcomes Semin Perinatol 201034434ndash45

Bick DE Kettle C Macdonald S Thomas PW Hills RK Ismail KM Perineal Assessment andRepair Longitudinal Study PEARLS protocol for a matched pair cluster trial BMC PregnancyChildbirth 20101010

Protocol for or descriptionof a study

Bijlenga D Koopmans CM Birnie E Mol BW Post JA Bloemenkamp KW et alHealth-related quality of life after induction of labor versus expectant monitoring ingestational hypertension or preeclampsia at term Hypertens Pregnancy 201130260ndash74

Bledsoe SE Grote NK Treating depression during pregnancy and the postpartuma preliminary meta-analysis Res Social Work Prac 200616109ndash20

Boath E Bradley E Henshaw C The prevention of postnatal depression a narrativesystematic review J Psychosom Obstet Gynecol 200526(3)185ndash92

Boulvain M Perneger TV Othenin G V Petrou S Berner M Irion O Home-based versushospital-based postnatal care a randomised trial BJOG 2004111807ndash13

Briscoe M The detection of emotional disorders in the post natal period by health visitorsHealth Visitor 198962336ndash8

Non-randomised controlgroup

Brown S Small R Argus B Davis PG Krastev A Early postnatal discharge from hospital forhealthy mothers and term infants Cochrane Database Syst Rev 20023CD002958

Buist AE Barnett BE Milgrom J Pope S Condon JT Ellwood DA et al To screen or not toscreen ndash that is the question in perinatal depression Med J Aust 2002177(Suppl)S101ndash5

Burns A OrsquoMahen H Baxter H Bennert K Wiles N Ramchandani P et al A pilotrandomised controlled trial of cognitive behavioural therapy for antenatal depressionBMC Psychiatry 20131333

Caramlau I Barlow J Sembi S McKenzie MK McCabe C Mums 4 Mums structuredtelephone peer-support for women experiencing postnatal depression Pilot and exploratoryRCT of its clinical and cost effectiveness Trials 20111288

Carroll JC Reid AJ Biringer A Midmer D Glazier RH Wilson L et al Effectiveness of theAntenatal Psychosocial Health Assessment ALPHA form in detecting psychosocial concernsa randomized controlled trial CMAJ 2005173253ndash9

No measure of PNDreported

Carter FA Postnatal home visits from healthcare professionals show promise for preventingpostnatal depression Evid Based Mental Health 20058108

Carty EM Bradley CF A randomized controlled evaluation of early postpartum hospitaldischarge Birth 199017199ndash204

Cattell DL King EA Estrogen for postnatal depression J Fam Practice 19964322ndash3 Commentary or clinicaloverview

Cerutti R Sichel MP Perin M Grussu P Zulian O Psychological distress during puerperiumA novel therapeutic approach using S-adenosylmethionine Curr Ther Res Clin Exp199353707ndash16

Chang MY Chen CH Huang KF Effects of music therapy on psychological health of womenduring pregnancy J Clin Nurs 2008172580ndash7

Chen CH Tseng YF Chou FH Wang SY Effects of support group intervention in postnatallydistressed women A controlled study in Taiwan J Psychosom Res 200049395ndash9

Cheng S Kondo N Aoki Y Kitamura Y Takeda Y Yamagata Z The effectiveness of earlyintervention and the factors related to child behavioural problems at age 2 a randomizedcontrolled trial Early Hum Dev 200783683ndash91

Intervention initiated after6 weeks postnatally

Cho HJ Kwon JH Lee JJ Antenatal cognitive-behavioral therapy for prevention ofpostpartum depression a pilot study Yonsei Med J 200849553ndash62

Cinciripini PM Blalock JA Minnix JA Robinson JD Brown VL Lam C et al Effects of anintensive depression-focused intervention for smoking cessation in pregnancy J Consult ClinPsychol 20107844ndash54

Clark R Hipke K Relational group intervention for postpartum depression [NCT00051246]2004 URL httpclinicaltrialsgovct2showNCT00051246 (accessed May 2013)

PND treatment trial

Collado MAO Saez M Favrod J Hatem M Antenatal psychosomatic programming toreduce postpartum depression risk and improve childbirth outcomes a randomizedcontrolled trial in Spain and France BMC Pregnancy Childbirth 20141422

Conrad P Adams C The effects of clinical aromatherapy for anxiety and depression in thehigh risk postpartum woman ndash A pilot study Complement Ther Clin Pract 201218164ndash8

Cope CD Lyons AC Donovan V Rylance M Kilby MD Providing letters and audiotapes tosupplement a prenatal diagnostic consultation effects on later distress and recall PrenatDiagn 2003231060ndash7

Costa D Lowensteyn I Abrahamowicz M Ionescu IR Dritsa M Rippen N et al Arandomized clinical trial of exercise to alleviate postpartum depressed mood J PsychosomObstetr Gynaecol 200930191ndash200

PND treatment trial

Craig M Howard L Postnatal Depression BMJ Clinical Evidence 2009 pii 1407URL httpclinicalevidencebmjcomxsystematic-review1407overviewhtml(accessed May 2013)

APPENDIX 5

Cresci M Self-help group intervention in post natal depression National Research Register1996 [NIHR no longer provide the National Research Register as a searchable online archivefollowing the migration of the NIHR website to a new platform in 2014]

Crowley SK Youngstedt SD Efficacy of light therapy for perinatal depression a reviewJ Physiol Anthropol 20123115

Cuijpers P Prevention an achievable goal in personalized medicine Dialogues ClinNeuroscience 2009112009

Curtis K Weinrib A Katz J Systematic review of yoga for pregnant women current statusand future directions Evid Based Complement Alternat Med 20122012715942

Daley A Exercise and depression a review of reviews J Clin Psychol Med Settings200815140ndash7

PND treatment trial

Dennis CL The effect of peer support on postpartum depression a pilot randomizedcontrolled trial Can J Psychiatr 200348115ndash24

Di Scalea TL Wisner KL Pharmacotherapy of postpartum depression Expert OpinPharmacother 2009102009

Doucet S Jones I Letourneau N Dennis CL Blackmore ER Interventions for the preventionand treatment of postpartum psychosis a systematic review Arch Womens Ment Health20111489ndash98

Dritsa M Costa D Dupuis G Lowensteyn I Khalifeacute S Effects of a home-based exerciseintervention on fatigue in postpartum depressed women results of a randomized controlledtrial Ann Behav Med 200835179ndash87

PND treatment trial

Elliott SA Sanjack M Leverton TJ Parents Groups in Pregnancy A Preventive Interventionfor Postnatal Depression In Gottlieb BH editor Marshaling Social Support FormatsProcesses and Effects London Sage pp 87ndash97

El-Mohandes AA El-Khorazaty MN Kiely M Gantz MG Smoking cessation and relapseamong pregnant African-American smokers in Washington DC Matern Child Health J201115(Suppl 1)96ndash105

Secondary analysis of datafrom a RCT

El-Mohandes AA Kiely M Gantz MG El-Khorazaty MN Very preterm birth is reduced inwomen receiving an integrated behavioral intervention a randomized controlled trialMatern Child Health J 20111519ndash28

Evans EC Bullock LF Optimism and other psychosocial influences on antenatal depressiona systematic review Nurs Health Sci 201214352ndash61

Feinberg E Stein R Diaz LY Egbert L Beardslee W Hegel MT et al Adaptation ofproblem-solving treatment for prevention of depression among low-income culturallydiverse mothers Fam Commun Health 20123557ndash67

Field T Deeds O Diego M Hernandez RM Gauler A Sullivan S et al Benefits of combiningmassage therapy with group interpersonal psychotherapy in prenatally depressed womenJ Bodyw Mov Ther 200913297ndash303

Field T Diego M Hernandez RM Medina L Delgado J Hernandez A Yoga and massagetherapy reduce prenatal depression and prematurity J Bodyw Mov Ther 201216204ndash9

Field T Diego MA Hernandez RM Schanberg S Kuhn C Massage therapy effects ondepressed pregnant women J Psychosom Obstet Gynaecol 200425115ndash22

Field T Figueiredo B Hernandez RM Diego M Deeds O Ascencio A Massage therapyreduces pain in pregnant women alleviates prenatal depression in both parents andimproves their relationships J Bodyw Mov Ther 200812146ndash50

Field T Hernandez RM Hart S Theakston H Schanberg S Kuhn C Pregnant women benefitfrom massage therapy J Psychosom Obstet Gynaecol 19992031ndash8

Field T Hernandez RM Taylor S Quintino O Burman I Labor pain is reduced by massagetherapy J Psychosom Obstet Gynaecol 199718286ndash91

Fink NS Urech C Cavelti M Alder J Relaxation during pregnancy what are the benefits formother fetus and the newborn A systematic review of the literature J Perinat Neonat Nurs201226296ndash306

Fisher JRW Brief behavioural intervention for infant sleep problems reduces depression inmothers Evid Based Mental Health 20091246

Fleming AS Klein E Corter C The effects of a social support group on depression maternalattitudes and behavior in new mothers J Child Psychol Psychiatry 199233685ndash98

Fleming VE Hagen S Niven C Does perineal suturing make a difference The SUNS trialBJOG 2003110684ndash9

Freeman MP Sinha P Tolerability of omega-3 fatty acid supplements in perinatal womenPLEFA 200777203ndash8

Freeman MP Complementary and alternative medicine for perinatal depression J AffectDisord 20091121ndash10

Freeman MP Omega-3 fatty acids and perinatal depression a review of the literature andrecommendations for future research PLEFA 200675291ndash7

Gagnon AJ Sandall J Individual or group antenatal education for childbirth or parenthoodor both Cochrane Database Sys Rev 20073CD002869

Gamble J Creedy D Content and processes of postpartum counseling after a distressingbirth experience a review Birth ISS Perinat C 200431213ndash18

Gamble JA Creedy DK Webster J Moyle W A review of the literature on debriefing ornon-directive counseling to prevent postpartum emotional distress Midwifery 20021872ndash9

Gentile S The role of estrogen therapy in postpartum psychiatric disorders an updateCNS Spectrums 200510944ndash52

Gjerdingen DK Yawn BP Postpartum depression screening importance methods barriersand recommendations for practice JABFM 200720280ndash8

Glavin K Smith L Sorum R Ellefsen B Redesigned community postpartum care to preventand treat postpartum depression in women ndash a one-year follow-up study J Clin Nurs2010193051ndash62

Gordon N Walton D McAdam E Derman J Gallitero G Garrett L Effects of providinghospital-based doulas in health maintenance organization hospitals Obstetr Gynecol199993422ndash6

Gordon RE Gordon KK Social factors in prevention of postpartum emotional problemsObstetr Gynecol 196015433ndash8

Griffiths K Christensen H Ellwood D Online cognitive behaviour therapy MoodGYM for theprevention of postnatal depression in at-risk mothers a randomised controlled trial [protocol][ACTRN12609001032246] Aust NZ Clin Trials Registry 2009 URL wwwanzctrorgau(accessed May 2013)

Guse T Wissing M Hartman W The effect of a prenatal hypnotherapeutic programme onpostnatal maternal psychological well-being J Reprod Infant Psychol 200624163ndash77

Halford WK Petch J Creedy DK Promoting a positive transition to parenthooda randomized clinical trial of couple relationship education Prev Sci 20101189ndash100

Hall W Mothers were less likely to be depressed after a structured behavioural interventionfor infant sleep problems Evid Based Nursing 2009129

Hawkins-Walsh E Hiscock H Wake M A behavioural infant sleep intervention resolved sleepproblems Evid Based Nursing 2003610

Heh SS Huang LH Ho SM Fu YY Wang LL Effectiveness of an exercise support program inreducing the severity of postnatal depression in Taiwanese women Birth 20083560ndash5

Hiscock H Bayer J Gold L Hampton A Ukoumunne OC Wake M Improving infant sleepand maternal mental health a cluster randomised trial Arch Dis Childhood 200792952ndash8

APPENDIX 5

Hiscock H Bayer JK Hampton A Ukoumunne OC Wake M Long-term mother and childmental health effects of a population-based infant sleep intervention cluster-randomizedcontrolled trial Pediatrics 2008122e621ndash7

Outcome measurementsafter twelve postnatalmonths

Hiscock H Wake M Randomised controlled trial of behavioural infant sleep intervention toimprove infant sleep and maternal mood BMJ 20023241062ndash5

Hiscock H Wake M The impact of an infant sleep intervention on postnatal depressiona randomized controlled trial J Paediatr Child Health 200137A1

Horowitz JA Bell M Trybulski J Munro BH Moser D Hartz SA et al Promotingresponsiveness between mothers with depressive symptoms and their infants J NursScholarsh 200133323ndash9

Hoseininasab D Ahmadianheris S Taghavi S The effect of antenatal education onpostpartum depression Int J Gynecol Obstetr 2009107S607ndash8

Hosli I Zanetti-Daellenbach R Holzgreve W Lapaire O Role of omega 3-fatty acids andmultivitamins in gestation J Perinatal Medicine 200735(Suppl 1)S19ndash24

Howard LM Boath E Henshaw C Antidepressant prevention of postnatal depressionPLOS Med 20063e389

Hubner-Liebermann B Hausner H Wittmann M Recognizing and treating peripartumdepression Dtsches Arztebl Int 2012109419ndash24

Ivey LC Behavioral health matters Effective nonpharmacological therapies for pregnantwomen with depression Evid Based Practice 20069(10)9 1 page URL wwwfpinorgwpwp-contentuploads201410733-EBP-October-2006pdf (accessed 4 March 2016)

Jans LA Giltay EJ Van der Does AJ The efficacy of n-3 fatty acids DHA and EPA (fish oil) forperinatal depression Br J Nutr 20101041577ndash85

Jesse DE Blanchard A Bunch S Dolbier C Hodgson J Swanson MS A pilot study to reducerisk for antepartum depression among women in a public health prenatal clinic Issues MentHealth Nurs 201031355ndash64

Karuppaswamy J Vlies R The benefit of oestrogens and progestogens in postnataldepression J Obstet Gynaecol 200323341ndash6

Kennedy HP Farrell T Paden R Hill S Jolivet RR Cooper BA et al A randomized clinical trialof group prenatal care in two military settings Mil Med 20111761169ndash77

Kenyon S Jolly K Hemming K Ingram L Gale N Dann SA et al The ELSIPS trial Evaluationof lay support in pregnant women with social risk a randomised controlled trialBMC Pregnancy Childbirth 20121211

Kersten-Alvarez LE Hosman CM Riksen-Walraven JM Doesum KT Hoefnagels C Whichpreventive interventions effectively enhance depressed mothersrsquo sensitivity A meta-analysis(Provisional abstract) Infant Ment Health J 201132362ndash76

King E The effectiveness of an internet-based stress management program in the preventionof postpartum stress anxiety and depression for new mothers Dissertations AbstractsInternational Section B The Sciences and Engineering 2009702560

Kitamura T Midwivesrsquo psychological group and individual support sessions as prevention ofpostnatal depression a randomised trial in Japan J Psychosom Obstet Gynecol 20072814[Abstract]

Kleeb B Rageth CJ [Influence of prophylactic information on the frequency of baby blues]Z Geburtshilfe Neonatol 200520922ndash8

Study reported in non-English language (German)

Ko YL Yang CL Chiang LC Effects of postpartum exercise program on fatigue anddepression during lsquodoing-the-monthrsquo period J Nurs Res 200816177ndash86

Koh TH Butow PN Coory M Budge D Collie LA Whitehall J et al Provision of tapedconversations with neonatologists to mothers of babies in intensive care randomisedcontrolled trial BMJ 200733428

Koltyn KF Schultes SS Psychological effects of an aerobic exercise session and a rest sessionfollowing pregnancy J Sports Med Phys Fitness 199737287ndash91

Langer A Farnot U Garcia C Barros F Victora C Belizan JM et al The Latin American trialof psychosocial support during pregnancy effects on motherrsquos wellbeing and satisfactionLatin American Network For Perinatal and Reproductive Research (LANPER) Soc Sci Med1996421589ndash97

Lavender T Walkinshaw SA Can midwives reduce postpartum psychological morbidityA randomized trial Birth 199825215ndash19

Lee KO Kim KR Ahn SH Effects of a Qigong prenatal education program on anxietydepression and physical symptoms in pregnant women Korean J Womens Health Nurs200612240ndash8

Study reported in non-English language (Korean)

Leung SS Leung C Lam TH Hung SF Chan R Yeung T et al Outcome of a postnataldepression screening programme using the Edinburgh Postnatal Depression Scalea randomized controlled trial J Public Health 201133292ndash301

Leung SSK Lee AM Chiang VCL Lam SK Yung C Wong DFK 2013 Culturally sensitivepreventive antenatal group cognitive-behavioural therapy for Chinese women withdepression 201319(Suppl 1)28ndash37

Levitt C Shaw E Wong S Kaczorowski J Springate R Sellors J et al Systematic review ofthe literature on postpartum care methodology and literature search results Birth200431196ndash202

Liberto TL Screening for depression and help-seeking in postpartum women duringwell-baby pediatric visits an integrated review J Pediatr Health Care 201226109ndash17

Manber R Schnyer RN Lyell D Chambers AS Caughey AB Druzin M et al Acupuncturefor depression during pregnancy a randomised controlled trial J Obstetr Gynecol2010115511ndash20

Matsuoka Y Itrsquos high time to challenge a collaboration of omega-3s in the preventionAsia-Pacific Psychiatry Conference 15th Pacific Rim College of Psychiatrists ScientificMeeting PRCP 2012 Seoul South Korea 25ndash27 October 2012 Conference Publication(var pagings) 20124October

Matthey S Telephone based peer support can reduce postnatal depression in women athigh risk Evid Based Mental Health 20091282

Medves J Review continuous caregiver support during labour has beneficial maternal andinfant outcomes Evid Based Nursing 20025105

Mendelson T Leis JA Perry DF Stuart EA Tandon SD 2013 Impact of a preventiveintervention for perinatal depression on mood regulation social support and copingArch Womens Mental Health 1ndash8

Mercado JM Changes in depression in pregnant and postpartum adolescents followingparticipation in a comprehensive preventive intervention Dissertation Abstracts InternationalSection B The Sciences and Engineering 2004651046

Middlemiss C Dawson AJ Gough N Jones ME Coles EC A randomised study of adomiciliary antenatal care scheme maternal psychological effects Midwifery 1989569ndash74

Miller BJ Murray L Beckmann MM Kent T Macfarlane B Dietary supplements forpreventing postnatal depression Cochrane Database Syst Rev 20115CD009104

Moshki M Beydokhti TB Cheravi K The effect of educational intervention on prevention ofpostpartum depression an application of health locus of control J Clin Nurs2014232256ndash63

Mozurkewich E Chilimigras J Klemens C Keeton K Allbaugh L Hamilton S et al Themothers Omega-3 and mental health study BMC Pregnancy Childbirth 20111146

Mozurkewich E Klemens C Omega-3 fatty acids and pregnancy current implications forpractice Curr Opin Obstet Gynecol 20122472ndash7

Mulcahy R Reay RE Wilkinson RB Owen C A randomised control trial for the effectivenessof group Interpersonal Psychotherapy for postnatal depression Arch Womens Ment Health201013125ndash39

PND treatment trial

APPENDIX 5

Murphy KE Hannah ME Willan AR Ohlsson A Kelly EN Matthews SG et al Maternalside-effects after multiple courses of antenatal corticosteroids MACS the three-monthfollow-up of women in the randomized controlled trial of MACS for preterm birth studyJOGC 201133909ndash21

Nanzer N Rossignol AS Righetti-Veltema M Knauer D Manzano J Espasa FP Effects of abrief psychoanalytic intervention for perinatal depression Arch Womens Ment Health201215259ndash68

Nardi B Laurenzi S Di NM Bellantuono C Is the cognitive-behavioral therapy an effectiveintervention to prevent the postnatal depression A critical review Int J Psychiatry Med201243211ndash25

Nascimento SL Surita FG Cecatti JG Physical exercise during pregnancy a systematicreview Curr Opin Obstet Gynecol 201224387ndash94

Ogrodniczuk JS Piper WE Preventing postnatal depression a review of research findingsHarvard Rev Psychiatry 200311291ndash307

Ogrodniczuk JS Increasing a partnerrsquos understanding of motherhood significantly reducespostnatal distress and depression in first time mothers with low self esteem Evid BasedMental Health 20047116

OrsquoMahen H Himle JA Fedock G Henshaw E Flynn H 2013 A pilot randomized controlledtrial of cognitive behavioral therapy for perinatal depression adapted for women with lowincomes Depress Anxiety 201330679ndash87

Ortega RM Rodriguez-Rodriguez E Lopez-Sobaler AM Effects of omega 3 fatty acidssupplementation in behavior and non-neurodegenerative neuropsychiatric disordersBr J Nutr 2012107(Suppl 2)S261ndash70

Paul IM Downs DS Schaefer EW Beiler JS Weisman CS Postpartum anxiety andmaternal-infant health outcomes Pediatrics 20131311ndash7

Pearson RM OrsquoMahen H Burns A Bennert K Sheppard C Baxter H Chauhan D Evans JThe normalisation of disrupted attentional processing of infant distress in depressedpregnant women following cognitive behavioural therapy J Affect Disord 2013145208ndash13

Peindl KS Wisner KL Hanusa BH Identifying depression in the first postpartum yearguidelines for office-based screening and referral J Affect Disord 20048037ndash44

Reay R Matthey S Ellwood D Scott M Long-term outcomes of participants in a perinataldepression early detection program J Affect Disord 201112994ndash103

Outcome measurementsafter 12 months postnatally

Rees AM Austin MP Parker GB Omega-3 fatty acids as a treatment for perinataldepression randomized double-blind placebo-controlled trial Aust NZ J Psychiat200842199ndash205

Robledo-Colonia AF Sandoval RN Mosquera-Valderrama YF Escobar HC Ramiacuterez VRAerobic exercise training during pregnancy reduces depressive symptoms in nulliparouswomen a randomised trial J Physiother 2012589ndash15

Roman LA Gardiner JC Lindsay JK Moore JS Luo Z Baer LJ Paneth N Alleviating perinataldepressive symptoms and stress a nurse-community health worker randomized trialArch Womens Ment Health 200912379ndash91

Rowan C Bick D Silva-Bastos MH Postnatal debriefing interventions to prevent maternalmental health problems after birth exploring the gap between the evidence and UK policyand practice (Structured abstract) Worldviews Evid Based Nurs 2007497ndash105

Ryding EL Wireacuten E Johansson G Ceder B Dahlstroumlm AM Group counseling for mothersafter emergency cesarean section a randomized controlled trial of interventionBirth 200431247ndash53

Sainz-Bueno JA Romano MR Teruel RG Benjumea AG Palaciacuten AF Gonzaacutelez CA et alEarly discharge from obstetrics-pediatrics at the Hospital de Valme with domiciliaryfollow-up Am J Obstet Gynecol 2005193714ndash26

Scott KD Klaus PH Klaus MH The obstetrical and postpartum benefits of continuoussupport during childbirth J Womens Health Gend Based Med 199981257ndash64

Seeman MV Group oriented interpersonal therapy reduced postpartum depression inwomen at risk Evid Based Mental Health 20014118

Shivakumar G Brandon AR Snell PG Santiago-Munoz P Johnson NL Trivedi MH et alAntenatal depression a rationale for studying exercise Depress Anxiety 201128234ndash42

Simons J Reynolds J Morison L Randomised controlled trial of training health visitors toidentify and help couples with relationship problems following a birth Br J Gen Practice200151793ndash9

Skibniewski-Woods D A review of postnatal debriefing of mothers following traumaticdelivery Community Pract 20118429ndash32

Spinelli MG Endicott J Controlled clinical trial of interpersonal psychotherapy versusparenting education program for depressed pregnant women Am J Psychiatry2003160555ndash62

Stomp-van-den-Berg-SG Poppel MN Hendriksen IJ Bruinvels DJ Uegaki K Bruijne MCet al Improving return-to-work after childbirth design of the MomWork studya randomised controlled trial and cohort study BMC Public Health 2007743

Stuart S OrsquoHara MW Gorman LL The prevention and psychotherapeutic treatment ofpostpartum depression Arch Womens Ment Health 20036(Suppl 2)57ndash69

Su KP Huang SY Chiu TH Huang KC Huang CL Chang HC et al Omega-3 fatty acids formajor depressive disorder during pregnancy results from a randomized double-blindplacebo-controlled trial J Clin Psychiatry 200869644ndash51

Sunder KR Wisner KL Hanusa BH Perel JM Postpartum depression recurrence versusdiscontinuation syndrome observations from a randomized controlled trial J Clin Psychiatry2004651266ndash8

Surkan PJ Gottlieb BR McCormick MC Hunt A Peterson KE Impact of a health promotionintervention on maternal depressive symptoms at 15 months postpartum Matern ChildHealth J 201216139ndash48

Svensson J Barclay L Cooke M Randomised controlled trial of two antenatal educationprogrammes Midwifery 200924114ndash25

Sword W Review some specific preventive psychosocial and psychological interventionsreduce risk of postpartum depression Evid Based Nurs 2005876

Taft AJ Small R Hegarty KL Watson LF Gold L Lumley JA Mothersrsquo advocates in thecommunity mosaic ndash non-professional mentor support to reduce intimate partner violenceand depression in mothers a cluster randomised trial in primary care BMC Public Health201111178

Tandon SD Perry DF Mendelson T Kemp K Leis JA Preventing perinatal depression inlow-income home visiting clients a randomized controlled trial J Consult Clin Psychol201179707ndash12

Tang YF Shi SX Lu W Chen Y Wang QQ Zhu YY et al Prenatal psychological preventiontrial on postpartum anxiety and depression Chin Ment Health J 20092383ndash9

Study reported in non-English language (Chinese)

Teissedre F Chabrol H Screening prevention and postpartum treatment a randomizedcomparative study on 450 women Neuropsychiatr Enfance Adolesc 200452266ndash73

Study reported in non-English language (French)

Tripathy P Nair N Barnett S Mahapatra R Borghi J Rath S et al Effect of a participatoryintervention with womenrsquos groups on birth outcomes and maternal depression in Jharkhandand Orissa India a cluster-randomised controlled trial Lancet 20103751182ndash92

Ushiroyama T Sakuma K Ueki M Efficacy of the Kampo Medicine Xiong-Gui-Tiao-Xue-YinKyuki-Chouketsu-In A Traditional herbal medicine in the treatment of maternity bluessyndrome in the postpartum period Am J Chin Med 200533117ndash26

Varo I Impact of a nursing intervention on pregnant women as a preventive tool forpostpartum depression Nure Investigacioacuten 20121ndash17

Study reported in non-English language (Spanish)

APPENDIX 5

Vieten C Astin J Effects of a mindfulness-based intervention during pregnancy on prenatalstress and mood results of a pilot study Arch Womens Ment Health 20081167ndash74

Wiggins M Oakley A Roberts I Turner H Rajan L Austerberry H et al Postnatal support formothers living in disadvantaged inner city areas a randomised controlled trial J EpidemiolCommun Health 200559288ndash95

Wiggins M Oakley A Roberts I Turner H Rajan L Austerberry H et al The Social Supportand Family Health Study a randomised controlled trial and economic evaluation of twoalternative forms of postnatal support for mothers living in disadvantaged inner-city areasHealth Technol Assess 20018(32)

Wilton G Moberg DP Fleming MF The effect of brief alcohol intervention on postpartumdepression MCN Am J Matern Child Nurs 200934297ndash302

Wirz-Justice A Bader A Frisch U Stieglitz R-D Aldfer J Bitzer J et al A randomizeddouble-blind placebo-controlled study of light therapy for antepartum depressionJ Clin Psychiatry 201172986ndash93

Wisner KL Gelenberg AJ Leonard H Zarin D Frank E Pharmacologic treatment ofdepression during pregnancy Structured JAMA 19992821264ndash9

Wisner KL Wheeler SB Prevention of recurrent postpartum major depressionHosp Commun Psych 1994451191ndash6

Yawn BP Dietrich AJ Wollan P Bertram S Graham D Huff J et al TRIPPD A practice-basednetwork effectiveness study of postpartum depression screening and management Ann FamMed 201210320ndash9

Yonkers KA Wisner KL Stewart DE Oberlander TF Dell DL Stotland N et al Themanagement of depression during pregnancy a report from the American PsychiatricAssociation and the American College of Obstetricians and Gynecologists Gen HospPsychiat 200931403ndash13

Zayas LH Six-month multicomponent intervention improves postnatal depression inlow-income settings Evid Based Mental Health 20081180 [Comment on Rojas GFritsch R Solis J Jadresic E Castillo C Gonzalez et al Treatment of postnatal depression inlow-income mothers in primary-care clinics in Santiago Chile a randomised controlled trialLancet 20073701629ndash37]

Appendix 6 Data extraction

Data extraction for quantitative studies

Data Extraction Form HTA 119503 Interventions to prevent postnatal depression Initials of first data extractor Initials of second data extractor Ref ID Citation Author contact details 1

Characteristics Options Intervention type Complementary and alternative medicines (eg music massage aromatherapy

Japanese herbal medicine) Maternity care organisation Mind-body interventions (eg acupuncture autogenic training auto-suggestion biofeedback

guided imagery hypnosis hypnotherapy meditation prayer sleep deprivation tai-chi yoga) Pharmacological (eg antidepressants calcium omega-3 supplements hormone therapy

thyroxine) Psychological psychotherapeutic psycheducational Social support (eg exercise lay support peer support) Other

Intervention mode Group Individual On-line Other

Intervention provider Doula Health visitor Midwife Nurse Psychiatrist Psychologist Other

Intervention duration Single contact Multiple contact

Intervention time Antenatal only During labour Antenatal and postnatal Postnatal only

Sample selection criteria Universal Preventive Interventions targeted at a whole population group not identified on the basis of increased risk

Selective Preventive Interventions for population subgroups whose risk of developing postnatal depression is higher than average (eg psychosocial risk factors)

Indicated Preventive Interventions for high-risk women identified as having a predisposition for PND but who do not meet diagnostic criteria for PND

RCT details Country Australia Canada China France Hong Kong India Italy Japan Korea Mexico

Netherlands Norway South Africa Sweden Taiwan UK US Other Study setting Antenatal clinic Home visits Labour delivery ward Postnatal ward Primary care Other Number of centres Recruitment Pregnancy During labour Postnatally Funding Government Private Scholarship award Other Aim of the study Intervention (same order as in the paper) Provide description of experimental interventions and controls (eg pharmacological social support mind-body intervention CAMs maternity care location number and length of sessions number per group professional background making diagnosis) Intervention 1 Intervention 2 (if applicable) Control

Participant recruitment Recruitment dates Total number of women randomised (n) screened (n) Inclusion criteria Exclusion criteria (eg risk history condition antenatal anxiety antenatal depression social support life events domestic violence method for identification) Baseline characteristics All (Total sample)

Mean (SD) n () Intervention 1 Mean (SD) n ()

Intervention 2 Mean (SD) n ()

Control Mean (SD) n ()

Age in years Mean (SD) or range Number randomised EPDS Other measure Raceethnicity Socio-demographic characteristics Education Diagnosis at baseline Populations of antenatal women Populations of early postnatal women Co-therapy or medication (Specify dose if applicable)

Outcomes summary 1 Maternal outcomes (eg depressive symptoms morbidity mortality)

Yes No 2 Neonatal post-neonatal and infant outcomes (eg Apgar morbidity mortality injury development)

Yes No 3 Family outcomes (eg dyadic relationship discord separation divorce abuse violence)

Yes No 4 Process outcomes (eg uptake did not receive intervention discontinued intervention number of sessions received)

Yes No 5 Cost of use of service outcomes

Yes No Primary outcome Secondary outcomes Timing of outcome assessments (eg 6 weeks postnatally 12 weeks 6 months 12 months) Total length of follow up Did not receive allocated intervention n= Number of participants All (Total sample) Intervention 1 Intervention 2 Control Randomised Losses to follow-updrop outsample attrition Time

n Time n

Time n

Number analysed Time n

Time n

Results Maternal outcomes Report n Mean (SD) for each time of assessment Report all categorical outcomes in a separate table or provide details in the notes column Outcome (Note whether it is actual score or change score)

Intervention 1 Time n Mean (SD)

Control Time n Mean (SD)

Categorical outcomes Notes

Anxiety measure BDI CES-D Diagnostic interviews DSM-IV EPDS

APPENDIX 6

GHQ Hopkins Scale ICD-10 Kellner symptom questionnaire MADRS Maternal dissatisfaction with intervention Maternal morbidity Maternal mortality Maternal perceived support Maternal-infant attachment Mood measure Other depressive symptoms POMS SCID Self-harm Stress measures Suicide attempts Others Results Neonatal post-neonatal and infant outcomes Report n Mean (SD) for each time of assessment Report all categorical outcomes in a separate table or provide details in the notes column Outcome (Note whether it is actual score or change score)

Apgar Child abuse Infant developmental assessments Infant health parameters Injury Morbidity Mortality Neglect Others Results Family outcomes Report n Mean (SD) for each time of assessment Report all categorical outcomes in a separate table or provide details in the notes column Outcome (Note whether it is actual score or change score)

Abuse Dyadic relationship Marital discord PSI Separation divorce Violence Others Results Process outcomes uptake (eg did not receive intervention discontinued intervention number of sessions received) Report n Mean (SD) for each time of assessment Report all categorical outcomes in a separate table or provide details in the notes column Outcome (Note whether it is actual score or change score)

Intervention 1 Mean (SD)

Control Mean (SD)

Please specify Authorsrsquo conclusion Reviewersrsquo conclusion

Data extraction for qualitative studies

Evidence from womenTo inform intervention ndash elementsof the intervention Service delivery

Data extraction Data synthesis Interpretation

What helped Which intervention elements helped Which intervention elements to include

What did not help What not to do How to counteract unhelpful experiencesduring pregnancy and postpartum

What did you need What to do and how to address it Which intervention elements to includeWill it fit into an intervention

How did you want it evidence ofpreferred service delivery

Vehicle Delivery types (leaflet peer group midwife)

What didnrsquot you want (servicedelivery)

Avoid including in interventions orassess which women were suitable forparticular elements

Which elements should be removed froman intervention

Barriers to participation To inform service delivery Allow for different circumstances (egunable to travel to groupphysicallimitations

APPENDIX 6

Appendix 7 Synthesis of findings from personaland social support strategy studies

Themes and subthemes from the synthesis of findings frompersonal and social support strategy studies

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

Explanationofcertainty

intheev

ceassessmen

Thingsthat

helpto

ntfeelingsofdep

ressionfrom

thewomen

rsquospersp

ective

Emotiona

portfrom

family

andfriend

respon

illustrated

friend

dfamily

provided

emotiona

providingextravisits

andextraph

onecallschecking

onmeto

makesure

Irsquomok

ything

Participan

greferences

286 30

Highmod

Highcertainty

eratequ

alityfin

across

severalstudies

across

opulations

andcultu

differen

dselectivegrou

Emotiona

portfrom

themothe

dmothe

thewom

emotiona

portap

peared

particularlyim

portan

selectivegrou

6ndash29

hadrecently

trylivingaw

ayfrom

theirextend

edfamily

rticipan

arelatio

nshipwith

Itseem

slikewhe

otpreg

tcloser

trsquosgo

Irsquolltellh

ertheprob

lemsan

dshersquollbe

ohwellyou

rsquollbe

okayJust

dothisan

drelax

Participan

Highmod

greferences

296ndash

298 30

3Highmod

Emotiona

portfrom

midwife

health

profession

alsndashthisap

pliedto

midwiveshe

visitors

andGPs3

particularlyim

portan

profession

owledg

drelated

issues3

greferences

303 31

ndashMod

APPENDIX 7

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

Instrumen

ractical

ortfrom

familyfrie

ndsFamily

andfriend

swereprovidingpractical

mymothe

r-in-la

volunteeredto

meacoup

aftertheba

soIcou

ldrest

Ihavefriend

mychurch

allvolun

teered

tomake

Participan

Instrumen

talsup

porttook

theform

ofmakingfood

sleepan

forothe

rchildren

305 31

particularlyprovided

bymothe

dmothe

r-in-la

319 32

greferences

286 29

5ndash31

Highmod

Instrumen

ractical

ortfrom

partne

rPartne

rswerecred

itedfor

taking

onpractical

tasksto

ortthewom

esetasksinclud

ingtheho

ingafterthechildren

Arespon

ingtheho

working

fulltim

everything

thechildren

Heworks

coming

homege

ttingthekids

toscho

sleepfor2ho

gettingup

ttingtheyoun

nursery

tosleep

solute

ankGod

Participan

greferences

305 31

Highmod

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

Instrumen

ractical

ortfrom

midwife

health

profession

everinteractions

health

profession

alsvarie

rsemidwife

delivered

learnho

onetold

methat

painfulId

idnrsquotha

vethat

ofsupp

ortsystem

hospita

lstaffbu

adawon

derful

midwife

Participan

greferences

303 30

eratehigh

ortndashsharingexpe

riences

rmalisation

fitsfor

enoftenap

peared

specificto

sharingexpe

riences

peerswho

teredsimilardifficultie

ringpreg

nancyan

dthepo

helped

rmalisethefeelings

riencing

greferences

302 31

eratehigh

APPENDIX 7

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

Adjustm

Realistic

ctations

(becau

antena

taledu

n)being

recogn

oftheim

portan

having

realistic

ctations

nancyan

dthepo

ingprep

forthese

educationwas

itedas

otingrealistic

ctations

respon

itexpe

ctingtheworse

anditen

alotbe

veprep

yourself

BasicallyIthink

useverything

inclasses

Participan

eratehigh

ndashMod

certainty

adjustmen

nancyan

dmothe

dmainlyof

eratequ

alityfin

across

severalstudies

althou

ghmostly

Awaren

potentialP

NDlearning

otiona

Forothe

ingprep

beingaw

potentialfor

andlearning

otiona

317 32

0Particularlyforwom

enwith

inthosewith

noprevious

history

pression

respon

Talked

toallm

yfriend

smyfamilymyhu

dsaidifyou

thinkan

ything

isdifferen

nrsquothe

sitate

totellme

iatelybe

causeId

onrsquotwan

ttheworse

enParticipan

eratehigh

Practical

rienceha

routinesgettin

byndash

enspok

having

practical

rienceof

aftertheba

0includ

routines

ttingto

enrepo

edmorepractical

skillsan

rienceforearly

postna

eriod(egchan

thingtheba

rovalo

nancyvalidationof

nancy2

96ndash29

8ndash

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

alsreligion

Prayingstrategy

otiona

ldistressan

provide

emotiona

spiritual

greferences

304 30

6ndash31

erate(times

certainty

iesrelatin

dreligionmainly

eratequ

finding

across

several

differen

pulatio

Health

icationndashRe

dentsha

profession

andmen

health

servicessuch

ascoun

selling

consultatio

physicians

midwivesan

lisation

303Nearly

halfof

respon

dents3

03repo

usingmed

icationforem

otiona

ldistress

ndashLow

certainty

eratequ

alityfin

onlyin

althou

dselective

enalso

ficiale

ffects

ofalternativetreatm

alities

asmassage

uncture

andhypn

erateHigh

tinuity

ofcarein

theform

e-to-one

acommun

itymidwife

particularlyhe

lpfulinon

Self-he

strategies

activities

isolation)talking

toothe

aintaining

asenseof

beingin

controlA

skingforhe

lppeersupp

ortgrou

psproblem

-solvingha

acultu

ralide

strong

Participan

tsrepo

asking

ysical

orsimplyasking

forabreakwas

strategy

tocomba

tfeelings

Askingthosearou

herabreakwas

portan

tstrategy

byayoun

gmothe

ShesaidlsquoIrsquolljust

tellthem

lsquoLoo

rsquosgo

adache

Yrsquoallgive

minutesrsquoTh

atrsquoswha

tIrsquolltellthe

mIrsquolltell

dlsquoJjust

minutes

Participan

greferences

286 30

6ndash31

2ndash31

erateHigh

Highmod

certainty

eratequ

alityfin

across

severalstudies

neralp

opulation

andcultu

APPENDIX 7

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

Baby-related

issues

Feelings

djoyga

iningstreng

thfrom

certainty

eratequ

alityfin

onlyin

althou

dcultu

dinfant

Synthesised

findingndashthingsthat

nothelpto

ressionfrom

thewomen

rsquospersp

ective

cerbated

feelingsofdep

ressionwere

ofsupp

derstand

ingfrom

partne

iguchi

318 ha

rassmen

babyrsquosfather

296ndash

298 fear

t315)So

rticipan

tsindicatedthat

theirdistress

hadane

gativeim

ontheirrelatio

andcaused

furthe

rstress

ssaying

lsquoFor

rsquossakeIw

ishwersquodne

nantIw

ishyoursquodha

ofhimrsquoHedo

esnrsquot

rstand

Hersquosjust

lsquoWha

trsquosup

inamoo

drsquoan

dIfindthat

abitha

rdParticipan

Highmod

certainty

eratequ

alityfin

across

severalstudies

across

opulations

andacross

differen

dselective

ofpractical

ortndashade

entale

ffectof

ofpractical

ortwas

dentsrepo

having

alwith

everything

bythem

selves

outpractical

bringtheba

toeatthefamily

toeatha

cleantheho

towashthechildren

toscho

oltake

toArabicread

ing(classes)You

allthisworkin

wcanyouge

Participan

ndashMod

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

traryto

tthena

oftheextend

edAsian

family

inBrita

lpfrom

relatives

notavailableto

enParticipan

ativeinteractions

health-careprofession

alsndashin

somecases

provided

profession

alswas

asinad

respon

revealed

Theinfant

criedalotIcalledthemidwife

andshesaid

lsquowha

youwan

dorsquo

disapp

ointed

dsomeo

mesupp

Participan

Interferen

family

bersunreliablemothe

rrejection

byfamily

berdisapp

rovalIn

onestud

entalked

rmothe

shelived

rsister

nearby

initiallyvery

ortivebu

tthissupp

cameun

helpful3

Ifeltqu

itejealou

dcolic

causehe

criedfrom

een6an

course

rsquoslsquoOhgive

donrsquotkn

dowith

rsquoan

tearsover

becauseshersquodtakenhim

Participan

Highmod

APPENDIX 7

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

agersde

edtheirow

nmothe

lsquounreliablersquoa

ndshecouldno

tproviderequ

iredsupp

ativeeffect

ersndashwom

enrepo

peersha

bellished

theirow

rienceto

conform

tosocial

beingalsquogoo

dmothe

rrsquo31

6forthem

onlyto

discover

laterthat

theiraccoun

riences

tirelytruthful

Iasked

friend

slsquohow

isyour

hterTh

eysaid

nevercriesRe

centlythey

couldno

Isaidlsquobut

shedidno

tcryrsquoAnd

worsethey

methetruth

andIfou

ndthis

extrem

elydistressing

Participan

ndashndash

Culturalb

eliefs

accessingsupp

ortndashrespon

enwereexpe

tdiscussprivatematters

byothe

oftheircommun

ndashMod

ndashndash

Culturala

ndcommun

includ

edthat

wereno

toprovidesupp

dthereforewom

enwerede

prived

ofthesupp

oftheirpa

ndashMod

ndashndash

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

Unsatisfactory

health

Multip

lecarers

nancyndashdissatisfactionwith

alth-care

system

303 31

6includ

gativepe

multip

lecarers

nancy3

ndashMod

certainty

eratequ

alityfin

across

iesacross

dacross

differen

dselectivegrou

Poor-qua

lityho

311One

respon

the[com

ity]midwife

shewas

helpfulb

midwives

neverad

anyone

seethem

couldbe

crying

and[the

y]willbe

treatin

gyoulikealog

Ididnrsquotfeel

likeahu

beingat

Participan

ndashHigh

Simplyno

rmalisingprob

lemsndashrespon

dentsexpresseddisapp

ointmen

nseekinghe

andfeltthat

health

profession

alsmerely

focusedon

alisingprob

Igothereon

IfeelI

havenrsquotgo

lpthere

havenrsquottakenmeserio

uslyan

dallthe

ysayisthat

lsquothis

rmalrsquo

Participan

ndashndash

Protocol-driven

ndashno

discusspsycho

logicald

istressndash

respon

dentscomplaine

dthehe

alth-caresystem

protocol

driven

noroom

todiscusspsycho

logicald

istressor

interven

tomaintainmaterna

ndashHigh

classdidno

lpndashan

talclasses

oflittle

respon

316Wom

endidno

interven

tionin

theform

class2

96ndash29

icationdidno

lpndashmed

icationmad

ethings

ineffective3

APPENDIX 7

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

ativeeffect

ofself-he

strategiesin

ability

plyself-he

coping

strategies

titivecleaning

ndashcompu

lsivebe

haviou

rsndashpa

rticipan

tedthat

somestrategies

couldbe

comeun

helpfulan

dcouldin

somecases

developinto

lsivebe

haviou

rssuch

asrepe

titivecleaning

Respon

dentscomplaine

wereun

plystrategies

hadreliedon

inthepa

causeof

theirinap

riatene

asdrinking

alcoho

ndashLow

certainty

ingfrom

onestud

qualityfin

ralised

toothe

pulatio

Toomuchinform

ationndashbo

dinternet

increaseddistress

plypreviouslyused

coping

strategies

anything

ndashlack

ofmotivation32

Baby-related

difficultie

bycrying

ndashMod

certainty

ingfrom

onestud

eratequ

alityfin

ralised

toothe

pulatio

Breast

ingdifficultie

Guiltbe

causeof

aturity

Physical

difficultie

ysical

lsquolimite

self-carersquo

Difficultie

sinclud

edfatig

dtheph

ysical

recovery

livery

312 31

difficultie

s318an

having

limite

eforself-care

dresssuch

issues

312 31

eratehigh

certainty

eratequ

alityfin

across

opulations

andacross

Eviden

urce(s)

Eviden

cefrom

studieswith

population

participan

lective

groupdata

Certainty

intheev

ce(CER

intheev

ceassessmen

Person

alinsecurity

Worrie

ingago

rentself-do

ubtfeelingapressure

ofrespon

sibilityan

dfeelings

ofinad

enrepo

putthem

selves

ralotpressure

perfectmothe

rienced

feelings

ofinad

nmothe

ddidno

tcomena

turally

certainty

qualityfin

across

severalstudiesacross

opulations

across

differen

dselectivegrou

Person

alinsecuritywas

associated

ofasenseof

ofselfinclud

edaloss

ofoccupa

312 31

daloss

pearan

cephysicala

ttractiven

ofselfinclud

edaloss

thefocuswas

andtherewas

asenseof

sacrificing

oneselffortheba

andaloss

ofsexuality

312 31

enrepo

having

concerns

detrim

entalto

theirmen

lievedthat

better

tocoun

otiona

ldistressiftheseconcerns

werealleviated

286 30

6ndash31

rethereweretw

iestheriskof

isindicatedin

theorde

thestud

iesarecited

APPENDIX 7

Appendix 8 Included systematic reviews

First author yearreference number Full reference Review type

Austin 2008230 Austin MP Priest SR Sullivan EA Antenatal psychosocial assessment forreducing perinatal mental health morbidity Cochrane Database Syst Rev20088CD005124

Cochrane review

Bennett 2008425 Bennett C Macdonald GM Dennis J Coren E Patterson J Astin M et alHome-based support for disadvantaged adult mothers [Update of CochraneDatabase Syst Rev 20073CD003759] Cochrane Database Syst Rev20081CD003759

Cochrane review

Cuijpers 200568 Cuijpers P Straten A Smit F Preventing the incidence of new cases ofmental disorders a meta-analytic review J Nerv Ment Dis 2005193119ndash25

Systematic reviewand meta-analysis

Dale 2008232 Dale J Caramlau IO Lindenmeyer A Williams SM Peer support telephonecalls for improving health Cochrane Database Syst Rev 20084CD006903

Cochrane review

Dennis 2004233 Dennis CL Creedy D Psychosocial and psychological interventions forpreventing postpartum depression Cochrane Database Syst Rev20044CD001134

Cochrane review

Dennis 2005234 Dennis CL Psychosocial and psychological interventions for prevention ofpostnatal depression systematic review BMJ 200533115ndash21

Systematic review

Dennis 2008118 Dennis CL Allen K Interventions (other than pharmacological psychosocialor psychological) for treating antenatal depression Cochrane Database SystRev 20084CD006795

Cochrane review

Dennis 2004235 Dennis CL Preventing postpartum depression part I a review of biologicalinterventions Can J Psychiatry 200449467ndash75

Systematic review

Dennis 2008236 Dennis CL Kingston D A systematic review of telephone support for womenduring pregnancy and the early postpartum period J Obstet GynecolNeonatal Nurs 200837301ndash14

Systematic review

Dennis 2008237 Dennis CL Ross LE Herxheimer A Oestrogens and progestins for preventingand treating postpartum depression Cochrane Database Syst Rev20084CD001690

Cochrane review

Dennis 2004238 Dennis CL Preventing postpartum depression part II A critical review ofnonbiological interventions Can J Psychiatry 200449526ndash38

Critical review

Dodd 2012239 Dodd JM Crowther CA Specialised antenatal clinics for women with amultiple pregnancy for improving maternal and infant outcomes CochraneDatabase Syst Rev 20128CD005300

Cochrane review

Fontein-Kuipers2014240

Fontein-Kuipers YJ Nieuwenhuijze MJ Ausems M Bude L Vries RAntenatal interventions to reduce maternal distress a systematic review andmeta-analysis of randomised trials BJOG 2014121389ndash97

Systematic review

Howard 2005241 Howard LM Hoffbrand S Henshaw C Boath L Bradley E Antidepressantprevention of postnatal depression Cochrane Database Syst Rev20052CD004363

Cochrane review

Jans 2010242 Jans LA Giltay EJ Does AJ The efficacy of n-3 fatty acids DHA and EPA(fish oil) for perinatal depression Br J Nutr 20101041577ndash85

Review

Lawrie 2008243 Lawrie TA Herxheimer A Dalton K Oestrogens and progestogens forpreventing and treating postnatal depression Cochrane Database Syst Rev20082CD001690

Cochrane review

Leis 2009244 Leis JA Mendelson T Tandon SD Perry DF A systematic review ofhome-based interventions to prevent and treat postpartum depressionArch Womens Ment Health 2009123ndash13

Systematic review

Lumley 2004245 Lumley J Austin MP Mitchell C Intervening to reduce depression after birtha systematic review of the randomized trials Int J Technol Assess Health Care200420128ndash44

Systematic review

Marc 2011246 Marc I Toureche N Ernst E Hodnett ED Blanchet C Dodin S et alMindndashbody interventions during pregnancy for preventing or treatingwomenrsquos anxiety Cochrane Database Syst Rev 20117CD007559

Cochrane review

Miller 2013247 Miller BJ Murray L Beckmann MM Kent T Macfarlane B Dietarysupplements for preventing postnatal depression Cochrane Database SystRev 201310CD009104

Sado 2012248 Sado M Ota E Stickley A Mori R Hypnosis during pregnancy childbirthand the postnatal period for preventing postnatal depression CochraneDatabase Syst Rev 20126CD009062

Cochrane review

Shaw 2006249 Shaw E Levitt C Wong S Kaczorowski J McMaster University PostpartumResearch G Systematic review of the literature on postpartum careeffectiveness of postpartum support to improve maternal parenting mentalhealth quality of life and physical health Birth 200633210ndash20

Systematic review

Sockol 2011250 Sockol LE Epperson CN Barber JP A meta-analysis of treatments forperinatal depression Clin Psychol Rev 201131839ndash49

Systematic review

Sockol 2013423 Sockol LE Epperson CN Barber JP Preventing postpartum depressiona meta-analytic review Clin Psychol Rev 2013331205ndash17

Meta-analysis

APPENDIX 8

Appendix 9 Qualitative reviewparticipant characteristics

cteristicsofparticipants

ivingpre

ventiveinte

rventions

Universalpreve

interven

included

studiesco

ncerned

withmidwiferymodelsofworking(n

author

reference

number

Country

Interven

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

ersson

gPregn

ed8male

partne

Individu

pinterviews

Firstba

second

babyn=7

gPregn

234(both

Semistructured

teleph

interview

Military

Mean25

(SD49)

African

American

)Latin

)white

)Asian

Pacific

Island

(n=9)othe

eligible

income)50

Nulliparou

ltHighscho

college

)college

uate98

)marrie

partne

)divorced

gPregn

5Focusgrou

AllAfrican

American

gPregn

12Interviewsan

dfocusgrou

ndash39

werebo

tsideCan

and412

non-Cau

casian

hadless

income

and412

ormore

1012were

first-tim

emothe

edfrom

1112were

marrie

Australia

gPregn

stionn

notrepo

WICWom

dInfants(sup

entaln

utritionprog

ramme)

APPENDIX 9

Universalpreve

interven

included

studiesco

ncerned

withCAM

author

reference

number

Country

Interven

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

Carolan

lullabies

6In-dep

thinterview

29ndash35

ployed

inprofession

aloccupa

iparou

s5tertiary

1second

0Australia

pdiscussion

15In-dep

thinterview

Mean32

ndash45

enwere

inAustralia

tifiedas

Indige

nousan

inthePacific

Mean16

children

rticipan

datechnical

andfurthe

ucationor

university

qualificatio

techniqu

interview

27ndash38

1Hispa

2African

American

casian

employmen

t1ndash

nancies

Highscho

degree

8marrie

d2sing

notrepo

Universalpreve

interven

included

studiesco

ncerned

withpsych

ological

interven

tions(n

author

reference

number

Country

Interven

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Age(yea

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

2China

IPTndashoriented

20Interview

Mean28

8(SD235

ndash34

seProfession

aln=10

semiprofessiona

skilled

First-tim

emothe

rsHighscho

belown=2

college

Allmarrie

Universalpreve

interven

included

studiesco

ncerned

withtheorgan

author

reference

number

Country

Interven

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Age(yea

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

Australia

Materna

health

nurses

Unclear

ndash7

(plus3nu

Interview

observation

nSelf-repo

pressed

notrepo

APPENDIX 9

Universalpreve

interven

included

studiesco

ncerned

withtheso

support

author

reference

number

Country

Interven

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

Online

discussion

stings

Online

message

nSelf-repo

pressed

Morrell

Postna

worker

stionn

notrepo

Universalpreve

interven

included

studiesco

ncerned

withusu

alcare

author

reference

number

Country

Interven

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

Individu

alpren

234(both

Semistructured

teleph

interview

Military

Mean25

5(SD54)

African

American

)Latin

)white

)Asian

Pacific

Island

(n=8)othe

eligible

income)

Nulliparou

ltHighscho

(n=8)high

college

)college

completed

)marrie

divorced

arated

partne

Selectivepreve

interven

included

studiesco

ncerned

author

reference

number

Country

Interven

tionnam

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

gPregn

10Interview

African

American

income

20ndash30

(mean22

)African

American

Low-in

children1ndash

ean23)

Novick

gPregn

21preg

en(18othe

rsattend

sessions

interviewed

Interviewsan

servation

African

American

niclow

income

18African

American

3Hispa

edfrom

somecollege

19sing

2marrie

notrepo

Indicated

andselectivepreve

interven

included

studiesco

ncerned

withpsych

ological

interven

tions(n

author

reference

number

Country

Interven

tionnam

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

296 ndash

42(plus4

clinicians)

Semistructured

interviews

clinical

interviews

oedtherapy

sessions

rticipan

dacurren

pressive

disorder

nopsycho

ticsymptom

sEPDSscore

13ndash19

(mean550

andHispa

verishe

Allfirst

child93

7 parenting

notrepo

APPENDIX 9

Indicated

interven

included

studiesco

ncerned

withso

support

author

reference

number

Country

Interven

tionnam

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

Teleph

one-ba

stionn

nEPDSscore10

ormore

notrepo

Indicated

interven

included

studiesco

ncerned

withtheorgan

author

reference

number

Country

Interven

tionnam

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

Australia

Specialistpe

rinatal

andinfant

health

service

11Interview

tifiedas

having

multip

andpsycho

social

issues

20ndash39

glish-speaking

backgrou

1ndash4children

Allwom

timeof

referral

notrepo

Selectivepreve

interven

included

studiesco

ncerned

withed

ucational

interven

tions(n

author

reference

number

Country

Interven

tionnam

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

ression

status

reported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

aringfor

parentho

Interview

(scorin

riskon

KeyGHQGen

Health

stionn

aireNR

notrepo

APPENDIX 9

Population characteristics for the service providers of preventiveinterventions

Universal preventive interventions included studies concerned withmidwifery models of working (n = 3)

Firstauthoryearreferencenumber Country Intervention name

Sample size(contributingqualitativeevidence)

Studymethods(yieldingqualitativedata)

Population details

Age(years) Gender Ethnicity Parity

Klima2009284

USA CenteringPregnancy 4 certifiednursemidwives 5health-centrestaff 5administrators

Focus groups NR NR NR NR

McNeil2013290

Canada CenteringPregnancy 3 physicians Interviewfocusgroups

NR Allfemale

Tanner-Smith2012291

USA CenteringPregnancy NR Questionnaire NR NR NR NR

Key NR not reported

Universal preventive interventions included studies concerned with socialsupport (n = 1)

Population details

Morrell2002287

UK Support workers NR ndash SWsMWs HVs

Questionnaire NR NR NR NR

Key HV health visitors MW midwife NR not reported SW support workers

Universal preventive interventions included studies concerned with theorganisation of maternity care (n = 1)

Population details

Scott1987288

Australia Maternal and childhealth nurses

3 nurses Interview andobservation

NR NR NR NR

Key NR not reported

Selective preventive interventions included studies concerned withmidwifery models of working (n = 1)

Population details

Novick2011363

2012293294

USA CenteringPregnancy 2 certifiednurse-midwifegroup leaders2 medicalassistants

Interviews andobservation

NR NR NR NR

Key NR not reported

Indicated preventive interventions included studies concerned with socialsupport (n = 1)

Population details

Dennis2013301

Canada Telephone-basedpeer support

Peervolunteers ndashmother fromthe communitywith resolvedhistory ofPND whoparticipatedin a 4-hourtraining session

Key NR not reported

Indicated and selective preventive interventions included studies concernedwith psychological interventions (n = 1)

Population details

Shanok2007296ndash298

USA IPT 4 clinicians Semistructuredinterviewsclinicalinterviewsvideoedtherapysessionstranscribed

26ndash35 Allfemale

2Caucasian1Hispanic1 MiddleEastern

Onepregnantandparentingothers didnot havechildren

APPENDIX 9

Personal

support

strategystudies

populationch

aracteristics

Firstau

reference

number

Country

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

Specific

groupif

cultural

selective

Antenatal

postnatal

ressionstatus

nonereported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

24Interview

ndashRe

cruited

antena

self-repo

depression

27ndash45

(meanag

casian

Variety

ofoccupa

social

classes

9first

child11

Variety

ucationa

llevels

22weremarrie

divorced

Corrig

8Semistructured

interview

ndashRe

cruited

antena

lfscoring

Curtis20

onlinesurvey

ndashRe

cruited

postna

Self-repo

pressed

10ndash62

(mean37

casian

8African

American

Filipino

1Native

American

icity9

6 ndash31

12In-dep

thinterviews

Caribbe

anCultural

Recruited

antena

sample

represen

tedthefull

scores

24ndash42

Caribbe

6marrie

d3coha

g3sing

42Focusgrou

pinterviews

Caribbe

anCultural

Recruited

postna

18ndash43

Caribbe

anLivedin

andsubu

Marrie

Furber20

12Interview

ndashRe

cruited

antena

24ndash39

tworking

4workedfull

5worked

parttim

fulltim

maternity

iparou

multip

19livingwith

partne

tlivingwith

partne

r2sing

3Norway

12Interview

ndashRe

cruited

postna

self-repo

depression

25ndash44

Allfirst

rsAllun

iversity

orcollege

Allcoha

father

Firstau

reference

number

Country

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

Specific

groupif

cultural

selective

Antenatal

postnatal

ressionstatus

nonereported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

10Focusgrou

pinterview

Minority

Cultural

Recruited

postna

self-repo

pressed

16ndash24

dsworkedin

caterin

2profession

1ndash4

ucated

inBrita

inAllmarrie

10Interview

Minority

income

ndashRe

cruited

antena

20ndash30

(mean22

)African

American

Low-in

1ndash4

(mean23)

5China

59Interviews

gChine

Cultural

gChine

Recruited

antena

depressed

pressed

gChine

seWorking

312313

36Interview

ndash1stud

self-repo

depression

22ndash41

Allcity

dwellers2

wereblack

(instud

onwith

WestIndian

origin1

Irish)

remaind

erBritish

alread

dchildrenwith

atleast1

r5years

18expe

lemothe

rsothe

relatio

nships

40Interview

ndashRe

cruited

postna

self-repo

depression

somediag

depression

20ndash39

39white

1Afro-

Caribbe

n-skilled

7skilled

non-man

6profession

7second

education

9vocatio

training

university

Alllivingwith

father

ofchildren

a Migl20

interview

ndashRe

cruited

antena

ndash27

ndash38

1Hispa

2African

American

casian

employmen

nancies

Highscho

degree

8marrie

d2sing

Oates20

15centres

Interview

focusgrou

ndashRe

cruited

postna

APPENDIX 9

Firstau

reference

number

Country

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

Specific

groupif

cultural

selective

Antenatal

postnatal

ressionstatus

nonereported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

Parvin20

25Focusgrou

psMinority

icdifferen

Cultural

Recruited

postna

21ndash54

andBritish-

Headof

househ

oldskilled

skilled

ployed

Mean39

Living

nuclearfamily

9Semistructured

interviews

Minority

Selective

Recruited

postna

Self-repo

pressed

(anten

depression

23ndash40

6white

1black

Caribbe

1black

African

1mixed

British

1ndash3

5livingwith

partne

contactwith

partne

Razurel20

itzerland

60Semistructured

interviews

ndashRe

cruited

postna

Mean31

Unclear

ndashmed

catego

ryoffice

workersservice

workersskilled

orkers

Allprim

iparou

livingas

Rodrigue

39Interview

ndashRe

cruited

antena

EPDSscore19

ormore

241ndash29

10first-tim

emothe

literate

participan

tsoverall

a b Sha

296 ndash

42Semistructured

interviews

clinical

interviews

videoedtherapy

sessions

transcrib

Minority

Selective

(teena

Recruited

antena

13ndash19

andHispa

verishe

Allfirst

renting

20In-dep

thinterview

ndashRe

cruited

antena

dpreviouslybe

pressed

Mean29

8(SD45)

ldincome

0ndashCA$3

0ndashCA$7

more(60

ecompleted

commun

itycollege

ortechnicalschoo

iversity

degree

Allmarrie

livingwith

partne

Firstau

reference

number

Country

Sample

(contributing

qualitative

eviden

methods

(yielding

qualitative

Populationdetails

population

minority

Specific

groupif

cultural

selective

Antenatal

postnatal

ressionstatus

nonereported

self-rep

diagnosed

Ethnicity

Socioeconomic

status

Parity

Education

Marital

status

Tanigu

45Semistructured

interview

Minority

Cultural

Recruited

postna

self-repo

antena

somediag

21ndash46

35prim

10multip

gt2years

college

Thurtle

14Semistructured

interview

ndashRe

cruited

antena

self-repo

depressed

17ndash38

husban

dswerein

employmen

tsocioe

psIIIII

rsII-IV

Living

inself-containe

Allprim

iparou

13marrie

livingwith

partne

r1lone

parent

interview

ndashPo

23ndash42

(mean32

)AllAng

loAmerican

1ndash4

Masters

Bachelors

college

17marrie

d3sing

notrepo

Somestud

relatin

interven

tionan

dPSSstrategies

andarethereforeinclud

sections

eseinterven

tionstud

APPENDIX 9

Qualitative studies of universal preventive interventions

First author yearreference number Full reference

Andersson 2012277 Andersson E Christensson K Hildingsson I Parentsrsquo experiences and perceptions of group-basedantenatal care in four clinics in Sweden Midwifery 201228502ndash8

Carolan 2012278 Carolan M Barry M Gamble M Turner K Mascarenas O Experiences of pregnant womenattending a lullaby programme in Limerick Ireland a qualitative study Midwifery 201228321ndash8

Carolan 2012279 Carolan M Barry M Gamble M Turner K Mascarenas O The Limerick Lullaby projectan intervention to relieve prenatal stress Midwifery 201228173ndash80

Doran 2012280 Doran F Hornibrook J Womenrsquos experiences of participation in a pregnancy and postnatal groupincorporating yoga and facilitated group discussion a qualitative evaluation Women Birth20132682ndash6

Evans 2012281 Evans M Donelle L Hume-Loveland L Social support and online postpartum depression discussiongroups a content analysis Patient Educ Couns 201287405ndash10

Gao 2012282 Gao LL Luo SY Chan SWC Interpersonal psychotherapy-oriented program for Chinese pregnantwomen delivery content and personal impact Nurs Health Sci 201214318ndash24

Kennedy 2009283 Kennedy HP Farrell T Paden R Hill S Jolivet R Willetts J et al lsquoI wasnrsquot alonersquo ndash a study of groupprenatal care in the military J Midwifery Womens Health 200954176ndash83

Klima 2009284 Klima C Norr K Vonderheid S Handler A Introduction of CenteringPregnancy in a public healthclinic J Midwifery Womens Health 20095427ndash34

McNeil 2012285 McNeil DA Vekved M Dolan SM Siever J Horn S Tough SC Getting more than they realizedthey needed a qualitative study of womenrsquos experience of group prenatal care BMC PregnancyChildbirth 20121217

Migl 2009286 Migl KS The Lived Experiences of Prenatal Stress and Mindndashbody Exercises Reflections ofPost-Partum Women PhD thesis Texas University of Texas Medical Branch Graduate School ofBiomedical Sciences 2009

Morrell 2002287 Morrell C Postnatal Support Who Wants it What is its Benefit and How Much Does it CostPhD thesis Sheffield University of Sheffield 2002

Scott 1987288 Scott D Maternal and child health nurse role in post-partum depression Aust J Adv Nurs1987528ndash37

Teate 2011289 Teate A Leap N Rising SS Homer CS Womenrsquos experiences of group antenatal care inAustralia ndash the CenteringPregnancy Pilot Study Midwifery 201127138ndash45

Qualitative studies (universal) reporting data fromservice providers

McNeil 2013290 McNeil DA Vekved MF Dolan SM Siever J Siever JF Horn S et al A qualitative study of theexperience of CenteringPregnancy group prenatal care for physicians BMC Pregnancy Childbirth201313(Suppl 1)6

Tanner-Smith 2012291 Tanner-Smith EE Steinka-Fry KT Lipsey MW A Multi-site Evaluation of the Centering Pregnancyreg

Qualitative studies of selective preventive interventions

Lehman 2012292 Lehman E Centering pregnancy A Combined Quantitative and Qualitative Appraisal of WomenrsquosExperiences of Depression and Anxiety During Group Prenatal Care Wheaton IL WheatonCollege 2012

Novick 2012293 Novick G Sadler LS Knafl KA Groce NE Kennedy HP The intersection of everyday life and groupprenatal care for women in two urban clinics J Health Care Poor Underserved 201223589ndash603

Novick 2013295 Novick G Sadler LS Knafl KA Groce NE Kennedy HP In a hard spot providing group prenatalcare in two urban clinics Midwifery 201329690ndash7

Novick 2011363 Novick G Sadler LS Kennedy HP Cohen SS Groce NE Knafl KA Womenrsquos experience of groupprenatal care Qual Health Res 20112197ndash116

Shanok 2007296 Shanok AF Miller L Stepping up to motherhood among inner-city teens Psychol Women Q200731252ndash61

Shanok 2007297 Shanok AF Miller L Depression and treatment with inner city pregnant and parenting teensArch Womens Ment Health 200710199ndash210

Shanok 2007298 Shanok AF Experiences of Pregnancy and Parenting Among Inner City Teens Attending anAlternative Public School PhD thesis New York NY Columbia University 2007

Wheatley 1999253 Wheatley SL Brugha TS lsquoJust because I like it doesnrsquot mean it has to workrsquo personal experiencesof an antenatal psychosocial intervention designed to prevent postnatal depression Int J MentHealth Promot 1999126ndash31

Wheatley 2003254 Wheatley SL Brugha TS Shapiro DA Exploring and enhancing engagement to the psychosocialintervention lsquoPreparing for Parenthoodrsquo Arch Womens Ment Health 20034275ndash85

Qualitative studies of indicated preventive interventions

Dennis 2010299 Dennis CL Postpartum depression peer support maternal perceptions from a randomizedcontrolled trial Int J Nurs Stud 201047560ndash8

Myors 2014300 Myors KA Schmied V Johnson M Cleary M lsquoMy special timersquo Australian womenrsquos experiencesof accessing a specialist perinatal and infant mental health service Health Soc Care Community201422268ndash77

Qualitative studies (indicated) reporting data from serviceproviders

Dennis 2013301 Dennis CL Peer support for postpartum depression volunteersrsquo perceptions recruitment strategiesand training from a randomized controlled trial Health Promot Int 201328187ndash96

APPENDIX 9

Appendix 10 Studies omitted from the networkmeta-analysis

Universalpre

ventiveinte

rventionstudiesomitte

-analysis

Interven

summary

Firstau

andreference

sonnot

included

Totaln

ofparticipan

tsComparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

-based

interven

Nousua

l-care

inChina

EPDSmean

score(Chine

seversion)

Intheem

otiona

lself-man

entgrou

p-training

theEPDSmeanscoreat

6weeks

postna

(SD109

)vs923

(SD291

theCGUsing

Structured

Clinical

Interview

forDSM

-IV(SCID)27

en(3113

en(1010

Unclear

IPT-ba

interven

154 32

7Nousua

l-care

inChina

EPDSscore

(Chine

seversion)

IntheIGtheEPDSmeanscoreat

6weeks

postna

(SD410

)vs887

(SD437

IPT-ba

interven

Nousua

l-care

gEPDSscore

Intention-to-treat

analysisshow

ificantlylower

perceivedstress

andgreater

inessthan

iatelyafterthe

interven

tion(in

nancy)Effectsno

tsustaine

postna

talfollow-up1

parentndashinfant

interaction

53Nousua

l-care

uthAfrica

EPDSmean

At6mon

tally12

werede

pressedaccordingto

redwith

TheEPDSmeanscorewas

(SD454

(SD580

Unclear

Psycho

educationa

linterven

Kozinszky

NoEPDSscore

educationa

linform

Leverton

stionn

Differen

ces6weeks

postpa

prevalen

celsquo(1

27vs17

5χ2plt

scores

(943plusmn216

1012plusmn363

n-Whitney

eplt000

1)forIG

vsCGlikelyrefle

cttheeffect

ofthegrou

pinterven

182 32

9NoEPDSscore

inAustralia

ificant

andsteady

ctionin

scores

(overallan

thesubscales)was

observed

timeforbo

thgrou

psthat

edsign

ificant

improvem

symptom

depression

Nodifferen

ncompa

ringIG

Unclear

APPENDIX 10

Interven

summary

Firstau

andreference

sonnot

included

Totaln

ofparticipan

tsComparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

83Nousua

l-care

inTaiwan

EPDSscore

(Chine

seversion)

Nosign

ificant

differen

ceforIG

at6weeks

(χ2=190

postpa

(χ2=102

Educationon

aringfor

parenting

Feinbe

0NoEPDSscore

intheUSA

ofsevenitems)

Intent-to-treatan

alyses

indicatedsign

ificant

effectson

rental

ortmaterna

pression

distress

inthepa

rentmdash

relatio

andseveralind

icatorsof

infant

Unclear

Educationon

aringfor

parenting

Gjerdinge

NoEPDSscore

intheUSA

Nosign

ificant

pdifferen

postpa

health

orworkou

Educationon

aringfor

parenting

Milgrom

Nousua

l-care

Educationa

linform

BDIEPDS

score13

ormore

IGrepo

ificantlylower

levelsof

depression

(BDI-II)po

st-treatmen

participan

routine

86=782

plt001

enrsquosd=06)

Unclear

Educationon

aringfor

parenting

7NoEPDSscore

38Usual

intheUSA

neralinterven

tionwas

effectivecompa

forwife

dmarita

forwife

depression

emajor

postpa

depression

1yearCG

increasedan

decreased

plt051

Self-he

lpsupp

200 26

8Nousab

leEPDSscore

intheUK

EPDSscore

therewereno

ificant

differen

theEPDSscores

eenthe

dtheCG

Social

Kieffer

Nousua

l-care

Educationa

linform

baselineto

postpa

themeanCES-D

scoreof

theMOMsgrou

creased145

points

morethan

themeanCES-D

scoreof

althou

ghthisdifferen

overallcha

ngescores

notsign

ificant

CIndash326

EPDSscore

(Dutch

version)

IGdidno

tdiffer

inmeanEPDSscores

orchan

EPDSscores

incide

severityof

postpa

Interven

summary

Firstau

andreference

sonnot

included

Totaln

ofparticipan

tsComparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

yLloren

89Usual

intheUSA

BDIEPDS

differen

tweengrou

either

self-ratin

nosticmeasuresof

depression

Unclear

Norethisteron

administered

intram

uscular

Lawrie

Nousua

l-care

uthAfrica

EPDSscore

Meande

pression

scores

ificantlyhigh

IGvsCG

at6weeks

postpa

(meanMADRS

score83vs49

11meanEPDSscore

Midwife

debriefin

selling

childbirth

Priest2

derson

inAustralia

EPDSscore

Nodifferen

iantim

onsetof

depression

(interven

terqua

e4ndash

9]weeks

control4weeksp=084

duratio

depression

(interven

24weeks

vscontrol22

Unclear

unclear

Midwife

riefin

nsellingafter

childbirth

Selkirk

inAustralia

EPDSmean

Nosign

ificant

differen

cesforIG

onmeasuresof

person

alinform

depression

percep

tionof

thebirth

rentingstress

yassessmen

intspo

contactwith

provider

27NoEPDSscore

intheUSA

Nodifferen

cesforIG

ncyroom

utilisatio

received

isations

ematerna

infant

carematerna

xietyor

postpa

depression

forHIV

alcoho

health

Rotheram

Nousua

l-care

uthAfrica

EPDSscore

PIPisamod

elforcoun

triesfacing

ificant

ctions

ingwho

sefamilies

multip

Sixplan

visitorvisits

Christie

Nousua

l-care

Health

visitor

levisit

Interven

tionha

mostou

howeveritwas

associated

anincreased

EPDSscore(after

adjustmen

at8weeks

(beforeaccoun

tingforou

tliers)bu

ths(ndash062

Unclear

massage

Fujita2

28Nousua

l-care

NoEPDSscore

57Usual

inJapa

version

thsafterde

liveryscores

proved

positivelyin

depression

andvigo

IGvsCG

ression

t=ndash257

KeyCGcontrolg

CIconfiden

ceintervalhigh

riskof

biasIGinterven

tiongrou

plowlow

riskof

biasMADRS

ressionRa

tingScale

Profile

dStatesun

clearun

clearriskof

rethereweretw

iestheriskof

isindicatedin

theorde

thestud

iesarecited

APPENDIX 10

Selectivepre

ventiveinte

-analysis

Interven

summary

Firstau

andreference

sonnot

included

Totaln

Comparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

-based

9NoEPDSscore

inAustralia

taltertheprevalen

depression

inthesemothe

-based

Silverstein1

61NoEPDSscore

50Usual

intheUSA

lem-solving

educationap

pearsfeasible

isingstrategy

topreven

pression

gmothe

preterm

infants1

IPT-ba

Phipps

Nousua

l-care

EPDSscore

Educationa

linform

KID-SCID

Interven

tionha

tentialtoredu

ceriskfor

postpa

depression

in[Hispa

dblack]

iparou

olescent

Psycho

educationa

Nousua

l-care

EPDSscore

inChina

CGIGHQ

Educationa

nsellingmay

deleterio

useffect

enrsquosqu

oflifein

thosewho

hadinstrumen

elivery1

Unclear

dsocial

workercall

0Nousua

l-care

Educationa

linform

EPDSscore

Interven

tionredu

sitivede

pression

screen

ongblackan

dLatin

Educationon

aringfor

parenting

Nousua

l-care

EPDSscore

Educationa

linform

efficacyof

paraprofession

al-delivered

Family

Spiritho

me-visitin

ginterven

tionforyoun

gAmerican

Indian

materna

owledg

dinfant

outcom

Unclear

letplus

oLogsdo

NoEPDSscore

intheUSA

Nosign

ificant

differen

cesfoun

scores

6weeks

postpa

Unclear

Interven

summary

Firstau

andreference

sonnot

included

Totaln

Comparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

living

Richter

Rotheram

Nousua

l-care

uthAfrica

forwom

enwith

EPDSscore

IGswas

ificant

differen

NoEPDSscore

intheUK

forinfant

developm

materna

at1year

urWolman

Trotter

Nousua

l-care

uthAfrica

EPDSmean

IGattained

erself-esteem

scores

andlower

postpa

depression

xietyratin

gs6weeks

afterde

livery2

Unclear

gPregn

222 26

2NoEPDSscore

intheUSA

lsquoBun

rsquointerven

tionha

iseforim

proving

psycho

social

outcom

esespe

ciallyforyoun

KeyCGIClinical

lImpression

sGHQGen

Health

stionn

aireHDSR

ressionRa

tingScale

riskof

biasKID-SCIDchildho

odversionof

Structured

Clinical

Interview

forDiagn

andStatistical

isorde

rslowlow

riskof

biasun

clearPD

IPittDep

ressionInventory

Inventoryof

ressiveSymptom

clearriskof

APPENDIX 10

Indicate

ventiveinte

-analysis

Interven

summary

Firstau

andreference

sonnot

included

Totaln

Comparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

-based

interven

67NoEPDSscore

intheUSA

ressionat

postpa

interview

intheinterven

tiongrou

inthecontrol

pp=030

Nosign

ificant

differen

-based

interven

1NoEPDSscore

intheUSA

BDI-II

interven

tionforlow-in

asredu

pressive

symptom

nancybu

ringthepo

Unclear

Nosign

ificant

differen

-based

interven

2NoEPDSscore

90Usual

intheUSA

BDI-II

ointerven

tioncond

swereeq

effectivein

depression

Nosign

ificant

differen

-based

interven

8Nousua

l-care

EPDSscore

inPakistan

Thispsycho

logicalinterventionde

livered

bycommun

ity-based

workers

hasthe

potentialtobe

integrated

health

system

resource-poo

rsettings

ificant

differen

wermen

ttraining

Tiwari17

5Nousua

l-care

gEPDSscore

powermen

tinterven

tionspecially

design

edforChine

effectivein

provingthe

health

status

ofthewom

ificant

differen

IPT-ba

interven

Crockett1

66NoEPDSscore

36Usual

intheUSA

-IVAt3mon

ificant

differen

tweenthetw

degree

pressive

symptom

levelo

rentalstress

Unclear

Nosign

ificant

differen

Interven

summary

Firstau

andreference

sonnot

included

Totaln

Comparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

IPT-ba

interven

Zlotnick

NoEPDSscore

35Usual

intheUSA

IDAfour-session

IPT-oriented

pinterven

successful

inpreven

tingtheoccurren

depression

cially

disadvan

Unclear

ificant

differen

IPT-ba

interven

Zlotnick

NoEPDSscore

99Usual

intheUSA

Thisstud

yprovides

furthe

reviden

ceforthe

efficacyof

abriefinterven

tionto

occurren

depressive

disorder

anciallydisadvan

postpa

Unclear

ificant

differen

Mindfulne

ss-based

interven

Vieten1

21NoEPDSscore

34Usual

intheUSA

PANAS-X

Differen

served

eentreatm

dwait-listcontrolsat

thfollow-upwereno

tstatisticallysign

ificant

Nosign

ificant

differen

parentndashinfant

interaction

Wilson

Nousua

l-care

31Usual

intheUK

EPDSmean

Theresults

estthat

psycho

educationa

linterven

inpreg

nancymay

fitwom

enwith

psycho

social

Nosign

ificant

differen

Psycho

educationa

linterven

6NoEPDSscore

inGerman

Thepsycho

somaticinterven

tionha

dasign

ificant

effect

xietyscores

(pndash000

depression

scoresph

ysical

complaintsan

dcharacteristicsof

livery1

Nosign

ificant

differen

APPENDIX 10

Interven

summary

Firstau

andreference

sonnot

included

Totaln

Comparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

Nousua

l-care

70Usual

inTaiwan

EPDSscore

(Chine

seversion)

ThemeanEPDSscorewas

interven

tiongrou

thecontrol

ificant

differen

194 33

4Nousua

l-care

inMexico

BDI-IISC

IDAvailableda

taareconsistent

ssibility

theincide

depression

theinterven

butdifferen

attrition

interpretatio

finding

sdifficult1

results

Harris

NoEPDSscore

65Usual

intheUK

SCANPSE

depression

fortheNew

friend

ergrou

)forthecontrolg

(x2=400

o-tailedtest)2

Unclear

ificant

differen

EPAplus

Mozurkewich2

14NoEPDSscore

intheUSA

BDIMINI

Nodifferen

tweengrou

BDIscoresor

pression

ointsat

the3tim

aftersupp

EPA-richfishoila

ndDHA-richfishoil

ndidno

tpreven

pressive

symptom

ringpreg

nancyor

postpa

Nosign

ificant

differen

Interven

summary

Firstau

andreference

sonnot

included

Totaln

Comparison

group(s)

ression

outcomes

Mainfindings

rallrisk

ofbias

Nortriptyline

NoEPDSscore

51Usual

intheUSA

(HAM-D)

subjects

nortrip

tyline

preven

tively

exactconfiden

ceinterval

[CI]=009

)suffered

recurren

subjects

placeb

o6(024

exactCI=

)suffered

recurren

ce(Fishe

rexactp=100

Nosign

ificant

differen

Sertraline

NoEPDSscore

25Usual

intheUSA

curren

-weekpreven

tivetreatm

doccurred

infour

oftheeigh

entaking

placeb

o(propo

rtion=007

ndash034

)(p=004

Fisherrsquosexacttest)2

ificant

differen

ncture

depression

29Nousua

l-care

EPDSscore

61Acupu

ncture

non-specific

BDIHDRS

postna

tallythemeanBD

Iscore

theacup

uncturegrou

69(SD77)

Inthe19

theactivecontrolitwas

(SD98)

themassage

pitwas

(SD66)Th

erewas

recontrol

Unclear

Limite

smallsam

KeyCIconfiden

ceintervalHAM-DHam

gScaleforDep

ression

ressionRa

tingScale

riskof

biasIPVIntim

atePartne

rViolence

lowlow

riskof

biasMINIMiniInterna

ropsychiatric

InterviewSC

SCANPresen

tStateExam

ination

unclearun

clearriskof

APPENDIX 10

Appendix 11 Sensitivity analysis of EdinburghPostnatal Depression Scale threshold score data usingvague prior distribution for the between-studystandard deviation

Treatment comparison

vs usual care

vs Calcium

vs DHA

Midwife-managed careMidwifery team careCalciumDHASupport in labour

Midwifery team careCalciumDHASupport in labour

CalciumDHASupport in labour

Support in labour

DHASupport in labour

066 (005 to 920)140 (011 to 1786)

068 (005 to 885)086 (006 to 1070)085 (006 to 1045)

207 (005 to 7844)102 (002 to 4126)129 (003 to 4585)129 (003 to 4294)

050 (001 to 1981)062 (001 to 2250)060 (002 to 2397)

099 (003 to 3878)

127 (003 to 4678)126 (003 to 4659)

OR (95 CrI)

005 018 063 225 800

FIGURE 79 EPDS threshold score for universal preventive interventions at 6 weeks postnatally odds ratios alltreatment comparisons

vs usual care

vs calcium

vs booklet on PND

Calcium

Booklet on PND

Exercise

Booklet on PND

Exercise

033 (002 to 461)

031 (002 to 528)

129 (009 to 1549)

073 (006 to 1019)

095 (002 to 4912)

394 (009 to 15301)

222 (006 to 9744)

402 (009 to 17811)

240 (005 to 11213)

057 (002 to 2320)

OR (95 CrI)

005 022 100 447 2000

FIGURE 80 EPDS threshold score for universal preventive interventions at 3 months postnatally odds ratios alltreatment comparisons

APPENDIX 11

vs usual care

vs DHA

083 (007 to 937)

067 (006 to 779)

069 (006 to 783)

090 (007 to 1066)

106 (009 to 1146)

082 (003 to 2494)

082 (003 to 2313)

108 (003 to 3165)

129 (004 to 3817)

103 (009 to 1196)

136 (004 to 4302)

158 (005 to 4751)

133 (004 to 4237)

155 (005 to 4749)

116 (004 to 4190)

OR (95 CrI)

005 018 063 225 800

057 (005 to 673)

059 (005 to 749)

060 (005 to 682)

103 (003 to 3507)

106 (003 to 3519)

102 (008 to 1246)

vs usual care

OR (95 CrI)

005 018 063 225 800

vs usual care

vs thyroxine

Thyroxine

091 (006 to 1307)

127 (009 to 1716)

046 (003 to 631)

139 (003 to 6219)

051 (001 to 2555)

037 (001 to 1470)

OR (95 CrI)

008 025 078 240 739

FIGURE 83 EPDS threshold score for selective preventive interventions at 6 weeks postnatally odds ratios alltreatment comparisons

APPENDIX 11

vs usual care

vs thyroxine

Midwife-led debriefing or counselling afterchildbirth

Thyroxine

016 (001 to 264)

142 (012 to 1621)

079 (006 to 1039)

847 (020 to 31952)

491 (010 to 21670)

056 (002 to 2019)

OR (95 CrI)

008 032 128 508 2009

FIGURE 84 EPDS threshold score for selective preventive interventions at 3 months postnatally odds ratios alltreatment comparisons

vs usual care

Thyroxine

123 (010 to 1438)

094 (007 to 1141)

076 (002 to 2557)

OR (95 CrI)

005 018 063 225 800

vs usual care

021 (001 to 283)

068 (005 to 1020)

320 (008 to 16000)

OR (95 CrI)

005 018 063 225 800

FIGURE 86 EPDS threshold score for indicated preventive interventions at 6 weeks postnatally odds ratios alltreatment comparisons

vs usual care

vs peer support

Peer support

047 (004 to 591)

068 (004 to 885)

144 (003 to 5768)

OR (95 CrI)

005 018 063 225 800

FIGURE 87 EPDS threshold score for indicated preventive interventions at 3 months postnatally odds ratios alltreatment comparisons

APPENDIX 11

vs usual care

Booklet on PND

066 (005 to 819)

080 (007 to 975)

121 (004 to 4078)

OR (95 CrI)

005 018 063 225 800

vs usual care

058 (004 to 703)

065 (005 to 888)

112 (009 to 1518)

176 (012 to 2421)

305 (007 to 10613)

267 (006 to 10050)

OR (95 CrI)

005 018 063 225 800

Appendix 12 Similarities and differences betweengroup- and individual-based approaches

FIGURE90

ryofch

angelogic

forthepreve

ntionofPN

APPENDIX 12

Appendix 13 Findings relating to a potentialserviceintervention

Meta-theme Subtheme(s)

Evidence source(s)(CASP) Evidence fromstudies with generalpopulation participants

Evidencesource(s)(CASP)

Certainty inthe evidence(CERQual)

Explanation ofcertainty in theevidence assessment

Synthesised finding ndash things that would have been needed to help prevent feelings of depression are [retrospective]

Support Support of midwiveswas reported asimportant Participantsfelt they needed to bein hospital314

ndash Moderate Moderatecertainty

Studies of generallyhigh quality findingseen across a smallnumber of studies andin only culturallydifferent and selectivegroupsDeprived women

reported that theyneeded peer supportand to shareexperiences315

ndash High

Health-caretreatment

Mono-ethnic lsquoculturallysensitiversquo interventionsare favoured less thancare and support inmixed ethnic groups311

ndash High Moderatecertainty

Studies of high tomoderate qualityfinding seen acrossseveral studies acrossgeneral populationsand across culturallydifferent and selectivegroups

Peer supportgroups315323 and havingsomewhere to go(for treatment)315

ndash ndash

Counselling306ndash310 andalternative medicinesuch as massage315

ndash High

The prescription ofmedication by the GP314

ndash Moderate

a community-basedmultiagency women-centred approach ndash twostudies of culturallydifferent womenrecommended a serviceto be a community-based multiagencywomen-centredapproach and toaddress the fullspectrum of need311

ndash High

More open discussion ofrealities of newmotherhood specificallyin relation tobreastfeeding323

High ndash

Practical skillsand experience

Knowledge of how tobreastfeed and how tobath a baby305321

Highmoderate ndash Low certainty Finding seen in onlytwo general populationstudies of high tomoderate quality

Barriers to help-seeking

Negativeperceptions ofhelp seeking

Perceptions of notcopingpressure to beseen as a good motherndash fear of beingperceived as not able tocope315319 and thus notbeing seen as a goodmother315324

Highmoderate Moderate Moderatecertainty

Stigmafear of childrenbeing removed ndash

women also worriedabout the stigmaattached to helpseeking303315325 and insome cases a fear oftheir children beingremoved if they soughthelp303 Women wereworried about beinglabelled as having amental illness and theeffect this may have306ndash310

Moderate Moderate ndash ndash

Cultural bias towards theunacceptability of helpseeking for mental illnessfor black Caribbeanwomen306ndash310

ndash thesewomen felt they werelsquonot allowed to getdepressedrsquo and thatdepression was notrecognised in theirculture306ndash310

ndash High ndash ndash

Barriers togainingsupport

Womanrsquos withdrawalfrom relationship withtheir partner andinability to share theirfeelings with theirpartner as a result ofemotional distress324325

Participants felt unableto access partnersupport

Highmoderate ndash Low certainty Studies of high tomoderate qualityfinding seen in only afew studies acrossgeneral populationsand across culturallydifferent groups

Cultural beliefs ndashrespondents wereadvised to performcertain rituals (egwearing particular itemsof jewellery or clothing)to ensure protectionfrom harm duringpregnancy and thepostnatal period304 Astudy304 reported abelief in the existence ofJinn (evil spirits)

ndash Moderate ndash ndash

APPENDIX 13

Authors commentedthat ailments given towomen as a result ofbeing possessed by theJinn wereindistinguishable fromsymptoms of PNDCultural beliefs maycreate a barrier toseeking help frommainstream routes

Barriers toapproachinghealth-careprofessionals

Not understanding thehealth visitorrsquos role(to address mothersrsquomental health)notunderstanding the GPrsquosrole ndash respondentsreported not feelingthat the mothersrsquomental health was therole of the health visitoror the GP and thereforethey did not addressany symptoms ofemotional distressin their interactionswith these healthprofessionals304311314

ndash Moderatehigh

Moderatecertainty

Health visitor notappropriate person todiscuss withpoorrelationship with GPdidnot want to discuss withGP ndash in one studywomen reported thatthey did not considerthe health visitor or GPan appropriate personwith whom to discussmental health issues314

Some women felt theyhad a poor relationshipwith the GP314

ndash Moderate

Health professionalsrsquolack of awarenessuncaring hospitalmidwiveshealth-careproviders perceived astoo busy ndash women feltthat they were aburden Healthprofessionalsparticularly hospitalmidwives wereconsidered to have alack of awarenessaround emotionaldistress they wereperceived as uncaringand too busy makingwomen feel like theywere a burden306ndash311315

High Moderate

Respondents reportednot knowing how to gethelp305

Moderate ndash

Health professionalfocus on the baby ndashhealth visitor focuson baby was a barrierto seeking helpfor emotionaldifficulties315321 Womenreported care giverswere concerned onlywith the well-being ofthe fetus and neverasked about them315

High Moderate ndash ndash

Practicalbarriers toseeking healthcare

Long waiting times ndash High Low certainty Studies of high tomoderate qualityfinding seen in onlytwo studies acrossculturally different andselective groups

Lack of black therapistsfor black women

Lack of child-carefacilities306ndash310

Inappropriate (male)interpreter ndash for someminority group womena language barrierpresenteddifficulties314318 Womenreported that they wereunable to understandthe midwives or gainaccess to theinformation theyneeded

ndash Moderate

APPENDIX 13

Appendix 14 CLUSTERs receiving detailedexamination

Sibling papers and kinship studies for CLUSTERs examined indetail

Sibling papers Kinship studies Reviews and syntheses

Definition papers conducted bysame authorial team or describingsame phenomenon of interest

Definition studies that relate to originalphenomenon of interest across one ortwo variables eg use of theorysetting of intervention maincomponents et cetera

Secondary studies sharing topic ordrawing on primary study data fromindex paper

CenteringPregnancy

l [I] Ickovics262

l Baldwin426

l [S] Baldwin427

l Novick294

l [W] Herrman368

l Ickovics222

l [S] Tanner Smith291

l [W] Novick293

l [W] Novick363

l Rising44

l [W] Novick382

l Shakespear428

l [W] Kennedy283

l Shakespear429

l [W] McNeil285

l Xaverius430

l [W] Gaudion431

l [W] Gaudion42

l [W] Gaudion43

l [S] Teate432

l Robertson433

l Sheeder434

l Morrell151

l [W] Slade435

l Morrell61

l Morrell436

l Brugha152

l Morrell326

ndash ndash

l [I] Armstrong164

l [I] Armstrong251

l [I] Fraser252

ndash ndash

l [I] Zlotnick179

l Zlotnick163

l Crockett166

ndash ndash

l [I] Gao154

l [W] Gao282

l [I] Gao327

l [W] Gao437

l [W] Ngai and Chan438

l Phipps160

l Zlotnick178

l Rahman8

l Chowdhary389

IPTndash brief

l [I] Grote170

l [W] Grote439

l Grote440

l Grote441

l Grote442

l Grote443

ndash l Dennis444

l [I]Gamble221 l [W] Fenwick445

l Fenwick446

l Gamble447

l Reed448

l Turkstra449

l [I] Shields219

l [WE] Young339

l [I] Shields337

l [W] Turnbull450

l Turnbull338

l [W] Shields451

l [E] Young452

ndash ndash

The Newpin Project

l Harris206

l [W] Ferguson453

l Harris387

l [W] Beynon340

l Lederer454

l [W] Barlow455

ndash ndash

l Bick456

l [S] Morrow457

l Macarthur146

l [W] Macarthur458

l Glavin459

l Macarthur264

ndash l [QS] Furuta460

l [NR] Bick461

l Dennis386

l [W] Dennis299

l [E] Dukhovny396

l [S] Dennis301

l Dennis205

ndash l [QS] Dennis and Chung-Lee366

l [SR] Dennis and Kingston236

l [SR] Dennis and Dowswell417

l [SR] Lavender462

l Rahman148

l [W] Rahman463

l Simon464

l [W] Rahman465

ndash l Rahman8

l Howell190

l [W S] Martin466

l Howell335

l [W] Negron467

l Martin336

ndash ndash

Key E Economic Study I Included trial NR Narrative Review QS Qualitative Synthesis S Service Providersrsquo viewsSR Systematic Review W Womenrsquos views

APPENDIX 14

Appendix 15 Examples of lsquoifndashthenrsquo propositionsused to refine lsquobest fitrsquo analytic framework

Illustration of lsquoifndashthenrsquo statements to refine lsquobest fitrsquoanalytic framework

Category number If Then Source reference

Population First-time mothers attend groupcare

First-time mothers receive helpfulinformation especially to helpprepare for labour

McNeil et al285

First-time mothers attend groupcare

First-time mothers know what toexpect

McNeil et al285

Facilitation Women feel group leadersextend themselves above andbeyond the usual norms of careto help them navigate throughcomplex even daunting healthsystems

Women perceive the programmeas successful

Novick et al293

Providers ensure a favourablegroup setting and atmosphere

Women realise it is a safe placeto ask questions and share

McNeil et al285

Group size Group size falls within range of8 to 12 women

Group size is efficient for systemand effective to promote theprocess

Rising44

Group size is kept small Women enjoy the group sessions Dennis301

Components Women gain exposure todifferent pregnancy experiencesand advice derived from diverseperspectives

Women value the group sessions Novick et al293

Group leaders spend extendedtime for discussion in afacilitative format

Group leaders gain a differentperspective on womenrsquos livesthan they would get fromconducting individual visits

Novick et al293

Frequency Group meetings take placeweekly

Women look forward to theopportunity to meet with thoseof like mind

Hanley and Long390

Home visits are more intensive(eg longer and more frequent)

Women find intervention morebeneficial

Morrell287

Duration Women attend 2-hour groupappointments (compared with15-minute individual sessions)

Women have more time to learnabout pregnancy-related topicsand become lsquoactive participantsin their own health carersquo

Novick et al293

Women are offered inflexiblyscheduled 2-hour groupappointments

Women do not attend becauseof limited control overtransportation or their dailyschedule

Novick et al293

Follow-up Women are offeredarrangements for individualisedfollow-up

Women have opportunity todiscuss medical or personalissues requiring more time orprivacy

Novick468

Peer support

Appraisal support Women are provided withinformation and appraisal fromtheir peers

Women assimilate knowledgemore effectively

Dennis299

Informationalsupport

Women receive informationalsupport about PND within6 weeks after birth

Women experience PND that isless severe

Fu and Heh469

Peer supporters are recruited forextroversion and communicationcharacteristics

Women perceive that they talktoo much

Dennis299

Emotional support Women discover that they arenot alone in their experiences

Women are lsquodelighted and oftensurprisedrsquo

Kennedy et al283

Women raise concerns or sharefrightening stories

Womenrsquos anxieties areheightened not decreased

Novick et al293

Instrumental support No data No data No data

Team composition No data No data No data

Other contacts Antenatal support groups areoffered separate from antenatalclasses

Women do not attend Stamp et al195

Womenrsquoscharacteristics

No data No data No data

Built environment Women have comfortable chairsfood and pleasant deacutecor

Women gain a sense ofattending a friendly socialgathering

Novick et al293

Dimensions of the group spacepermit pregnant women tomove around comfortably andan area rug is provided for floorexercises

Women enjoy relaxed pleasantatmosphere that promotesinteraction and development ofrelationships among women

Novick et al293

Social support Women only receive help if theyhave to ask for it

Women suffer PND Brugha et al152

Women have someone to talkopenly with who has shared asimilar problem

Women do not suffer PND Brugha et al152

Women lack an intimateconfidant or friend to conversewith

Women feel socially isolated Women suffer PND Mills et al470

APPENDIX 15

Partner support

Appraisal support No data No data No data

Emotional support Women do not receive supportfrom their partners

Women suffer PND Mason et al471

Family support Women have little or no familysupport

Women perceive themselves asbeing under stress

Novick et al293

Instrumental support Women have someone to offerpractical help

Women are able to get morerest

Ugarriza et al320

Women feel able to ask for help Others are likely to providepractical support

Knaak472 Ugarizzaet al320

Women ask for help Others perceive that they are notable to handle things on theirown

Knaak472

Support from healthprofessional

Women experience continuity ofcare from the health professional

Women develop a relationshipwith their care provider and trustthem with sensitive issues

Novick et al293

Physicians and educators provideinformation that lsquoyou canrsquot getfrom booksrsquo

Women feel supported McNeil et al285

Emotional support No data No data No data

Instrumental support Women are given practicaldemonstrations of how to baththe baby change a nappy andput the baby to sleep

Women experience reduction intheir perceived stressors

Razurel et al316

Adherence Women are members of groupswith short duration highturnover or irregular attendance

Groups are less stable andcohesive and thus lesstherapeutic

Novick et al293

Physical signs andsymptoms (wasbiophysical markers)

Women experience highexpectations on what they needto purchase for the imminentbaby

Women may feel overwhelmedto the point of tears

Migl286

Women learn practical strategiesduring the group intervention

These strategies prevent panicattacks combat physicalsymptoms of stress and couldbe combined with existingstrategies

Carolan et al278279

Migl286

Women perceive that depressivesymptoms are associated withstigma

Women complain about physicalsymptoms such as headachesand tiredness

Rodrigues et al325

Women hear other womendescribing and comparingsymptoms

Women feel reassured that theirown experience is normal

Teate et al432

Self-efficacy

Self-efficacy Women experience discomfort atthe level of responsibilityrequired for self-care

Women do not engage withgroup care programme

McNeil et al285

Women experience a loss ofcontrol as a result of the feelingsengendered by pregnancy

Women feel powerless over theirphysical responses emotionsand interactions

Mason et al473

Women feel able to develop aconscious resistance to dominantcultural norms about goodmothering

Women develop lsquorealisticrsquo corebeliefs and expectations

Knaak472

Womenrsquosparticipation

Women feel that that selectionfor the intervention is basedupon being at increasedvulnerability to PND

Women do not participate inprogramme

Wheatley254

Women find it difficult to accessgroup interventions because oftransport constraints

Wheatley254

Prevention of PND(was long-termsymptommanagement)

Women learn practical strategiesat the group intervention

Women find it difficult toallocate time to use the practicalstrategies learned

Migl286

Women report that they forgetto implement the strategies

Migl286

Women report that they do notuse the strategies because ofperceptions of stigma

Migl286

Psychological status(was functional status)

Women do not feel that themental health of the mother isthe role of the health visitor orthe GP

Women do not discuss theirsymptoms of emotional distressin their interactions with thesehealth professionals

Parvin et al314

Black Caribbean women have adeep-seated fear of mentalhealth services

Women are reluctant to seekhelp

Edge et al308

Quality of life No data No data No data

Unplanned utilisation ofhealth services (wasemergency departmentvisits rehospitalisationsand unplanned officevisits)

Suicide ideation (wasmortality)

Women isolate themselves fromfriends family and providers

Women entertain thoughts ofsuicide

Beck381

Women put their childrsquos needsabove their own and want toprotect their infant

Women resist temptation toattempt suicide

Beck381

Costs Classes are run by suitablyqualified and experienced staff

Costs may be prohibitive Saligheh474

APPENDIX 15

Confidentiality Examinations are conducted in amanner that affords womenprivacy

Women are more likely to feelcomfortable about participation

Novick et al293

Examination space is locatedaway from other activities usingvisual barriers (eg screens orlarge plants) and playingrecorded music to create soundprivacy

Women feel less anxious aboutparticipation

Novick et al293

Participation (non-) First sessions get off to a slowstart with reluctance to talk

Women feel sessions are wasteof time

McNeil et al285

Missed appointments Women do not attend regularly Other women expressdisapproval and perceive a lackof commitment

Novick et al293

Appendix 16 TIDieR checklists forfocal interventions

TIDier checklist for Health Visitor PoNDER training

Psychological

Brief name

1 Health Visitor PoNDER Training61151

2 Person-centred counselling is based on idea that opportunities to explore difficulties with another who listensnon-judgementally and reflects empathically allows a person to feel validated as a person and facilitates their abilities tomanage their distress and find their own solutions Cognitive Behavioural Counselling assumes that events thoughts andfeelings are linked in a predictable way and that by understanding these patterns particularly where patterns of thinkinglead to distress there is the opportunity to make active change and test out new ways of thinking and behaving

3 Materials manualised HV training addressed therapy allegiance and prepared HVs to provide appropriate pragmaticdistinctive derivative approach delivering critical elements from CBT or person-centred therapy not psychotherapy

4 Procedures both training approaches sought to enable HVs to acquire further generic skills in developing helpfulrelationships for example positive regard and empathy CBT-based intervention training emphasised normalisingrationale and identification of unhelpful patterns of behaviours perceptions or thoughts in the womanrsquos life tohelp woman to change these herself347

Person-centred training used three principles of the actualising tendency a non-directive attitude and the necessaryand sufficient conditions of change348 Details of the HV training are provided in the section on training of theintervention group HVs

Who provided

5 Two main psychotherapist trainers were specialists with experience in practice as trainers and supervisors Theyprepared a manual for each HV and a separate trainerrsquos manual Manuals included theoretical basis for relevantpsychological approach and training plan so that if necessary training could be replicated

6 Face-to-face training

7 No details

When and how much

8 No details

Tailoring

9 No details

Modifications

10 No details

How well

11 Planned to enhance rigour and effectiveness of training for both psychotherapeutic approaches to maximisecomparability of programmes and to ensure that trial was a credible and fair test a training reference group wasestablished before the trial This comprised experienced academically based psychotherapy trainers from England andScotland including representatives of both CBAs and PCAs

12 Actual no details

Psychological

Brief name

1 IPT-brief

2 Multicomponent model of care derived from IPT440 It retains essential theory targets and techniques of IPT by helpingwomen resolve one of four interpersonal problem areas (role transition role dispute grief and interpersonal deficits)related to the onset or maintenance of a depressive episode It differs from IPT in several ways eg to reducetreatment burden and activate change in (participant) format is restructured into eight rather than 16 sessions afocus on the long-term problem area of interpersonal deficits is avoided and between-session behavioural activationstrategies with interpersonal focus are encouraged

3 Materials participants given written educational materials about depression

4 Procedures participants informed of their diagnoses given written educational materials and referred for treatmentInterviewer approaches (participant) in culturally sensitive manner consistent with principles of ethnographicinterviewing the interviewer adopts a one-down position as a learner tries to understand cultural perspectives andvalues of woman without bias inquires about the womanrsquos view of depression health-related beliefs and copingpractices (eg the importance of spirituality or familismo in her life) and asks what woman would like in a therapistincluding the importance of race-ethnicity

Who provided

5 One doctoral-level clinician and one master-level clinician both of whom had supervised training and experience inenhanced IPT-brief served as therapists followed detailed treatment manuals and received weekly supervision by anexpert

6 Delivered face to face when participants could not attend treatment session conducted on phone to maintaincontinuity

7 Engagement and IPT-brief sessions delivered in an office in the large obstetrics and gynaecology clinic to maketreatment more accessible and less stigmatising Therapistrsquos office displayed culturally relevant pictures of racially andethnically diverse infants

When and how much

8 Consists of engagement session followed by eight acute IPT-brief sessions before the birth and maintenance IPT upto 6 months postpartum475 Engagement session described elsewhere439476 is based on principles of motivationalinterviewing and ethnographic interviewing and is designed to promote engagement by building trust and addressingthe practical psychological and cultural barriers to care experienced by individuals who are socioeconomicallydisadvantaged Biweekly or monthly maintenance IPT sessions help participants deal effectively with social andinterpersonal stressors associated with remission475 As goal of maintenance is to maintain recovery the woman isencouraged to be watchful for the appearance of early somatic affective or cognitive symptoms related to priordepressive episodes and to practice skills learned in IPT-brief to prevent relapse Maintenance IPT differs from IPT-briefin that a woman can focus on more than one interpersonal problem area while in remission

Tailoring

9 During engagement interviewer elicits each (participant)rsquos unique barriers to care and engages in collaborativeproblem-solving to ameliorate each barrier for example if (participant) doubts relevance of treatment (eg specificallywhether enhanced IPT-brief could reduce depression triggered by losing her job) ndash interviewer would inform her thatIPT-brief can assist her in finding a new job or job training as well as help her manage the interpersonal difficultiesresulting from the job loss

APPENDIX 16

Psychological

Modifications

10 Augmented with modifications to make it culturally relevant to socioeconomically disadvantaged women440

Enhanced IPT-brief reflected seven of eight components from culturally centred framework of Bernal andSaez-Santiago477 persons metaphors concepts content goals methods and contexts (eg addressed component ofpersons by employing therapists trained in cultural competence with considerable experience working with personsof racial-ethnic minority groups who were living in poverty)477 Components of metaphors and stories from theparticipantsrsquo cultural background were used to reinforce treatment goals To address concepts therapists providededucation about depression congruent with (participant)rsquos culture and used the word lsquostressedrsquo instead of the wordlsquodepressedrsquo if (participant) desired to minimise perceived stigma of depression Content addressed by exploringwhich coping mechanisms and cultural resources such as spirituality or familismo had helped participants throughadversity in the past and by building on these resources during treatment Therapists helped clients develop treatmentgoals personally and culturally relevant to them Methods addressed by intensive outreach and shortening treatmentto reduce (participant) burden Contexts addressed by pragmatic additions such as free bus passes child care and thefacilitation of access to needed social services (ie food job training housing and free baby supplies)

How well

11 Planned no details reported

12 Actual engagement and IPT-brief sessions were audiotaped and 77 were reviewed for fidelity to the model

TIDieR checklist for Thinking Healthy Programme

Psychological interventions

Brief name

1 Thinking Healthy Programme148463465

2 Intervention CBT-based intervention especially for developing countries such as Pakistan Intervention targets motherswho have many psychosocial stresses and may be depressed However it can be used as a motivation tool for allmothers living in socioeconomically deprived areas with low literacy rates It focuses on health of both mother andbaby and encourages participation of the whole family Approach used is simple and pictorial but retains the essentialcharacteristics of CBT

3 Materials training manual in English andor Urdu478 Activity workbooks Each of five modules had specially designedpictorial activity workbook used by trainer to conduct a session with the mother Each mother had her own activityworkbook where activities carried out in each session were noted Calendar consists of pictorial and verbal keymessages of each session and serves as a visual cue for whole family to follow programme between sessions Inaddition calendar has monitoring tools to help the mother chart her own progress and that of infant throughoutthe programme

4 Procedures Thinking Healthy has five modules covering period from third pregnancy trimester to first year of infantrsquoslife preparing for the baby the babyrsquos arrival and early mid and late infancy Each module contains sessions on themotherrsquos health her relationship with her baby and the relationships with people around her

Who provided

5 Designed for delivery by supervised female health workers following brief 2-day training strengthened byexperiential learning and monthly half-day facilitated group supervision

6 Face-to-face delivery to individual mothers

7 Delivered in home visits

When and how much

8 Sixteen-session programme targeted at women with depression and their families beginning around 30 weeksrsquogestation and continuing to 10 months postpartum

Tailoring

9 No details although has been adapted to Vietnam

Modifications

10 No details

How well

11 Planned no details

APPENDIX 16

TIDieR checklist for home-based intervention

Brief name

1 Home-based intervention164251252

2 The focus of the programme was to (1) establish relationship of trust with infantrsquos family (2) enhance parentingesteem and confidence through reinforcement of success (3) provide anticipatory guidance for normal childdevelopment (4) promote preventive child care and (5) facilitate access to appropriate community services

3 Materials no details given

4 Procedures structured programme of child health nurse visits Weekly case conference

Who provided

5 Child health-care nurses social worker and community paediatrician (for case conferences only)

6 Face to face provided to individuals

7 In womanrsquos home

When and how much

8 Weekly for first 6 weeks fortnightly until 3 months then monthly until 6 months postpartum

Tailoring

9 No details

Modifications

10 No details

How well

TIDieR checklist for IPT standard antenatal care plus theROSE programme

Brief name

1 IPT standard antenatal care plus the ROSE programme179

2 Intervention based on IPT treatment for depression targeting factors (eg poor social support role transition and lifestressors) that may play a crucial role in onset of PND ROSE programme designed to help mothers-to-be in anethnically diverse population to improve their close interpersonal relationships and change their expectations aboutthem build and use their social support networks and master their role transition to motherhood The emphasis wason social relationships especially relevant for low-income women who have recently delivered research suggests thatsocial support can limit the negative effects of chronic stress479 and that social support is inversely associated withperinatal symptoms of depression480

3 Materials handouts based on the material presented in each session were given as well as session-related homeworkassignments Therapists were nurses who had received intensive training and supervision in delivery of theintervention

4 Procedures the intervention Survival Skills for New Moms involved four sessions (1) rationale for the programmeand psychoeducation on lsquobaby bluesrsquo and postpartum depression (2) identifying role transitions changes associatedwith role transitions and goals for successfully managing role transitions with emphasis on transition to motherhood(3) setting goals developing supports and identifying potential interpersonal conflicts especially once the baby wasborn and (4) skills for resolving interpersonal conflicts and review of main themes of intervention178 Booster sessionaims to reinforce skills learned in the group sessions and to address current or expected mood changes associatedwith interpersonal difficulties on arrival of the newborn infant ROSE programme

Who provided

5 Nurses who had received lsquointensive training and supervisionrsquo

6 Face to face delivered to group

7 Not specified

When and how much

8 Four 60-minute group sessions (3ndash5 womengroup) over 4-week period and 50-minute individual booster sessionafter delivery

Tailoring

9 Not specified

Modifications

10 Not specified

How well

APPENDIX 16

TIDieR checklist for IPT plus telephone follow-up

Brief name

1 IPT plus telephone follow-up154327

2 IPT specifically targets interpersonal relationships and is designed to assist clients in modifying either theirrelationships or their expectations about those relationships IPT could help new mothers in three areas

l role transitions ndash situations in which clients have to adapt to change in life circumstancesl interpersonal disputes ndash occur in marital family social or work settings Clients may have diverging expectations

of a situation Conflict is excessive enough to lead to significant distressl interpersonal deficits ndash situations when clients report impoverished interpersonal relationships in term of both

number and quality of the relationships

3 Materials written material for programme provided to participants in each session

4 Procedures intervention targeted specific concerns and interpersonal problem areas (role transitions and interpersonalconflicts) experienced by women during the postpartum period Two 2-hour group sessions and one telephonefollow-up in postpartum period

Each programme consisted of no more than 10 participants Specific IPT techniques such as information givingclarification communication analysis role-playing and brainstorming were applied throughout the programmeDuring session participants are encouraged to express emotions attached to each of their new roles in motherhoodand to explore any ambivalent feelings Through role-play and discussion participants could develop a more balancedview of each role and to modify their expectations and restructure their priorities Participants were encouraged toshare and role-play their experiences Group could learn from analysing ways of communication through therole-play Brainstorming session could enable participants to consider different ways to cope with difficulties that theywould encounter after delivery

Telephone follow-up provided within 2 weeks after delivery Aims of follow-up were to reinforce skills learned insessions to deal with any current or expected mood changes or interpersonal issues during the postpartum periodA brief outline of IPT-oriented childbirth psychoeducation programme is provided154

Who provided

5 Group sessions run by midwife educator who had received intensive training and supervision in delivery of IPTintervention Telephone follow-up provided by same midwife educator

6 Two group sessions telephone follow-up provided individually

7 Group sessions arranged to follow routine childbirth education sessions to encourage attendance

When and how much

8 Two group sessions and telephone follow-up within 2 weeks of birth

Tailoring

9 No details

Modifications

10 No details

How well

11 Planned five experts in postpartum depression and childbirth education confirmed the validity of the intervention

TIDieR checklist for two-step behavioural educationalintervention

Education

Brief name

1 Two-step behavioural educational intervention190337388

2 Based on prior research suggesting that situational factors (ie postpartum physical symptoms overload from dailydemands and poor social support) play a major role in generation of depressive symptoms the team created abehavioural educational intervention aimed at reducing frequency of depressive symptoms in postpartum mothers bypreparing women about specific situational triggers of depressive symptoms bolstering their personal and socialresources suggesting specific actions to enhance self-management skills and buffer postpartum demands Content ofintervention based on prior studies focus groups with postpartum mothers obstetricians psychiatrists social workersand community advisory board

3 Materials pamphlet represented each potential trigger of depressive symptoms as a lsquonormalrsquo aspect of thepostpartum experience and provided specific suggestions for management (eg prevalence of moderate or heavyvaginal bleeding immediately postpartum was depicted by 8 of 10 female silhouettes coloured red whereas only 1 ofthe 10 silhouettes was red 3 months post delivery) Simple lsquoto dorsquo statements (rest use pads) were listed between thetwo rows of figures Postpartum and 3-month rates and intermediate lsquoto dorsquo lists also were provided A separatepage was dedicated to social support and lsquohelpful organisationsrsquo A partner summary sheet spelled out the typicalpattern of experience for mothers postpartum that is to lsquonormalisersquo the feelings and behaviours experienced andenacted by most mothers postpartum and stress the importance of social support for the woman Content pictureswording and length were revised after input from two focus groups and a community advisory board Materials weretranslated to Spanish and back and were translated for accuracy and consistency of meaning

4 Procedures 15-minute in-hospital review of an education pamphlet and partner summary sheet by the mother withsocial worker Social worker reviewed the education pamphlet and partner summary sheet with the woman duringpostpartum hospital stay and answered questions Two-week post-delivery call when social worker assessed womanrsquossymptoms skills in symptom management and other needs lsquoTo dorsquo lists to help alleviate symptoms were reviewed asneeded and woman and social worker created action plans to address current needs including accessing communityresources

Who provided

5 1 and 2 masterrsquos-trained bilingual social worker

6 1 face-to-face individual interaction 2 individual telephone call

7 1 in hospital 2 in womanrsquos home

When and how much

8 1 15-minute session 2 telephone call ndash duration unspecified

Tailoring

9 In the telephone call the social worker assessed the womanrsquos symptoms skills in symptom management and otherneeds

Modifications

10 Not described

How well

11 Planned fidelity of intervention maintained by repeated training and review of scripts for both in person in-hospitaland telephone components of intervention

12 Actual approximately 5 of in-hospital sessions and 2-week telephone needs assessments were observed by aphysician or project manager on the team

APPENDIX 16

TIDieR checklist for telephone peer support

Social support

Brief name

1 Telephone peer support

2 Three theoretical mechanisms for behaviour change underpin peer support interventions

l impact through lsquodirect effectrsquo peer support directly influences outcomes for example by enabling socialintegration access to information or through provision of informal health care

l impact via a lsquobuffering effectrsquo peer support protects individuals from potentially harmful influences or stressorsl impact occurs as a result of a lsquomediating effectrsquo peer support indirectly influences health outcomes by changing

emotions thoughts and behaviours

3 Materials a Mothers Helping Mothers with Postpartum Depression manual was developed pilot-tested and distributedto trainees205 A take-home 121 page training manual developed and piloted by the principal investigator386 wasdistributed to new peer volunteers to guide the training session and intervention Manual outlined professional servicesavailable for referral and covered (1) introduction to peer support (2) potential benefits of peer support (3) relationshipdevelopment (4) techniques for effective telephone support (5) general postpartum depression information and (6) thehelping process All peer volunteers participated in a 4-hour training session Role-playing and strategising wereimportant components of the training session Focus of training was to develop skills required for effective telephone-basedsupport and to make referrals to health professionals as necessary Peer volunteers provided with clear guidelinesregarding thoughts of self-harm indicating when to refer mothers to professional health services or crisis careTraining workshop provided opportunity to select applicants best suited for peer support with postpartum mothers

4 Procedures

l Peer volunteer recruitment and training ndash recruited through distribution of flyers advertisements in the localnewspapers and word of mouth Selection criteria were ability to speak and understand English and self-reportedhistory of and recovery from PND It employed a paid peer volunteer co-ordinator to organise recruitment of peervolunteers and obtain informed consent conduct training sessions for peer volunteers match women withappropriate peer volunteer and monitor implementation of the intervention

l Contact ndash telephone contact to be initiated in the 48ndash72 hours after randomisation Peer volunteers wererequested to make a minimum of four contacts and then to interact as deemed necessary

Who provided

5 Those whose communication skills were deemed inadequate who demonstrated difficulties participating indiscussions about postpartum depression or who showed evidence of unresolved depression were excluded from thepeer support programme Of those attending training approximately 86 were accepted as peer volunteers andwere matched with at least one new mother in the trial based on residency and ethnicity if the mother desired

6 By telephone having been matched individually by a volunteer co-ordinator

7 Based in womanrsquos own home

When and how much

8 Each peer volunteer who actively participated in the trial and was matched with a (participant) on average supportedtwo women with a range from one to seven

Tailoring

9 Only according to ethnicity

Modifications

10 No details

How well

11 Planned during training sessions peer volunteers were given activity logs to complete for each supported mother Todocument initiation of the intervention the volunteer co-ordinator interacted with the peer volunteer 1 week aftermatching to confirm that contact was made with the (participant) All peer volunteers were requested to complete anactivity log386 for each woman supported to document specific intervention activities and duration to 12 weeks postpartum

TIDieR checklist for The Newpin Project

Social support

Brief name

1 The Newpin Project340

2 An empowering strengths-based model that helps parents face their responsibilities with support from other parentsas well as from trained staff Lack of marital and extended family support adverse experiences in the motherrsquos ownchildhood and poor material circumstances are implicated not only in the causation and maintenance of maternaldepression but also in child abuse and neglect Befriending schemes may be accessible to many clients Volunteersmay show more commitment and flexibility in work with the families than is possible by professional health or socialservices Such schemes are also cheaper than a professionally staffed service

3 Materials group uses variety of methods including information handouts structured group discussion and detailedvideo feedback on parenting practice

4 Procedures key to the model is mutual support with every member being expected to support other parents bydrawing on their own strengths and abilities The combined support from both trained staff and other parentsenables vulnerable families to be held through times of extreme distress

Who provided

5 Women in the intervention group matched with a Newpin volunteer befriender Befrienders were recruited throughadvertising or family centres where service users have already gained some experience of befriending other parentsusing the centre Most befrienders were aged 31ndash45 years and young befrienders were matched with youngerparents Volunteer training consists of two half-days per week over a 6-month period One session consists of lecturesand workshops on topics such as child development play marriage and childbirth problems in parenting and thebefriending relationship The other consists of a self-development group run by a group therapist in which membersare encouraged to explore current and past relationships and to come to terms with earlier trauma and loss Onconclusion of training volunteers are assigned to support new clients and continue to receive weekly supervisionwhile befriending

6 No details

7 No details

When and how much

8 Group ran for one day a week for 12ndash14 weeks from 1000 until 1430 and was open to mothers it was facilitatedby two trainers

Tailoring

9 The only adaptation is the additional 2 weeks lsquosettling inrsquo period

Modifications

10 No details

How well

APPENDIX 16

TIDieR checklist for CenteringPregnancy

Midwifery-led intervention

Brief name

1 CenteringPregnancy262

2 Founded on set of lsquoEssential Elementsrsquo providing structure for effective group prenatal care Premise ofCenteringPregnancy model is that by receiving prenatal care and education through a supportive group processwomen gain power and confidence as knowledgeable health consumers increased personal and maternalself-efficacy and strengthened community networks Theory of mutual intentionality posits that the giver and recipientof social support make active decisions to give and receive support Women give support to others as they seek tohave their own needs met in the group and less through an active conscious choice

3 Materials hand-outs and worksheets facilitate the discussion and are completed during the initial minutes

4 Procedures women are invited to join group sessions after initial prenatal assessment and laboratory testing iscompleted Sessions comprise prenatal health care and education and within the group space women learn self-careskills including measuring their own blood pressure and weight which they record in their medical record and theyreceive individual physical assessment from prenatal care provider Women then meet as a group to discuss issuesaround the content of pregnancy childbirth and parenting

Who provided

5 Groups led by a certified nurse midwife certified midwife or nurse practitioner skilled in group process An additionalperson a nurse or aide facilitates flow of the group and help with any follow-up necessary Consistency in leadershipis important to provide continuity to the group and ensure comprehensive content presentation Other professionalswho assist as group leaders include social workers nutritionists physical therapists birthing unit nurses and parenteducators

6 Face-to-face group sessions supplemented with individual sessions as considered necessary

7 Hospital clinic requires space for self-examination activities and possibly private office space for individualconsultations

When and how much

8 Ten 2-hour prenatal group sessions with 8 to 12 women with similar due dates Sessions begin at 12 to 16 weeks ofpregnancy concluding in the early postpartum

Tailoring

9 Group discussion facilitated by prenatal care provider stimulated by self-assessment sheets geared to the contentplan for each session and completed by women at beginning of each session

Modifications

10 Not identified

How well

12 Actual process fidelity reflected how facilitative leaders were and how involved participants were in each sessionContent fidelity reflected whether recommended content was discussed in each session Fidelity rated at eachsession by trained researcher294

TIDieR checklist for midwife-led brief counselling

Brief name

1 Midwife-led brief counselling221

2 Counselling intervention based on a theoretical perspective focus group discussions with childbearing women andmidwives and reviews of the literature

3 Materials none described

4 Procedures counselling processes incorporated elements of critical stress debriefing and issues pertinent to thechildbearing context Content of the intervention specifically reviewed lsquomanagement of labourrsquo This review of theactions of others particularly professionals involved in and possibly contributing to traumatic aspects of the birthdiffers from standardised debriefing or other counselling interventions reported to date

Who provided

5 A midwife knowledgeable about childbirth and trained in counselling approach conducted sessions Interventiondoes not require sophisticated psychotherapeutic skills Model did not require substantial training and were a briefintervention that could be integrated with existing service frameworks

6 Delivered face to face on postnatal ward and then via the telephone

7 On postnatal ward and then remotely via telephone

When and how much

8 Intervention group received face-to-face counselling within 72 hours of birth and again via telephone at 4 to 6 weekspostpartum Counselling duration ranged from 40 to 60 minutes

Tailoring

9 None described

Modifications

10 None described

How well

11 Planned adherence to a standard time frame enabled the incidence of acute and chronic trauma symptoms inchildbearing women to be determined according to DSM-IV criteria

12 Actual not described

APPENDIX 16

TIDieR checklist for midwife-managed care

Brief name

1 Midwife-managed care338

2 Based on continuity of care and building of relationship of trust with care provider

3 Both intervention and control group women encouraged to access community-based child health services Providedwith written information on service

4 Procedures each pregnant woman had named midwife whom she met at first antenatal visit and who aimed toprovide the majority of planned episodes of care from booking to discharge to the health visitor

Who provided

5 Care was provided by group of 20 midwives who volunteered to join the unit from the hospitalrsquos existingcomplement of midwives When named midwife was unavailable the woman was cared for by an associate midwifefrom the MDU team women were referred to the obstetric medical team when there was deviation from normalrather than at routinely specified times The programme of care in comparison with shared care is care is describedelsewhere481482

6 Face to face provided individually

7 Antenatal and postnatal care provided within existing facilities which included the hospital home and communityhealth centres Designated birth rooms provided in hospital so that women could deliver in less clinical surroundings

When and how much

8 Each mother offered the opportunity of one home visit and unlimited visits to the centre

Tailoring

9 No details

Modifications

10 No details

How well

TIDieR checklist for midwifery redesigned postnatal care

Brief name

1 Midwifery redesigned postnatal care146264

2 No theory Government recommendations for wide-ranging changes to maternity highlighting often inappropriateand fragmented delivery of postnatal care led to a midwife-led service with continuity of care and involvement ofwomen that is sensitive to the womenrsquos individual needs and preferences at the centre of the reforms

3 Ten evidence-based guidelines for main postpartum disorders identified from literature for subsequent midwifemanagement of physical and psychological disorders all with clear criteria for referral to GPs Each guidelinepeer-reviewed by national experts and summarised in a leaflet A description of how to use the checklists andguidelines to make visits more flexible also included A symptom checklist was used alongside usual clinicaljudgement An abbreviated version of the checklists was used at the first visit to assess more immediate symptomsand then a full list was used at the 10- and 28-day visits and again at the postnatal discharge check EPDS was alsocompleted at the 28-day visit and at the discharge check to screen for PND

4 Procedures particular symptoms or problems included on checklist were main ones shown by literature to occur afterbirth and those for which guidelines were developed From this information care plans were made after discussingneeds with the woman

Who provided

5 Midwifery-led with GP contact only if midwife considered necessary if requestedpreferred by woman or GPMidwife undertook all postnatal home visits and postnatal maternity discharge check Midwives attached to recruitedpractices attended an English National Board for Nursing Midwifery and Health Visiting accredited training dayprovided by the study team Midwifery managers were able to claim the cost of bank staff to cover clinical workof attending midwives although most did not claim Four training days held and midwives attended in groups ofabout 15

6 EPDS used to screen for depression at day 28 and at discharge consultation

When and how much

8 To identify specific needs even if not spontaneously reported by women or observed by midwife symptom checklistused at first visit (immediate symptoms only) at days 10 and 28 and at discharge consultation at 10ndash12 weeks

Tailoring

9 Care plans madevisits scheduled based on EPDS results so care tailored to individual needs rather than based onpredetermined schedule

Modifications

10 No details

How well

12 From trial documentation most midwives in intervention group recorded care plans and visits as part of care regularuse of the guidelines and the completion of symptom checklists suggesting package was implemented withreasonable fidelity

APPENDIX 16

Part of the NIHR Journals Library wwwjournalslibrarynihracuk

Published by the NIHR Journals Library

This report presents independent research funded by the National Institute for Health Research (NIHR) The views expressed are those of the author(s) and not necessarily those of the NHS the NIHR or the Department of Health

EMEHSampDRHTAPGfARPHR

Health Technology Assessment 2016 Vol 20 No 37

List of tables

List of figures

List of boxes

Glossary



Scientific summary



Prevalence

Impact of health problem


Variation in service and uncertainty about best practice

Identification of postnatal and antenatal depression

Current service costs


Preventive interventions for postnatal depression


Psychological approaches to the prevention and treatment of depression

Educational interventions

Social support

Pharmacological interventions or supplements

Complementary and alternative medicine

Summary


Decision problem


Service user involvement




Search strategies for identification of studies

Search strategy for randomised controlled trials and systematic reviews

Review protocol


Search strategy and outcome summary for the qualitative studies

Electronic databases

Study selection

Study selection criteria and procedures for the quantitative review

Study quality assessment checklists and procedures for the randomised controlled trials

Data extraction for randomised controlled trials

Data synthesis of randomised controlled trials


Methods of evidence synthesis



Study selection criteria and procedures for the effectiveness review

Inclusion and exclusion criteria for qualitative studies

Study quality assessment checklists and procedures for qualitative studies

Data extraction strategy for qualitative studies

Data synthesis for qualitative studies


Identification of key potential CLUSTERs

Searching for CLUSTER documents

Synthesis and construction of a theoretical model


Chapter 4 Overview of results for quantitative and qualitative studies


Quantitative review study characteristics

Yield of systematic reviews


Outcome assessment


Quality of systematic and other reviews


Qualitative studies level of preventive intervention


Qualitative review study characteristics personal and social support strategy studies

Quality of the qualitative intervention studies

Certainty of the review findings intervention studies


Quality of the qualitative personal and social support strategy studies

Qualitative studies further analysis by level of preventive intervention universal selective and indicated

Chapter 5 Results for universal preventive intervention studies

Characteristics of randomised controlled trials of universal preventive interventions

Description of qualitative studies of universal preventive interventions


Characteristics and main outcomes of randomised controlled trials of universal preventive interventions of psychological interventions

Description and findings from qualitative studies of universal preventive interventions of psychological interventions


Characteristics and main outcomes of randomised controlled trials of universal preventive interventions of educational interventions


Characteristics and main outcomes of randomised controlled trials of universal preventive interventions of social support

Description and findings from qualitative studies of universal preventive interventions of social support

Universal preventive interventions pharmacological agents or supplements

Characteristics and main outcomes of randomised controlled trials of universal preventive intervention of pharmacological agents or supplements

Universal preventive interventions midwifery-led interventions

Characteristics and main outcomes of randomised controlled trials of universal preventive interventions of midwifery-led interventions

Description and findings from qualitative studies of universal preventive interventions of midwifery-led interventions


Characteristics and main outcomes of randomised controlled trials of universal preventive interventions of organisation of maternity care

Description and findings from qualitative studies of universal preventive interventions of organisation of maternity care

Universal preventive interventions complementary and alternative medicine or other

Characteristics and main outcomes of randomised controlled trials of universal preventive interventions of complementary and alternative medicine or other

Description and findings of qualitative studies of universal preventive interventions of complementary and alternative medicine or other

Results from network meta-analysis for universal preventive interventions for Edinburgh Postnatal Depression Scale threshold score

Results for universal preventive interventions for Edinburgh Postnatal Depression Scale threshold score at 6 weeks postnatally

Results for universal preventive interventions for Edinburgh Postnatal Depression Scale threshold score at 3 months postnatally



Summary of results from network meta-analysis for universal preventive interventions for Edinburgh Postnatal Depression Scale threshold score

Results from network meta-analysis for universal preventive interventions for Edinburgh Postnatal Depression Scale mean scores

Summary of results from network meta-analysis for universal preventive intervention studies for Edinburgh Postnatal Depression Scale mean scores

Summary of results for universal preventive interventions for Edinburgh Postnatal Depression Scale threshold and Edinburgh Postnatal Depression Scale mean scores

Overall summary of results for universal preventive interventions for Edinburgh Postnatal Depression Scale threshold and Edinburgh Postnatal Depression Scale mean scores

Chapter 6 Results for selective preventive intervention studies

Characteristics of randomised controlled trials of selective preventive interventions

Description of qualitative studies of selective preventive interventions


Characteristics and main outcomes of randomised controlled trials of selective preventive interventions of psychological interventions

Description and findings from qualitative studies of selective preventive interventions of psychological interventions


Characteristics and main outcomes of randomised controlled trials of selective preventive intervention of educational interventions

Description and findings from qualitative studies of selective preventive interventions of educational interventions


Characteristics and main outcomes of randomised controlled trials of selective preventive interventions of social support

Selective preventive interventions pharmacological agents or supplements

Characteristics and main outcomes of randomised controlled trials of selective preventive interventions of pharmacological agents or supplements


Characteristics and main outcomes of randomised controlled trials of selective preventive interventions of midwifery-led interventions

Description and findings from qualitative studies of selective preventive interventions of midwifery-led interventions

Selective preventive interventions organisation of maternity care

Selective preventive interventions complementary and alternative medicine or other interventions

Results from network meta-analysis for selective preventive interventions for Edinburgh Postnatal Depression Scale threshold score

Results from network meta-analysis for selective preventive intervention for Edinburgh Postnatal Depression Scale threshold score at 6 weeks postnatally

Results from network meta-analysis for selective preventive intervention for Edinburgh Postnatal Depression Scale threshold score at 3 months postnatally


Summary of results from network meta-analysis for selective preventive interventions Edinburgh Postnatal Depression Scale threshold score

Results from network meta-analysis for selective preventive interventions for Edinburgh Postnatal Depression Scale mean scores

Summary of results from network meta-analysis for selective preventive interventions for Edinburgh Postnatal Depression Scale mean scores

Chapter 7 Results for indicated preventive intervention studies

Characteristics of randomised controlled trials of indicated preventive interventions

Description and findings from qualitative studies of indicated preventive interventions


Characteristics and main outcomes of randomised controlled trials of indicated preventive interventions of psychological interventions


Characteristics and main outcomes of randomised controlled trials of indicated preventive interventions of educational interventions


Characteristics and main outcomes of randomised controlled trials of indicated preventive interventions of social support

Description and findings from qualitative studies of indicated preventive interventions of social support

Indicated preventive interventions pharmacological agents or supplements

Characteristics and main outcomes of randomised controlled trials of indicated preventive interventions of pharmacological agents or supplements

Indicated preventive interventions midwifery-led interventions

Characteristics and main outcomes of randomised controlled trials of indicated preventive interventions of midwifery-led interventions

Indicated preventive interventions organisation of maternity care

Characteristics and main outcomes of randomised controlled trials of indicated preventive interventions of organisation of maternity care

Description and findings of qualitative studies of selective preventive interventions of the organisation of maternity care

Indicated preventive interventions complementary and alternative medicine or other interventions

Characteristics and main outcomes of randomised controlled trials of indicated preventive interventions of complementary and alternative medicine or other interventions

Results from network meta-analysis for indicated preventive interventions for Edinburgh Postnatal Depression Scale threshold score

Results from network meta-analysis for indicated preventive intervention for Edinburgh Postnatal Depression Scale threshold scores at 6 weeks postnatally

Results from network meta-analysis for indicated preventive intervention for Edinburgh Postnatal Depression Scale threshold scores at 3 months postnatally



Summary of results from network meta-analysis for indicated preventive intervention for Edinburgh Postnatal Depression Scale threshold scores

Results from network meta-analysis for indicated preventive intervention for Edinburgh Postnatal Depression Scale mean scores

Summary of results from network meta-analysis for indicated preventive intervention for Edinburgh Postnatal Depression Scale mean scores

Chapter 8 Results of realist synthesis what works for whom




Description of included personal and social support strategy studies

Study respondents in the personal and social support strategy studies

Study setting of the personal and social support strategy studies

Synthesis of findings across personal and social support strategy studies



Identification of provisional lsquobest fitrsquo conceptual framework for realist synthesis

Population of the conceptual framework

Identification of existing theory underpinning specific mechanisms


Group-based interventions

Continuity of care

Individual-centred interventions

Considerations shared by group-based and individual-centred interventions

Support to providers

Components of the interventions

Sustainability


Mechanisms for improving appropriateness of strategies

On adverse effects

Testing of the programme theory and integrating quantitative and qualitative findings

Response from the service user group to optimal characteristics identified from the qualitativerealist reviews

Modifications to the list

Additions to the list

Additional nuances emerging from the consultation




Identification of cost-effectiveness studies

Study selection criteria and procedures for the health economics review

Overview of papers included in the health economics review

Population considered in the health economics review

Interventions in the health economics review

Health-related quality-of-life data in the health economics review

Costs and health-care resources reported in the health economics review

Main results reported in the health economics review

Summary of appropriateness of previously published models

The de novo model

The conceptual model

Model parameters

The effectiveness data for each intervention

The incremental costs associated with each intervention

The relationship between utility and Edinburgh Postnatal Depression Scale scores

The relationship between total health costs and Edinburgh Postnatal Depression Scale scores

The analyses undertaken

Results

The estimated quality-adjusted life-year gain compared with usual care for each intervention

Calculating cost per quality-adjusted life-year values

Producing cost-effectiveness acceptability curves

Interpretation of the cost-effectiveness results produced

Interventions for the universal preventive interventions

Interventions for the selective preventive interventions

Interventions for indicated preventive interventions

Assessing the impact of using total health-care costs when these were available rather than intervention costs


Expected value of perfect information results

Expected value of partial perfect information results

Discussion of the assessment of cost-effectiveness of interventions


Introduction



Conceptualisation of postnatal depression and the potential for prevention





Pharmacological or supplements


Universal preventive interventions not included in the network meta-analysis

Summary of qualitative findings for universal preventive interventions




Social support

Summary of qualitative findings for selective preventive interventions


Indicated preventive interventions not included in the network meta-analysis

Social support


Complementary and alternative medicine or other interventions

Summary of qualitative findings for indicated preventive interventions

Economic analysis


Replication of interventions

Moderators and mediators


Quality of the trials

Heterogeneity of trial participants

Intervention provider

Usual care in the UK

Measures of depression

Treatment end points

Infant outcomes





Findings associated with the evidence base methodological implications

Implications for future research in the prevention of postnatal depression

Implications for individual interventions





Acknowledgements

References


Appendix 2 Randomised controlled trials and systematic reviews number retrieved

Appendix 3 Key journals hand-searched via electronic alerts

Appendix 4 Qualitative studies and mixed-methods studies number retrieved

Appendix 5 Reason for exclusion of quantitative studies


Appendix 7 Synthesis of findings from personal and social support strategy studies


Appendix 9 Qualitative review participant characteristics

Appendix 10 Studies omitted from the network meta-analysis

Appendix 11 Sensitivity analysis of Edinburgh Postnatal Depression Scale threshold score data using vague prior distribution for the between-study standard deviation

Appendix 12 Similarities and differences between group- and individual-based approaches

Appendix 13 Findings relating to a potential serviceintervention

Appendix 14 CLUSTERs receiving detailed examination

Appendix 15 Examples of lsquoifndashthenrsquo propositions used to refine lsquobest fitrsquo analytic framework

Appendix 16 TIDieR checklists for focal interventions

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Crossmark

Page 1