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. Author manuscript; available in PMC: 2020 Oct 1.
Published in final edited form as: J Adv Nurs. 2019 Jul 21;75(10):2223–2235. doi: 10.1111/jan.14114

Technology-assisted nursing for postpartum support: A randomized controlled trial

DE McCarter 1,2,*, E Demidenko 3, TS Sisco 4, MT Hegel 5
PMCID: PMC6746586  NIHMSID: NIHMS1531964  PMID: 31222789

Abstract

Aim:

To determine if an electronic nursing intervention during the first six months postpartum was effective in improving mood and decreasing stress.

Background:

Unmet needs postpartum can have a negative impact on mood and parenting stress. Technology-assisted nursing care may provide needed support and reduce risk.

Design:

Randomized controlled trial (RCT) with three conditions.

Methods:

Enrollment began on 11 May 2017. Participants were randomized into one of three groups after completion of the baseline survey. Intervention I participants received standardized electronic messages four times/week for six months postpartum. Intervention II participants additionally received the option for nurse contact. Depression and parenting stress as measured using the Edinburgh Postnatal Depression Scale (EPDS) and Parenting Stress Index-Short form (PSI-SF) was obtained at 3 weeks, 3 months and 6 months postpartum and results compared with a usual care group. Patient satisfaction and nursing factors were measured.

Results:

Significantly higher satisfaction scores were found in both intervention groups as compare with control, but there were no significant changes in EPDS or PSI-SF.

Conclusion:

The interventions were perceived as helpful and not burdensome. Better nurse-sensitive outcome measures are needed to adequately assess effectiveness.

Keywords: postpartum, nursing, technology, depression, parenting stress, nurse-sensitive

Introduction

Education and health promotion postpartum are key aspects of nursing care (American Nurses Association, 2015). However, nurses and patients alike experience competing demands during the short maternity stay (Martin, Horowitz, Balbierz, & Howell, 2014). Physical recovery, particularly from Cesarean birth, is a priority, as well as infant feeding, amidst many visitors welcoming the newborn. Education during the hospitalization may not be effective (McCarter-Spaulding & Shea, 2016) and the need for education and support after hospital discharge is largely unmet (Kleppel, Suplee, Stuebe, & Bingham, 2016), increasing the risk for postpartum depression and high stress levels. Post-discharge nursing care could address mothers’ needs for education and support (Kanotra et al., 2007). Electronic interventions could expand the reach of nursing (Henshaw et al., 2018; Plantin & Daneback, 2009) and improve screening for depression and elevated stress levels (Danbjørg, Wagner, Kristensen, & Clemensen, 2015; Drake, Howard, & Kinsey, 2014; Guerra-Reyes, Christie, Prabhakar, Harris, & Siek, 2016; Wellde & Miller, 2016).

There is widespread agreement that untreated depression is a risk for mothers (Logsdon, Wisner, Sit, Luther, & Wisniewski, 2011), children (Earls & The Committee on Psychosocial Aspects of Child and Family Health, 2010) and families (Paulson & Bazemore, 2010), particularly when other risk factors such as low socioeconomic status are also present (Wang, Wu anderson, & Florence, 2011). Parenting stress may also interact with depression during the postpartum period (Reck, Zietlow, Müller, & Dubber, 2016). Connection with a nurse from the maternity hospital could provide a trusted link to health care providers for support and education (Henshaw et al., 2018), as well as timely identification and referral for postpartum depression treatment. The purpose of this study was to determine if an electronic nursing intervention provided during the first six months postpartum would improve maternal mood and decrease parenting stress compare with the usual postpartum care.

Background

Standard postpartum care in the United States is a single visit to an obstetrical provider six weeks after discharge, but as many as 40% of women do not attend even this visit. (American College of Obstetricians and Gynecologists (ACOG), 2016). Women who do attend still may not be screened for postpartum depression (Kim et al., 2009). Mothers experience the postpartum period as a time when education and support is needed but not readily available (Henshaw et al., 2018; Martin et al., 2014). Frequent well-baby checks often do not meet needs of mothers (Henshaw et al., 2018). There is no universal agreement about whether pediatric, obstetric or family practice providers are responsible for screening the mother and thus it may be neglected (Goldin Evans, Phillippi, & Gee, 2015). Nurses may be able to fill this gap (Association of Women's Health Obstetric and Neonatal Nurses (AWHONN), 2015; Segre, O'Hara, Arndt, & Beck, 2010a, 2010b), as part of a multidisciplinary team.

Nurse-provided education, support and screening, as the continuation of a relationship begun during the maternity hospitalization, could reduce stigma associated with accessing mental health services (Smith et al., 2009; Sword, Busser, Ganann, McMillan, & Swinton, 2008) and provide an opportunity for care, triage and any indicated referrals (Henshaw et al., 2018), using a nurse care-coordinator model (Baker anderson, & Johnson, 2017; Camicia et al., 2013; Vanderboom, Thackeray, & Rhudy, 2015). However, it is not known how much nursing time or expertise would be required to extend this model of maternity care nursing services beyond hospital discharge.

Digital applications have been proposed as a way to reach socioeconomically and culturally diverse populations (Aguilera & Berridge, 2014; Emily D., Erica H., & K., 2014), particularly when paired with a personal encounter (Carta, Lefever, Bigelow, Borkowski, & Warren, 2013; Danaher et al., 2012; Piette & Schillinger, 2007). Virtually all women of reproductive age in the United States have use of a cell phone, regardless of socioeconomic status, education, race or residence (Pew Research Center, 2017) and most also have email access (Drake et al., 2014). Mothers welcome an electronic connection with a postpartum nurse (Danbjørg et al., 2015) and already seek parenting and health information using electronic devices (Guerra-Reyes et al., 2016; Wellde & Miller, 2016), but few studies have measured patient-centered outcomes.

The Study

Aims

The primary aim of this study was to determine whether using an electronic intervention to support and facilitate nurse contact postpartum would improve mood and decrease parenting stress. and identify women needing further evaluation and treatment. Secondary aims included determining whether women found the intervention satisfying and helpful. In addition, we aimed to determine the amount of nursing time and expertise required to provide this service. We hypothesized that the intervention would decrease parenting stress and postpartum depressive symptoms greater than usual care and would be perceived as helpful to mothers and not unduly burdensome to nurses.

Design

This was an open, parallel, three arm randomized controlled trial. Two intervention groups were compared with a control group receiving the usual post-discharge care. The intervention was evaluated for feasibility and acceptability(McCarter, Demidenko, & Hegel, 2018).. The protocol was reviewed by the Institutional Review Board of the hospital from which the participants were recruited; approved initially on May 12, 2015 and reviewed annually.

Interventions

Usual care.

Usual nursing care following discharge from the birth hospital consists of a follow-up phone call made by a nurse within the first two weeks postpartum, using standardized questions about mother and infant health, postpartum mood and follow-up provider visits. If the patient is not reached by phone, no further attempts are made, but a message is left inviting a return call is.

Intervention Groups I and II.

Both intervention groups received four standardized electronic messages weekly for 26 weeks, beginning the Monday following enrollment in the study. The messages were developed by nurses employed at the study hospital [see McCarter et al. (2018) for more information].

Intervention group I received the four weekly messages for 26 weeks. To distinguish between the effects of this one-way communication and that of the option for nurse contact as well, the Intervention II group was asked following two of the four weekly messages: “would you like a nurse to call you?” to which they could respond back with “yes” or “no.” Participants were instructed during consent that they should not use the nurse-contact offer for urgent requests, to avoid any delays in receiving urgent or emergency care.

Reports of calls requested were available via the software (Televox) website on the morning after the messages were delivered and accessed by the PI, who responded to call requests by phone within 1–2 days. Women not reached by phone were emailed and responses were made via email or during a mutually convenient time for another phone call.

Safety intervention

For women whose responses on the follow-up surveys indicated a high risk of postpartum depression or a risk of self-harm, an alert was sent to the principal investigator who contacted the participant and evaluated for safety, regardless of treatment group designation.

Participants

Setting and inclusion criteria.

Participants were recruited between May 2016 and August 2017 from the postpartum unit of an urban hospital in the state of New Hampshire, USA, at which approximately 1000 women give birth each year. Participants were eligible if they were at least 18 years old and could read and speak English and had access to an electronic device which could receive either text or email messages. Exclusion criteria included women less than age 18, non-English speaking or those without a device. Women with healthy newborns as well as those with newborns evaluated by or admitted to a Level II Special Care Nursery were eligible.

Clinical use of scores on the EPDS suggest three categories. EPDS scores <10 appear to indicate a low risk for depression, scores 10–12 suggest further evaluation and scores of 13 or higher indicate a high probability of major depression (Davies, Howells, & Jenkins, 2003; Matthey, Henshaw, Elliott, & Barnett, 2006). This level of minimal detectable difference between groups is sufficient to identify whether the intervention reduces the risk of postpartum depression with the difference between the three categories equal to 2 points on the EPDS (effect size=0.44). A power calculation suggests that for an n= 44 in each group the power of detecting the difference of at least one category on the EPDS score is 80% with the type I error 5% under the assumption that the standard deviation of EPDS scores is 4.5 based on previous studies. At least 63 participants in each group by the six-month follow-up were needed for sufficient power (McCarter et al., 2018) based on an expected attrition of 30%, which was achieved by recruiting an initial sample of 547 women at baseline.

Data collection

Potential participants were offered participation on the day prior to hospital discharge by a member of the research team. If interested, informed consent was obtained in writing and baseline surveys were administered using a tablet computer. The survey took approximately 10 minutes to complete, after which the tablet was retrieved. Participants received a small gift valued at $5 US dollars (a small towel with the study logo) after completing the baseline hospital surveys. Simple randomization by the survey software to one of three groups (1:1:1) occurred after baseline surveys were uploaded to a secure server.

Follow-up -up surveys were administered by email at three weeks, three months and six months postpartum. The approximate time to complete follow-up surveys was 20 minutes. Participants received a $10 US gift card after completing each of the follow-up surveys.

Baseline demographics and risk factors.

At baseline, participants provided information on age, race/ethnicity, education, parity, mode of delivery, infant health status and infant feeding intent. In addition, contact information and preferred mode of communication (i.e., texting or email) were collected. Participants reported where they had received their prenatal care (either the private practice associated with the hospital or the hospital-based clinic which serves a primarily low-income population). Low-income women were also identified by self-report of their eligibility for the Special Supplemental Program for Women and Children (WIC) (U.S. Department of Agriculture Food and Nutrition Service, 2014) which is based on income and family size and on source of payment for health care. Participants reported their partner status as either married, single/cohabitating, single/in significant relationship, or single/not in significant relationship. Women reported whether they had previously experienced, either during or before the pregnancy, symptoms of depression and/or anxiety and if they were currently receiving treatment (Table 1).

Table 1:

Phase 3 Baseline Patient Characteristics1. [All results noted as frequency (percent)]

Sample Characteristics Usual Care n=167 Intervention I (text only) n=181 Intervention II (text & RN) n=190
Mean age 29.3 28.9 29.8
Parity:
 Primipara 71 (43) 81 (45) 85 (45)
 Multipara 96 (57) 100 (55) 105 (55)
*Race:
 White Women 151 (90) 159 (88) 155 (82)
 Women of Color 16 (10) 22 (12) 35 (18)
Hispanic/Latina: 11 (7) 9 (5) 18 (9)
Birth:
 Vaginal 133 (80) 140 (78) 150 (79)
 Cesarean 34 (20) 40 (22) 40 (21)
Infant status:
 Level 1 nursery 150 (90) 169 (93) 177 (94)
 Level 2 or higher 17 (10) 12 (7) 12 (6)
Education:
 High school or less 34 (20) 40 (22) 46 (24)
 Some college 60 (36) 71 (39) 57 (30)
 College degree or higher 73 (44) 70 (39) 89 (47)
Partner status:
 Married or cohabitating 153 (92) 164 (91) 173 (91)
 In significant relationship 8 (5) 6 (3) 9 (5)
 Single 6 (4) 11 (6) 7 (4)
Intended infant feeding plan2
 Breastfeeding only 123 (74) 135 (75) 134 (71)
 Formula feeding 16 (10) 23 (13) 18 (10)
 Combination breast & formula 28 (17) 23 (13) 37 (20)
Eligible for WIC benefits 64 (39) 72 (40) 67 (36)
Depression during this pregnancy2 23 (14) 30 (17) 23 (12)
Treated for depression during pregnancy 8 (5) 15 (8) 12 (6)
Anxiety during this pregnancy2 61 (37) 65 (36) 54 (29)
Treated for anxiety during pregnancy 18 (11) 14 (11) 16(12)
Depression prior to this pregnancy2 64 (38) 68 (38) 66 (35)
Treated for depression prior to pregnancy 41 (24) 55 (31) 54 (28)
*Baseline EPDS (mean, SD) 4.3 (4.5) 4.5 (4.4) 3.2 (3.6)
EPDS score <10 (no depression) 146 (87) 154 (85) 179 (94)
EPDS score 10–12 (risk for depression) 10 (6) 14 (8) 7 (4)
EPDS score >12 (high risk for depression) 11 (7) 13 (7) 4 (2)
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*

significant difference between groups p<.05

1

Percentages may sum to greater than 100 based on rounding figures

2

Based on self-report

Primary outcomes

Postpartum mood.

Mood was measured at all four data collection points by scores on the Edinburgh Postnatal Depression Scale (EPDS). The EPDS (Cox, Holden, & Sagovsky, 1987) is a well-validated screening instrument to measure symptoms of postpartum depression. The EPDS has been demonstrated to have excellent psychometric qualities (Hanusa, Scholle, Haskett, Spadaro, & Wisner, 2008) in various samples in the United States as well as many other countries and thus was a reliable and valid instrument for assessing depressive symptoms in this sample. It consists of 10 items in Likert format, with total scores ranging from 0–30. The EPDS has been used extensively among various cultures and in different countries (Schumacher & Zubaran, 2008) with good specificity and sensitivity.

Scores on the EPDS were analyzed as a continuous variable as well as a categorical variable based on the clinically focused categories of EPDS <10 as low risk, scores between 10 and 12 as suggestive of minor depression (Cox et al., 1987) and score of 13 or above as indicating a high probability for major depressive disorder (Matthey et al., 2006). Additionally, EPDS scores were used to identify women who required follow-up, based on a score of 13 or above, or any responses indicating a risk for self-harm.

Parenting Stress.

To quantify parenting stress, the Parenting Stress Index Short Form (PSI-SF) was administered at each of the follow-up points. The PSI-SF measures stresses related to child characteristics, parental characteristics and situational and demographic factors. It includes 36 items, in three domains including how parents feel in their role, how satisfied they are in the relationship with the child and how difficult the child is perceived to be (Abidin, 2012). A Total Stress score was calculated and analyzed as a continuous variable. In the feasibility testing phase (McCarter et al., 2018), the PSI-SF was administered at baseline as well as at each of the follow-up points. However, at baseline respondents reported that they could not appropriately answer questions about their experience of parenting when the infant was only one day old. Thus, for this RCT, the PSI-SF was only administered at each of the three follow-up points.

Secondary Outcomes

Participant satisfaction.

Satisfaction was measured by an investigator-developed instrument designed in collaboration with the Patient Satisfaction Committee of the maternity unit at the study site. The survey included 13 items measured using a 5-point Likert scale and assessed participants’ experience with the messages, if they would recommend them to others and for the Intervention II participants, their satisfaction with being offered a call from a nurse. The responses were analyzed using a contrived index for the satisfaction scale. An exploratory factor analysis using oblique rotation was conducted on thirteen items. The Kaiser-Meyer-Olkin measure verified the sampling adequacy for the analysis, KMO = .90. Two factors had eigenvalues over Kaiser’s criterion of 1 and in combination explained 64.2% of the variance. The scree plot showed inflections that would justify retaining one factor. Cronbach’s α for the satisfaction index was .93 which indicates high reliability. The 13 items for the index all represent a single factor interpreted as Satisfaction and are a standardized weighted average.

Nurse-centered outcomes.

Data were collected on the frequency of requests for phone calls, the content of these calls and the length of time spent on the phone. Any interventions required for the safety of participants, triggered by EPDS scores >13 or any indication of thoughts of self-harm, was documented.

Attrition from study.

Any factors (e.g. baseline EPDS scores, socioeconomic status, infant feeding choice, multiparity) which were suspected to contribute to loss to follow-up were analyzed to address any potential attrition bias.

Data analysis

Analytic procedures.

For primary treatment outcomes, the principles of intention-to-treat analyses were followed. Both the public-domain statistical package R (R Core Team, 2014), as well as SPSS were used to analyze the data. Demographic characteristics of the sample and risk factors for depression were analyzed using descriptive statistics combined with the data visualization techniques such as box plots and quantile-quantile (q-q) plots. Any differences in demographics between the groups were assessed by statistical hypothesis testing such as t-test or Z test for proportions. The primary outcome measure was the EPDS score over the six-month follow-up period. Methods of univariate and multivariate statistical analysis were applied to detect the relationship of other factors, such as socio-economic factors, partner status and history of depression/anxiety, with the dynamic of the EPDS score over time. Differences in EPDS between the three groups were analyzed using t-tests with preliminary assessment of the normal distribution using q-q plots. Additionally, groups were analyzed for differences in the Total Stress Scores of the PSI-SF, using methods outlined above. The relationship between the EPDS and the PSI was addressed using correlation analysis. Factors known to be associated with depression such as socioeconomic status, partner status, history of depression/anxiety were controlled for in the analysis. Data from women who requested a nurse phone call were analyzed to determine if there were factors predicting need for follow-up care.

Validity and reliability

The validity and reliability of the instruments is described above. Differences in baseline characteristics between groups was accounted for in the statistical analysis. The Cronbach’s α for the EPDS in this study was .802 and for the PSI-SF was .774.

Results

Sample

Five hundred forty-seven (547) women were randomized to the three groups (see Figure 1). Baseline demographics (see Table 1) obtained at enrollment demonstrated that the groups were equivalent in age, parity, infant health, partner status, education or intended infant feeding plan. The Intervention II group had significantly more women of color (18%) than either the control group (10%) or Intervention I (12%). There were no significant differences in prior history or treatment for of depression, or history of anxiety and/or depression during the current pregnancy. However, the Intervention II group had fewer women with clinically significant symptoms of depression at baseline (EPDS<10), which was adjusted for in the main analyses.

Figure 1.

Figure 1.

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Phase 3: Trial design

Risk factors identified at baseline.

Using the total sample, baseline EPDS scores were significantly higher in women of lower socioeconomic status, as measured by WIC eligibility. Baseline EPDS scores were also significantly higher in single women who were living with their partner as compare with married women. These differences did not persist over time at 3 weeks, 3 months or 6 months postpartum. However, there was significantly more attrition from the study before the three-week follow-up for women eligible for WIC, younger or single.

Depression symptoms as measured by EPDS.

There were no significant differences between either treatment group as compare with control, nor any differences between intervention I (electronic only) and intervention II (electronic and nurse option) at any follow-up measure based on EPDS scores. The chi-square statistic versus Intervention I was is 0.38 with the p-value = 0.99. The chi-square statistic for the control group & Intervention I versus Intervention II is 45.0 with the p-value = 4.85e–6 as displayed on the Figure 2. In addition, there was no significant difference between groups when analyzed by clinically significant categories of EPDS baseline <10, EPDS 10–12 and EPDS or higher. Participants contacted due to high-risk responses to the EPDS are analyzed separately (Figure 2).

Figure 2.

Figure 2.

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Edinburgh Postnatal Depression Scale score over time after the birth

Women contacted for safety assessment.

Regardless of group designation, participants were contacted if their EPDS score on a follow-up measure was 13 or greater, or if they indicated any risk for self-harm. Sixty-two calls were made in response to these criteria, representing 50 participants. Women who reported a history of depression during pregnancy, delivery by Cesarean birth and who denied being low-income as measured by WIC eligibility were more likely to have EPDS scores which triggered a call to assess for safety.

Parenting stress as measured by the Parenting Stress Index.

While total stress decreased significantly over time for all three groups (F=16.743; p=.000), there was no significant difference between groups (Figure 3). While total stress was significantly lower in women who reported being satisfied with the messaging intervention, it only accounted for 2.6% of the variability in total stress. Depression as measured by EPDS was highly correlated with total stress at all follow-up measures.

Figure 3:

Figure 3:

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Total parenting stress over time by group designation

Satisfaction with messaging intervention.

While changes in depression symptoms and parenting stress were not significant between treatment and control, participants were positive about their experience of receiving messages (Figure 4) based on their scores on the satisfaction index. On average, women who received messages and the option for nurse calls (intervention II group) had higher levels of satisfaction (M=3.94, SD .69) than women who received only electronic messages (intervention group I) (M=3.69, SD .73). This difference, .244, was statistically significant t (174) =2.264, p=.025. Depressive symptoms at all four time periods and stress at three time periods were not significant predictors of satisfaction.

Figure 4.

Figure 4.

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Satisfaction score

Attrition from the study.

Differences in baseline characteristics between women who remained in the study until 6 months and those who were lost to follow-up by 3 weeks or 3 months postpartum were analyzed. There was a 39% attrition rate for married women but a 64% attrition rate for women who were living with partners (Table 2). More women eligible for WIC reported living with partner, single (in relationship) or single compare with married (Table 3). We further analyzed attrition connected to marital status and prenatal care location (Table 4). We then followed the attrition over the four waves by practice location and baseline marital status. The group least likely to leave the study were married women who received prenatal care at the private practice (36% attrition rate). Their attrition was less than their married counterparts receiving prenatal care at hospital clinics (51%) or other facilities (55%). While married women in care at a private practice persisted in the study, women who were living with partner, single in a relationship, or single and used a private practice for prenatal care had attrition rates at 62%, 77% and 67%, respectively. Non-married patients using the hospital-based clinic practice for prenatal care had the highest rates of attrition over the four time periods (80%).

Table 2:

Attrition rates by partner status

Married Living with Partner Single, in relationship Single Total
Baseline 352 137 23 24 537
3 weeks 250 (29%) 66 (51%) 6 (73%) 8 (75% 330
3 months 223 (11%; 37%) 57 (13.6%;58%) 7 (0%; 69%) 8 (0%; 75%) 296
6 months 215 (3.5%;39%) 49 (14%; 64%) 5 (28%; 79%) 7 (12.5%;70%) 276
Attrition Rate 39% 64% 79% 70% 49%; AVE=63%
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Table 3:

Attrition rates by socioeconomic status (WIC eligibility at baseline)

Married Living with Partner Single, in relationship Single Total
WIC eligible? Yes 71 (35%) 89 (44%) 21 (10.4%) 21 (10.4%) 202
No 280 (84.3%) 47 (14.2%) 2 (<1%) 3 (<1%) 332
Total 351 (65.7%) 136 (25.4%) 23 (4.3%) 24 (4.4%) 534
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Table 4:

Attrition by prenatal care practice and EPDS

Married Living with Partner Single, in relationship Single Total
PNC site C P O C P O C P O C P O
Baseline EPDS 52 289 9 20 111 5 5 18 0 5 18 1 553
3 weeks 38 205 6 8 54 4 1 5 0 2 6 0 329
3 mos. 29 191 4 8 45 1 1 6 0 2 6 0 294
6 mos. 25 185 4 4 42 3 1 4 0 1 6 0 275
Attrition 51% 36% 55% 80% 62% 40% 80% 77% - 80% 67% 100%
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Key: PNC=prenatal care

C=clinic

P=private

O=other

Nursing time and expertise required

Calls requested by participants.

Participants in Intervention II group (n=189 at enrollment) were offered a call twice per week for six months. Thirty-five calls were requested, of which four were requested by mistake. Of the remaining 31 calls, 8/31 (26%) were related to maternal physical or psychosocial care and the other requests (23/31 or 74%) were infant-related or a combination of topics. The average amount of time spent per call was 9 minutes (range 1–34 minutes). The most common study time period (modal) for requesting a call was approximately one month postpartum but calls were requested from one week to 6 months postpartum. Only 101 women in the intervention II group completed follow-up until 6 months postpartum, however, all 189 enrolled continued to receive the messages unless technical problems or a request to opt-out prohibited receiving the messages (n=11).

Calls initiated by nurse.

In the total sample (n=538) 62 calls were initiated by the research team nurses, based on EPDS scores 13 and above, or a positive response to thoughts of self-harm (see Figure 2). Twelve of the 62 calls were repeat calls, meaning the participants were called more than once over the six months due to concern generated by their EPDS scores. Each of these calls required an average of 13 minutes per call (range 3–60 minutes) of nursing time to assess for safety. A total of twelve respondents were referred for treatment. Twenty-three others were already in treatment when contacted. The most common study time period (modal) for scores generating a nurse-initiated call was at 6 months postpartum, with a range from 1–7 months.

Discussion

Depression and parenting stress

While participants were generally positive about receiving the intervention (both groups I and II), the intervention was not associated with any significant change in depressive symptoms or parenting stress, thus rejecting the hypothesis. Nonetheless, the high satisfaction rates, particularly for Intervention II participants was encouraging.

It is likely that the nursing contact provided and made available electronically was supportive and perhaps preventative. However, the EPDS does not appear to be a sensitive enough instrument to reflect benefit received from a simple nursing intervention such as a phone call or text. This appears to be the case with the PSI-SF as well, as the intervention was experienced by women as a support during a stressful time of adjustment to parenthood but was not substantial enough to change scores on the PSI. The results highlight an ongoing challenge to measure “nurse-sensitive” outcomes (Heslop & Lu, 2014; Start, Matlock, Brown, Aronow, & Soban, 2018) to evaluate the quality of nursing care. Very few nurse-sensitive indicators have been researched, even fewer outside of acute care and none that are maternity-specific. The only nurse-sensitive indicator widely used currently for measurement of nursing care quality in maternal-child health is patient/family satisfaction (Heslop & Lu, 2014). Satisfaction is important but is not sufficient to support a change in practice requiring nursing time and expertise. A recently developed measure of child-care stress (Dennis, Brown, & Brennenstuhl, 2018), may be a more sensitive measure than parenting stress for evaluating effects of nursing support. In addition, maternal confidence (self-efficacy) may be a better measure of outcomes (Bryanton, Gagnon, Hatem, & Johnston, 2008; Henshaw et al., 2018), as self-efficacy mediates the effect of interventions on outcomes such as depression or parenting stress (Bandura, 1997).

These outcomes reinforce the need to identify more appropriate outcome measures which can be used to evaluate nursing interventions focused on education, support and identification of physical and psychosocial risk. These measures need to go beyond adverse outcomes such as falls, infections or errors (Start et al., 2018) to include the contribution of nurses to outcomes such as improved self-efficacy in maternal self-care, breastfeeding and parenting (Copeland & Harbaugh, 2017; Leahy-Warren, McCarthy, & Corcoran, 2012; Sheeran et al., 2016), factors which ultimately lead to positive health outcomes. More nurse-sensitive measures will aid in accurately evaluating outcomes of nursing intervention.

Nursing expertise and time

Responding to call requests and initiating calls based on EPDS scores did not represent a significant burden on nursing time. The needs expressed by patients were readily met by an experienced maternal-child nurse, with knowledge of maternal mental health and skills in phone triage. In the future, protocols based on a care coordinator model could readily meet this purpose (Vanderboom et al., 2015). The most common time for patients to request a nursing call was in the first month, so perhaps interventions such as text messages could be more frequent during the first month. It is interesting that more nursing time was spent on calls made due to EPDS scores that were of concern (versus routinely offered calls) and many of these occurred around 6 months postpartum, suggesting that screening for depression should be included as part of a nursing intervention which extends until at least 6 months postpartum, far beyond the usual six-week postpartum appointment. This supports the recommendation by Peindl, Wisner and Hanusa (2004) that patients at high-risk for depression should be screened up until a year postpartum. On-line screening would help fill the gap that currently exists between pregnancies (Lu et al., 2006).

Respondents were more likely to have actionable scores on the EPDS if they had a history of depression, delivered by Cesarean section or were not low-income. It is widely accepted that a history of depression and anxiety is a risk factor for postpartum depression (Guintivano, Meltzer-Brody, & Manuck, 2018). Similarly, Cesarean birth has been identified as a risk factor for postpartum depression (Xu, Ding, Ma, Xin, & Zhang, 2017). Nursing intervention such as continued contact through electronic messages could be prioritized for women with known risks. The findings of increased depression in women who do not identify as low-income may be due to the attrition of low-income women in the study or may suggest other risk factors not measured such as employment/work stress in higher income women (Hewitt, Strazdins, & Martin, 2017). This suggests that work variables such as maternity leave options should be measured in future research on postpartum mood.

Limitations

Women who declined participation generally stated they were too busy or didn’t anticipate any issues with depression, which may have introduced bias related to self-selection. The intervention was offered to all interested women, regardless of depression risk and thus there may have been insufficient power to detect a preventative effect of the intervention. The messages may have affected women differently if they were already depressed or at high-risk, compare with women whose baseline EPDS scores were low. Further research with populations at higher risk or elevated baseline EPDS scores would be needed to determine effectiveness in women most at risk. This is particularly important given that women who did not continue in the study were more likely to be single and low-income, a group generally understood to be at higher physical and psychosocial risk for depression and parenting stress. It The length of the survey may have been burdensome amidst the demands of an infant and other responsibilities. The actual reasons for attrition from the study are not known and should be explored qualitatively in future studies.

The study is limited to a population from one hospital in the Northeast United States (i.e., predominantly white and well educated) and thus results cannot be readily generalized to other more diverse populations. Additionally, the study employed technology designed for another use (appointment reminders) and while economical, was limited in functionality and difficult to modify. More user-friendly electronic applications (i.e., “apps”) may be easier for women to use. The rudimentary functionality of the Televox technology used in the current study may have diluted the effect of the intervention being tested.

Conclusion

Women found the messages from nurses to be helpful and appreciated receiving them, despite the lack of significant change in outcome measures of depression or stress. In unsolicited communication at the end of the study, one respondent emailed “I love that it (the messages) asked me if I would like a nurse call. It really makes me feel like there is someone there to listen if I need it.” Another wrote “Words really could not describe how important the text messages were to my mental health while recovering from childbirth.” The high level of satisfaction with the intervention is promising. Future research is needed to identify nurse-sensitive outcome measures, particularly in women known to have one or more risk factors for postpartum depression.

A maternity nurse with triage skills and knowledge of referral sources would have the expertise required to administer the Intervention II model of care and thus could be a nurse already employed by the birth hospital. Respondents felt comforted and secure with the option to ask for a nurse, even when they did not choose to do so, suggesting an intervention effect which is preventative. Studies are needed which address prevention of postpartum mood disorders and/or benefits of timely intervention for women in the four trimester and beyond.

The number of calls initiated in response to high-risk scores on the EPDS suggests screening for depression using technology is a benefit to women and may facilitate access to care, minimizing complications of untreated depression. Using a high-quality app to facilitate nursing interaction and screening would facilitate outreach far beyond the usual six-week obstetrical follow-up. Further research is needed to determine nurse-sensitive outcomes of technology-assisted interventions which include the support, triage, education and screening provided in this study. Models which include a care-coordination role of the nurse assisted by technology could contribute significantly to the health and well-being of families during the postpartum period.

Impact:

Postpartum women report unmet needs for support and education. The interventions were perceived as being helpful but did not significantly reduce depressive symptoms or parenting stress. Nurses can use this research to inform development of innovative approaches to support postpartum women.

Footnotes

Trial registration number: ClinicalTrials.gov

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