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Running head: SUPPORT FOR MOTHERS WITH POSTPARTUM DEPRESSION

Mama’s Little Helpers:

A Community Support Campaign For Mothers with Postpartum Depression

Dana Hasert, Kaylen Hebert, Shelby Marber, Haley Thomas, Savannah Woodward

Western Washington University

Community Health

March 2017

SUPPORT FOR MOTHERS WITH POSTPARTUM DEPRESSION

TABLE OF CONTENTS

Section I. Program Rationale……………………………………………………………………...3

Section II. Literature Review: Contributing Factors……………………………..……………….8

Section III. Program Intervention and Implementation……………………………………….…17

Section V. Program Evaluation…………………………………………………………………..26

References…………………………………………………………………...…………………...30

Section I. Program Rationale

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Postpartum depression (PPD) is the most common complication of childbearing affecting

both women and their families (DMHSA, 2003). At a national level, PPD affects one in eight

new mothers (postpartum up to six weeks) with more than three million new mothers developing

PPD each year (CDC, 2017). Though all women of childbearing ages are susceptible to PPD,

mothers who experience unintended pregnancy, live in a lower socioeconomic status, have had

previous experience with mental illness, and who have a lack of social support are at a higher

risk for PPD (Abbasi, 2013; Muzik et al., 2015). In 2004, the Office of Disease Prevention and

Health Promotion (ODPHP) recognized PPD as a priority illness by including it as a Healthy

People 2020 sub-objective under the Maternal, Infant, and Child Health goals (Healthy People

2020, 2017). The sub-objective focuses on reducing hospitalizations related to postpartum

complications, including PPD (Healthy People 2020, 2017). The national recognition of PPD and

its related health complications suggest that there are further preventative measures to be

developed (Healthy People 2020, 2017).

In King County, Washington, mothers experience PPD at twice the global average, where

one in four mothers experience postpartum depressive symptoms (“Health of mothers and

infants”, 2015). Specifically, rates among 19-40 year old women with infants two to six months-

old in King County climb to a prevalence of 27% (CDC, 2017). Postpartum depression is a

recurring health problem that can lead to chronic depressive disorders, anxiety disorders, and

suicide in mothers as well as affect the developmental and cognitive competence of infants

(Chadha-Hooks, Park, Hilty, & Seritan, 2010). These symptoms stemming from the depression

following a pregnancy have a severe effect on daily tasks due to a loss of confidence in parenting

(Anderson, 2013). This may isolate a woman from her family and loved ones, including her own

child, resulting in infant learning and behavioral problems, inability for the child to interact with

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peers, or Sudden Infant Death Syndrome (SIDS) in extreme cases (Anderson, 2013). Considering

the widespread adverse consequences of PPD, this illness needs to be acknowledged as a

prominent health issue within King County, Washington. Collective preventative measures such

as family support groups and social awareness campaigns can thoroughly address determinants

of PPD (Muzik et al., 2015).

Defining PPD

There are three types of PPD illnesses: the baby blues, puerperal psychosis, and

nonpsychotic PPD (Rai, Pathak, & Sharma, 2015). Baby blues is a term referring to the sadness,

tiredness, and worrying following the birth of a baby, but typically resolves itself within one

week (CDC, 2017). Around 50-80% of all women experience the baby blues postpartum (Glavin,

Smith, Sørum, & Ellefsen, 2010). Puerperal psychosis is a disorder defined by severe episodes of

mental illness due to immediate biochemical imbalances following pregnancy (Glover, Jomeen,

Urquhart, & Martin, 2014). Symptoms present themselves within 72 hours postpartum with the

most severe symptoms lasting up to 12 weeks (Glover, Jomeen, Urquhart, & Martin, 2014).

Puerperal psychosis is rare with 0.1-0.2% of women experiencing symptoms (Glavin, Smith,

Sørum, & Ellefsen, 2010). Nonpsychotic PPD, generally just referred to as PPD, is defined as

moderate to severe depression experienced by a woman up to a year after giving birth (Glavin,

Smith, Sørum, & Ellefsen, 2010). Postpartum depression is experienced in roughly 8-15% of

pregnancies (Glavin, Smith, Sørum, & Ellefsen, 2010). Most commonly, PPD is diagnosed

within the first three months following delivery and can follow the preliminary baby blues

experienced by women (Glavin, Smith, Sørum, & Ellefsen, 2010). This program focuses on PPD

as it stands as the most common debilitating complication of childbearing (DMHSA, 2003).

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Diagnosing PPD occurs four weeks after delivery when a woman experiences five or

more of the following symptoms nearly every day for at least two weeks: depressed mood,

increased or decreased appetite, noticeable weight gain or loss, insomnia or hypersomnia,

psychomotor agitation, fatigue, feelings of worthlessness or inappropriate guilt, indecisiveness or

lack of concentration, or recurrent thoughts of death or suicidal ideation (American Psychiatric

Association, 2013). Experiencing any of these symptoms can make daily existence more

difficult. To experience five or more of the listed symptoms demonstrates an obvious impairment

to daily living and a severe drop from optimal physical and emotional health.

Risk Factors of PPD

The causes of mental illness prove challenging to pinpoint. Postpartum depression as a

mental illness, however, maintains a few key factors that put some mothers at a higher risk. In a

2008 meta-analysis of postpartum studies conducted by the National Institutes of Health, it was

found that previous experience with mental disorders is the single most predictive factor of PPD

(Haidich, 2010). A lack of social support in combination with an abundance of stressful life

events experienced during pregnancy are the second strongest indicators (DMHSA, 2003).

Stressful life events may include pregnancy complications or birth defects, illness, job loss,

relationship instability, and financial instability (NIMH, n.d.). Among the 14,000 women

studied, the moderate predictors of PPD also included child care stress, infant temperament, and

neuroticism (DMHSA, 2003). Personal factors like stress and social support can reinforce

depressive symptoms of PPD (e.g. anxiety, guilt, hopelessness, mood swings, panic attacks), and

cause minor precursors to the compounded experience that is PPD.

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Effects of PPD

Postpartum depression can have long-lasting effects when untreated. Specifically,

mother-infant attachment can be significantly compromised when mothers suffer from PPD

(Chadha-Hooks, Hui Park, Hilty, & Seritan, 2010). In addition to infant developmental delays,

the mother may experience a significant increase in morbidity and mortality risks when

symptoms are ignored. Nearly half of all women who suffer from PPD continue to show elevated

depressive symptoms one year after diagnosis (Chadha-Hooks, Hui Park, Hilty, & Seritan,

2010). When untreated, suffering from PPD can become a chronic depressive disease with the

potential for suicide or self-harm (NIMH, n.d.). It is also important to note that women who have

previously suffered from PPD have a 25% recurrence risk in future pregnancies (Chadha-Hooks,

Hui Park, Hilty, & Seritan, 2010). It is critical to either detect and intervene on PPD, or impede

the onset altogether by using preventative measures.

Screening of PPD

Preventing PPD at the individual level is a daunting task, especially due to the

uncertainty of the new life changes childbearing may bring. Because parenting comes with its

own variety of biological, social, and emotional factors, it is challenging to address preventative

measures for PPD. Even though PPD is difficult to prevent on the individual level, there are

proven techniques that reduce its widespread effects. Prenatal screening has proven to be one of

the most effective preventative services currently available for new mothers and ultimately

decreases PPD rates (Chadha-Hooks, Hui Park, Hilty, & Seritan, 2010). These screenings take

place routinely within obstetrics and gynecology (OB/GYN) practices, family practices, and

pediatric specialties. There has been success in identifying mothers who eventually develop PPD

by using the Edinburgh Postpartum Depression Scale (EPDS) at three to five days postpartum

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(Chadha-Hooks, Hui Park, Hilty, & Seritan, 2010). In addition, healthcare providers in family

and OB/GYN practices screen and assess at-risk women using clinical methods such as analysis

of symptoms and physical examinations (Chadha-Hooks, Hui Park, Hilty, & Seritan, 2010). The

complexity of developing PPD speaks to the multidimensional interventions required for

prevention, and will not be impacted by one universal approach. This program is similar in

philosophy by culminating a comprehensive route to mitigate effects of PPD.

Prevention and Treatment of PPD

Although the impacts of PPD upon a mother’s health are well-understood, a lack of

preventative measures, treatment, and support are available for those affected (Stewart,

Robertson, Dennis, & Grace, 2004). Therefore, a proposed approach for PPD must align with

treatments used for generalized depression. Such treatments may include antidepressants,

acupuncture, and an increased intake of omega-three fatty acids (Fitelson, Kim, Baker, & Leight,

2010). Therapeutic treatments may include a variety of therapy-based approaches such as

interpersonal therapy, cognitive behavioral therapy, and nondirective counseling. Furthermore,

because the biggest preventable risk factor for PPD is lack of social support, addressing social

satisfaction is crucial. Treatment options such as prescription antidepressants or therapy remain

significant resources for new mothers. Postpartum depression, as demonstrated in the literature,

is most successfully managed with protective factors such as positive social support and

community foundation (Leger & Letourneau, 2015).

Taking Action for King County Mothers with PPD

Mama’s Little Helpers: A Community Support Campaign For Mothers with Postpartum

Depression addresses social and economic barriers of prevention and treatment. Mama’s Little

Helpers aims to destigmatize and bring awareness to PPD in King County. In addition to

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community outreach, this program provides support for those suffering and at-risk for PPD so

mothers can experience a healthy mental state through the postpartum period and beyond. While

a number of support groups exist within King County, Mama’s Little Helpers addresses several

barriers which often hinder at-risk populations from seeking help (Stenius and Veysey, 2005;

Washington Resource Guide, n.d.). Overall, this program seeks to decrease the rates and impacts

of PPD in vulnerable mothers living in King County, Washington. Public understanding and

social support systems can be realized through this program’s focus on inclusivity, education,

and social marketing.

Section II. Literature Review

Intrapersonal Factors

Biology. Postpartum depression (PPD) is a complex condition, and determinants of the

disease span from public policy to a woman’s individual biology. The physical and hormonal

changes that occur over a nine-month period which enable a woman’s body to support the

growth of new life are significant (Lokuge et al. 2011). Women are at high risk for depression

during pregnancy-related hormonal fluctuations (Lokuge et al. 2011). Unfamiliar biological

changes add to the overwhelming emotional and physical experience of having a child. Women,

spouses, families and healthcare professionals are often challenged by differentiating PPD and

the typical effects of post-childbirth emotions (Holopainen, 2002). Postpartum depression can go

undetected by mothers when they disregard key symptoms as the mere changes of becoming a

new mother (Holopainen, 2002).

Mehta and colleagues found that increased sensitivity of estrogen during the third

trimester of pregnancy, and up to six weeks postpartum, can lead to decreased levels of serotonin

release, a neurotransmitter that is commonly associated with happiness (Mehta, 2014). In

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addition, women may experience mood-change symptoms due to changes of estradiol, a steroid

precursor to estrogen, causing a negative or adverse state of mind (Holopainen, 2002). These

hormonal changes alone can put women at a high risk for PPD (Holopainen, 2002). A systematic

review of 214 publications found that the highest biological risk factors for PPD are

hypothalamic-pituitary-adrenal dysregulation, inflammatory processes, and genetic

vulnerabilities (Yim, 2015). Although the root cause of PPD is difficult to pinpoint, it is clear

that hormones are heavily involved. Considering the role of hormones is imperative when

addressing PPD, yet other biological factors exist.

History of mental illness can also put a mother at-risk of PPD (Yim, 2015). Several

publications found that a previous mental illness (e.g. bipolar I and II, major depressive disorder,

and anxiety) is a significant contributory cause of PPD in new mothers (Yim, 2015).

Compounding social factors can cause relapse in mental illness, and reinforce biological

determinants of PPD.

Personal beliefs. Provided inclusive and appropriate resources, PPD has the potential to

be managed and treated. One of the first steps needed in addressing PPD is acknowledgement of

the significant lack of awareness surrounding this health issue (Mikelson, 2016). With the rush of

life changes that childbearing brings, women may be unable to identify the symptoms of

depression (Dennis, 2006). Without an understanding of PPD and recognizing its high

prevalence, experiencing such distress can be misunderstood as the fault of the individual. When

expecting a new child, harmony and joy are also expected to follow, but this is not a universal

reality (Zauderer, 2009). In turn, some women may feel ashamed by any emotion other than

elation, and may take extraordinary efforts to deny or mask negative feelings experienced

alongside motherhood. The symptoms of PPD truly exemplify the antithesis of what society

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assumes a new mother to feel (Zauderer, 2009). Anxiety, guilt, apathy, doubt of self-efficacy, or

lack of connection to the child prove to be feelings some women hide in fear of having their

child taken away or in an effort to buffer the deviance from such high expectations (Zauderer,

2009). Symptoms should not be absconded, but understood as indications of a legitimate illness

(Mikelson, 2016).

Vulnerable populations. Unintended pregnancy has also been linked to increased risks

of PPD (Kettunen, Koistinen, & Hintikka, 2016). A study surveying approximately 3,000 women

found that PPD prevalence is higher among women who did not have a planned pregnancy

(Abbasi, 2013). The possible implications of these findings may be important in preventing PPD

within populations susceptible to unintended pregnancy. Specifically, teenagers, non-white,

unmarried women of a lower socioeconomic status are more likely to have an unintended

pregnancy (Abbasi, 2013). Unintended pregnancy is not the only complication that factors into

the risk of PPD for these vulnerable populations. Access and availability to screening for PPD

also present barriers (Gjerdingen & Yawn, 2007). Further discrepancies exist, however, even

when these women receive screening or seek maternal health resources (Gjerdingen & Yawn,

2007). To effectively prevent PPD, the socioeconomic and racial determinants that influence this

population’s vulnerability must be counteracted through recognition and personalized care.

Interpersonal factors

Cultural stigma. Susceptibility to PPD can also be determined by forces beyond the

individual. Social norms, cultural beliefs, and attitudes of close family and friends propagate the

stigma around mental illness in western culture (Office of the Surgeon General, 2001). Cultural

stigma permeates many levels of intervention, from the home all the way to diagnosis in a

professional medical setting. Stigma of PPD results in the dismissal of its legitimacy by health

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professionals, family, and peers (Boyd, Mogul, Newman, & Coyne, 2011). Bias such as this

hinders treatment and preventative processes (Boyd, Mogul, Newman, & Coyne, 2011).

Providers have acknowledged that they view PPD as common, serious, and treatable.

(Gjerdingen & Yawn, 2007).

Even though providers may tend to acknowledge PPD as a prevalent and serious illness,

implementation of regular screening is low, ranging between 0% and 50%, which is in part due

to the stigma attached to PPD (Seehausen, Baldwin, Runkle, & Clark, 2005). Without screening,

treatment, and rehabilitation, PPD continues to burden women in western culture. Social and

cultural acceptance, or lack thereof, determines the duration, severity and frequency of PPD in a

culture that undermines mental health altogether (Abdollahi, Lye, Zain, Ghazali, & Zarghami,

2011). Mothers themselves may internalize such stigma especially when faced with the isolation

motherhood may bring (Braun, 2015). Solitude can intensify doubt, and prevent mothers from

seeking help in friends, family and healthcare professionals (Braun, 2015).

Social support. Women without a strong social support network are at risk for PPD

(Elsenbruch et al., 2006). Pregnancy and childbearing can be challenging to navigate. Without a

community to provide care and insight, additional stressors can take a serious toll on mental

health and, in turn, lead to PPD. Coburn and colleagues evaluated women for PPD and its

relationship to prenatal stress (Coburn, Gonzales, Luecken, & Crnic, 2016). Higher levels of

interpersonal support and proactive stress management are associated with reducing risks for

PPD (Coburn, Gonzales, Luecken, & Crnic, 2016). Those women who received consistent social

support throughout the entirety of their pregnancy and postpartum period exhibited a decreased

risk (Coburn, Gonzales, Luecken, & Crnic, 2016). Furthermore, without social support, women

are less likely to become involved in social programs designed to support new mothers such as

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lactation support groups and new mom counseling groups (Elsenbruch et al., 2006). Mothers

lacking sufficient support also have a more difficult time reaching out to others who may be

having similar experiences and may not be prepared with the appropriate psychosocial resources

for self and new-child care (Elsenbruch et al., 2006). Information such as this indicates that a

reliable support system has the potential to help treat and prevent PPD. With the emotional and

social support from loved ones, women often find increased self-efficacy and preparedness for

the stresses that new parenthood brings (Elsenbruch, 2006).

Institutional factors. Institutions have the potential to form behavior and attitudes

surrounding health and healthcare. Women and mothers expect to receive the best quality of care

when relying on the healthcare system throughout pregnancy and their child’s life. When the

institution (i.e. the healthcare system) neglects certain aspects regarding mental health, many

women can slip through the cracks and miss the crucial early-diagnosis of PPD (Andrews-Fike,

1999). Conversely, many positive changes may arise when intervention occurs within the

healthcare system as hospitals, clinics, and pediatrician offices treat patients throughout

pregnancy and the postpartum period.

Attitudes of healthcare workers. Screening procedures like the Edinburgh Postnatal

Depression Scale (EPDS) maintain a potential to diagnose and therefore treat PPD in women

before and after pregnancy (Provincial Health Services Authority, 2017). Renowned screening

procedures, however, obtain zero potential to diagnose the target population if healthcare

professionals are ill-trained or uncomfortable to use or interpret them. Healthcare professionals

may be reluctant to bring up PPD due to inadequate training in mental health treatment or in fear

of offending patients (Jones et al., 2013). Even when they receive training, many medical

professionals report a lack of confidence within the realm of mental health, resulting in the

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avoidance of conversations about PPD (Jones et al., 2013). While most health care providers

believe PPD is a serious illness that may be prevented and treated, many providers fail to screen

or bring up the subject of mental health throughout perinatal and prenatal visits due to a low

confidence and discomfort with the subject (Jones et al., 2013).

Along with this bias that discourages healthcare professionals from screening, the

attitudes and dispositions of healthcare workers influence whether or not women will disclose

symptoms, undergo PPD screenings, and subsequently receive treatment when needed

(Shakespeare et al., 2003; Jones et al., 2013; Buist, 2006).

Confidence in screening process within healthcare facilities. Contrary to the

discomfort held by providers, many studies show women find the PPD screening process

acceptable and simple to use (Bilszta, Ericksen, Buist, Brealey et al., 2010). Although the EPDS

proves itself a manageable instrument for diagnoses, social stigma of PPD for mothers prevents

many from either accepting or taking action on a diagnosis (Brealey, Hewitt, Green, Morrell,

Gilbody, 2010). Brealey and colleagues investigated the screening process in hospitals and

pediatric offices, finding 25% of women to score a 12 or higher on the EPDS, and thus were

diagnosed as ‘at-risk’ for PPD (Brealey, Hewitt, Green, Morrell, Gilbody, 2010). Of the women

that scored higher than a 12 on the EPDS, 16% ignored the assessment altogether, 29%

experienced some level of upset upon learning the diagnosis, 27% were unsure of the results, and

23% were somewhat relieved by having a diagnosis (Brealey, Hewitt, Green, Morrell, Gilbody,

2010). The 16% who ignored the results illustrate how a crucial amount of women who get

screened remain idle in the wake of a valid diagnosis.

Stigma aside, new mothers may also fail to take action due to the hassle, follow-up

appointments, and availability of establishments that can provide treatment and further diagnosis

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(Nelson, Freeman, Johnson, McIntire, & Levano, 2013). The outlined procedure for all hospitals

that screen with the EPDS states patients with high scores (above 11 or 12) be referred to a

mental health professional in order to receive a full diagnosis and/or subsequent treatment

(Mental Health America, 2013). Anywhere from 17.6% to 47% of women who receive referrals

for further evaluation or treatment complete that referral (Goodman & Tyer‐Viola, 2010; Kelly,

Zatzik, & Anders, 2001; Nelson, Freeman, Johnson, McIntire, & Levano, 2013). Most facilities

where women tend to get screened lack the necessary infrastructure to also diagnose and treat

PPD (Goodman & Tyler-Viola, 2010; Nelson, Freeman, Johnson, McIntire, 2013). With this

disconnect between providers, many women neglect follow-up on screenings, referrals, and

therapy appointments (Buist, O’Mahen, & Rooney, 2015). Even for sites with an adequate

foundation including the required services available, barriers to full implementation still exist

(Nelson, Freeman, Johnson, McIntire, & Levano, 2013). When appropriate infrastructure is in

place to remedy the disconnect, it is still difficult to find sufficient time required to treat and

diagnose mental illness for mothers (Nelson, Freeman, Johnson, McIntire, & Levano, 2013).

Still, many women report a need for mental health resources that incorporate this inclusive

foundation, pointing to a need for intervention on a systemic and community level (Buist,

O’Mahen, & Rooney, 2015).

Community Factors

The community a new mother is a part of is a potential determinant of PPD. As current

literature demonstrates, accessibility to community resources ‒ or lack thereof ‒ can have a

significant impact on mothers suffering from PPD (Buist, O’Mahen, & Rooney, 2015).

Resources within a community. According to Buist and colleagues, a huge barrier for

women experiencing PPD is the availability and accessibility to a therapist located within their

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community (Buist, O’Mahen, & Rooney, 2015). New mothers submerged in newfound

obligations, such as balancing finances and arranging childcare, may find it overwhelming to

also find an appropriate therapist for themselves (Buist, O’Mahen, & Rooney, 2015). Though

community factors are often overlooked, it is important to recognize that new mothers benefit

from a community conducive to maternal wellness and connectivity. Other community factors

that may increase the likelihood of PPD include one's proximity to exercise or recreational

activities, maternity care centers, or support groups with other mothers and families that may be

experiencing the same challenges of parenthood (Sutter, White, Bora, Morchen, & Magee,

2012).

Community diversity. Another community factor to consider is linguistic diversity

among a population. Buist and colleagues observed women from a range of culturally and

linguistically diverse groups in the year following birth (Buist, O’Mahen, Rooney, 2015). When

trying to seek treatment, mothers who had just given birth and were from a migrant background

proved to have a difficult time identifying their mental health problems to health professionals

(Buist, O’Mahen, Rooney, 2015). Emotional terminology can take on several different

connotations depending on one’s background. To reinforce potential misunderstandings,

language barriers persist as a large hindrance when attempting to divulge sensitive information

about mental state and emotions (Buist, O’Mahen, Rooney, 2015). Health care professionals’

limited familiarity of other cultures can compromise the services offered to a patient (Milgrom &

Gemmill, 2015). Certain communities may be unable to support this need for cultural diversity.

However, at a societal level, policies can remedy shortcomings like language barriers and more.

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Public Policy

Postpartum depression can also be managed at a public level, where nationwide policy

influences change on a personal level. Policies can include parental leave and mandatory

screening standards (Dagher, Hofferth, & Lee, 2014; Pirkis et al., 2005).

Standardized screening. Stigma percolates into all corners of mental illness, even into

the professional sector, skewing the screening process (Seehausen, Baldwin, Runkle, & Clark,

2005). To mitigate undetected cases of PPD (among other mental illnesses) some countries have

mandated universal screening procedures (Pirkis et al., 2005). Australia has one of the largest

mental health care initiatives, where the government partners with individual clinics, hospitals,

and other institutions to standardize the screening process (Pirkis et al., 2005). Depending on

national, state or local regulations to ensure thorough and unbiased screening, a mother can be at

a higher risk of PPD (Boyd, Mogul, Newman, & Coyne, 2011). Since Washington does not

require standardized screening, stigma can cause negligence among providers to ensure thorough

detection (Nelson, Freeman, Johnson, McIntire, & Levano, 2013; Rhodes, & Segre, 2013).

Maternal leave. Welfare programs, such as nationally subsidized or mandated maternity

leave, allow mothers to recover from birth and bond with their child (Dagher, Hofferth, & Lee,

2014). Maternity leave policies conventionally only allow six weeks for new mothers to recover,

which is typically before most women are mentally and physically able (Dagher, McGovern, &

Dowd, 2014). In addition, the Family and Medical Leave Act of 1993 does not require employers

to compensate women at all while on maternity leave (Dagher, McGovern, & Dowd, 2014). In

the U.S., maternity leave applies to a small portion of the population, where it only provides

employment security for women fully established in their careers (Dagher, McGovern, & Dowd,

2014). Otherwise, mothers with inconsistent employment, or those who worked for small

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organizations are at risk of losing their jobs altogether, creating more stress and urgency to return

to the workforce. Considering the insufficient social welfare programs on a federal level,

mothers in modern America are faced with a multitude of stressors that predispose them to

developing depression as new parents (Dagher, McGovern, & Dowd, 2014). National

interventions cultivate a potential to mitigate the determinants so far discussed.

The development of PPD has compounding determinants that cannot be addressed in one

sweeping policy or program. This health problem is a cultural crisis, and results from a

culmination of social isolation, emotional neglect, and internalization of unrealistic expectations

of motherhood (Abbasi, 2013; Zauderer, 2009). Whether it be on personal or societal level,

evidence-based intervention has the ability to diffuse a sense of destigmatization and promotion

of maternal mental health for an entire population. This program intends to imbue a sense of

urgency in care for King County’s maternal population to do its part in the collective force for

healing maternal mental illness as a whole.

Section III. Program Intervention and Implementation

Focus of the Intervention

Mama’s Little Helpers: A Community Support Campaign for Mothers with Postpartum

Depression aims to deliver an awareness of postpartum depression (PPD) to King County in an

effort to destigmatize and promote a culture of mental health resilience through a

multidimensional approach. In one dimension, this program targets all King County citizens in

an effort to inform and destigmatize PPD. Another dimension targets vulnerable populations of

mothers who are more likely to develop PPD by providing a support group. Women who

experience unintended pregnancy, who have previous experience with a mental illness, or who

reside at a low socioeconomic status are considered vulnerable populations for this program.

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The educational television advertisement from this program ignites an urgency within

mothers and community members of King County to view a comprehensive online resource.

This website seeks to break down misconceptions surrounding PPD with inclusive, factual

information about symptoms, treatment, and prevalence as well as personal testimonials of real

community members. Should women self-identify with symptoms of PPD, the website

encourages them to sign up for the program’s weekly support group devoted to building

confidence and reducing symptoms of PPD. Due to the extensive research that points to social

support as a way to remedy PPD, Mama’s Little Helpers considers the needs of new mothers (i.e.

has a child ages 0-1) experiencing PPD symptoms. These needs include an intense focus on

camaraderie and self-confidence, as well as community awareness to reduce stigma.

Mama’s Little Helpers is modeled after two evidence-based interventions (EBIs),

Beyondblue and Mom Power. Both EBIs aim to activate change on the interpersonal and cultural

determinants, as well as the larger cultural factors of PPD. Beyondblue is a widely encompassing

depression initiative which was implemented in Australia in the early 2000’s. Their initiative

focuses on community awareness and destigmatization via advertisement and community events

(Beyondblue, 2004b). Australia’s success in enrolling citizens in advocacy programs (e.g.

Beyondblue) and patient-provider networks can offer guidance in future programs for specific

forms of mental illness, like PPD. Similar to telehealth, a patient-provider network is an online

community where sufferers of mental illness connect with healthcare professionals in their area.

Mama’s Little Helpers also incorporates a community support group based off of Mom

Power, which emphasizes the importance of considering the diverse needs of mothers in a

vulnerable population. This program seeks to break down barriers that often prevent vulnerable

populations from accessing such care (Muzik et al., 2015). Onsite childcare, a meal at the

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beginning of each session, and transportation are provided to mothers at no cost. These

provisions incentivize attendance of the support group for mothers and, more importantly,

alleviate the pressures of common barriers to receiving treatment.

Core components. Several integral components are crucial to fulfilling the overall goals

and mission of Mamma’s Little Helpers.

Advertising. To destigmatize PPD in the community, a television advertisement brings

PPD into mainstream media and reaches a wide range of residents in King County. Media

initiatives engage viewers on an anonymous, non-confrontational forum, and present factual

information on PPD. Broadcasting this information directs viewers to the program’s website,

which provides further information on recognition, risk factors and symptoms of PPD.

Additionally, the advertisement directs viewers to mental health hotlines and therapists within

the county.

Support group. Traffic on the website also provides a platform for support group

recruitment. Mothers pursuing a supportive community are directed to a registration form for the

13-week support group, which is offered four times per year.

Support group content. Two mental health care professionals facilitate a support group

that is both educational and conversational based. Over the course of 13 weeks, six to eight

mothers attend a small group meeting. Three out of the 13 meetings will be a one-on-one session

between a facilitator and a mother. By providing a safe and welcoming space for mothers to

practice self-care, this support group focuses on building confidence and increasing self-efficacy

of parenting skills.

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Program mission, goals, and objectives

Mission statement. The purpose of ‘Mama’s Little Helpers: A Community Support

Campaign for Mothers with Postpartum Depression’ is to bring awareness to and destigmatize

PPD in King County. In addition to community outreach, this program provides support for those

experiencing and at-risk for PPD so that women can experience a healthy mental state through

the postpartum period and beyond.

Goals & objectives.

Goal one. Deliver awareness campaign to citizens of King County in effort to

destigmatize PPD while promoting a culture of maternal mental health resilience prior to

initiation of Mama’s Little Helper support groups.

Objective 1.1 Process. Recruit two spokespersons, adequate crewmembers, and sufficient

television equipment necessary to write, perform, film, and edit content before airing the

advertisement.

Objective 1.2 Process. Prior to airing the advertisement, develop convenient, easy-to-use

website where community members and mothers can access educational information, learn about

available local resources, and sign up for the program’s support group.

Objective 1.3 Process. Air advertisement 14 times per week for 12 months on local

children's television and local news networks. Advertisement has one month of air time prior to

starting the program’s support group.

Objective 1.4 Impact. Of the community members in King County who are exposed to

advertisement, 20% become more aware of effects, symptoms, treatment, and prevalence of PPD

within first year of advertisement airing.

Objective 1.5 Impact. Of the new mothers (i.e. has a child ages 0-1) in King County who

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are exposed to the advertisement, 20% become aware of effects, symptoms, treatment, and

prevalence of PPD within the first year of the advertisement airing.

Objective 1.6 Outcome. Of the community members that visit the website, 60% are able

to list five or more symptoms/risk factors of PPD.

Objective 1.7 Outcome. Mothers who may have PPD or show symptoms feel

empowered and able to attend a support group. At least 40% of mothers who attend support

group have seen the advertisement.

Goal two. Provide support and create a community for vulnerable women (i.e. previously

addressed population) experiencing PPD in King County with the intention of reducing the

impacts and rates of PPD.

Objective 2.1 Process. Before implementation of support group, recruit eight clinicians to

facilitate four support groups throughout the year. All facilitators complete an eight-hour online

training prior to initiation of the support group.

Objective 2.2 Impact. Upon completion of the support group, participating mothers report

their experience (i.e. satisfaction, improvement of understanding how to handle their children’s

behaviors when upset, learned useful coping strategies, felt supported by the facilitators, made

social connections with the other support group participants) using a Likert scale on a post-

support group survey.

Objective 2.3 Impact. Upon completion of the support group, at least 90% of participating

mothers report a high satisfaction with the support group and 60% of participating mothers report

experiencing fewer self-reported PPD symptoms.

Objective 2.4 Impact. Upon completion of the support group, 85% of mothers feel

confident utilizing self-care tools practiced throughout the 13 weeks and all participating mothers

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know of resources that may be accessed beyond the program to ensure continuation of PPD care.

Objective 2.5 Impact. When screened with the EPDS at the end of the program, at least

70% of participating mothers report less symptoms and score lower than their original score on

the EPDS scale, indicating reduction in PPD symptoms.

Objective 2.6 Outcome. Within five years, rates of PPD in King County decrease by 15%,

translating to one in just over six women experiencing PPD.

Intervention Plan

Key features. The first key feature of delivering awareness of PPD to King County is

prompted by the television advertisement that discusses the stigma surrounding maternal mental

illnesses. This requires several steps, which starts with the writing of a script that brings to light

the high rates of PPD in King County and provides facts encompassing PPD. The advertisement

features local community members who are charismatic and have personally experienced the

impact of PPD, whether it be themselves or a loved one. By discussing stigma with respect to

PPD, mothers are encouraged to feel empowered and take action in seeking help. Emphasis is

placed on dispelling shameful or negative feelings, as PPD does not decipher one’s parenting

skills or represent a lack of love for one’s child (Anderson, 2013). In addition, examples of how

to recognize the signs of PPD are presented within the advertisement. The advertisement airs

twice a day, once in the morning and once at night for a 12 month period. To reach a wide

population of new mothers, the advertisement is aired on a network directed toward young

children, as well as on a local news networks.

Mama’s Little Helper’s web developer and supporting staff maintain the website that

presents current resources within King County such as hotlines, online therapists, and the

program support group information and registration. Information regarding the support group is

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directed toward a vulnerable population who would generally be less likely to attend, due to lack

of resources.

To sufficiently fulfill goal two (providing support and creating a community for women

experiencing PPD in King County with the intention of reducing the impact of PPD symptoms),

four community support groups are held every year. These support groups span a 13-week period

and are facilitated by two trained mental health professionals. Three one-on-one sessions

between mother and facilitator take place to evaluate the mother’s goals for the support group.

Here, the mother and facilitator discuss specific barriers for the mother and how they may be

reduced or eliminated to maximize benefits. These sessions are placed during the first, sixth, and

thirteenth week of the program. During the final one-on-one session, the clinician refers a mother

to further care on an individualized basis. The other 10 sessions are held once a week in a group

setting, with six to eight other participating mothers. To address common help-seeking barriers

within this population, onsite childcare and a group meal are provided free of charge.

Transportation arrangements are made for those in need. Starting each session with a group meal

allows for mothers to connect with others in situations similar to their own, working to build a

source of social support. Facilitators create a space for mothers where they are treated with

compassion, respect, and positive encouragement. Following the meal, facilitators lead

discussions around breaking down stigma and shame of PPD, developing self-care skills, and

building effective parenting skills. Provided with a safe space, mothers can share their personal

experiences, allowing responses from both facilitators and other participants. Each session is

concluded with child-mother playful activities to end on an uplifting note.

Program support components. To ensure sustainability of this program, there are

several support components set in place. The awareness campaign advertisement is written with

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consultation from a mental health professional. Community members for the awareness

campaign receive a script with educational information about PPD as well as resources that may

be accessed for those experiencing PPD.

Prior to meeting with mothers, two mental health care professionals complete an eight

hour online training focused on supporting women with PPD. This online module is hosted by

Postpartum Services International and the 2020 Mom Project (Maternal Mental Health

Certificate Training, n.d.). At the beginning of each support group, any new facilitators must take

the online training and previous facilitators take a brief online refresher course. Facilitators also

attend one training with a program director to discuss guidelines, curriculum, and expectations

specific to Mama’s Little Helpers. A hard copy overviewing the 13-week support program is

provided to each facilitator. The outline contains checklists for topics to cover each week, a

debrief section for each session, as well as contact information for further support from the

program coordinators if necessary. Evaluation of these components are discussed further on.

Other programmatic needs. The awareness campaign requires studio space to film,

community members to read the script, directors, and script writers. A technical support staff are

available for maintaining the website. The YMCA provides space for the support group

component of the program. Two to three child-care staff are available during support group

sessions. Other needs include transportation, local restaurants to contribute to the weekly meal,

and supplemental materials (e.g. diapers, changing table, baby wipes, formula, first-aid-kit, baby

carrier/sling, nursing pad, nipple cream, nursing pillow) used during the support group.

24


Logic Model

25

Meal Coordinator

Web Design Crew

Childcare

Camera crew& Film

equipment

Website

Support group

TV advertiseme

nt

Facilitators

Funding

Transportation

Training for

facilitators

Evidence Based

material

OutputsInputs

Planned Work

Prevalence:

Raised public

awareness of PPD

Reduced stigma

surrounding PPD within

county

Lower Rates of PPD

Less reported

Behavior:

Attendance of Support

Group

Facilitators make

referrals for participants

in need

Mitigate symptoms of PPD within

participating mothers

High number

Knowledge:

King County is exposed

to advertiseme

nt

Community members

can identify PPD

symptoms

Long-term

Mid-termShort-term

Outcomes

Intended Results


Section IV. Program Evaluation

This evaluation gauges the success of the implementation of Mama’s Little Helpers: A

Community Support Campaign For Mothers with Postpartum Depression. To evaluate the

entirety of this program, the process, impact, and outcome objectives are assessed separately.

Process Objectives

Goal one. Before airing the awareness advertisement, various groups are engaged to

ensure the message is appropriate, effective, and all of the logistics go smoothly. The initial

process of recruiting a spokesperson, crew, and equipment for the advertisement requires a

checklist of all roles. A confirmation with the television station that plays the advertisement is

needed to establish that the advertisement is aired 14 times per week, for 12 months. Pilot tests

of the advertisement are presented to third party community members. Pilot test participants are

questioned on whether or not the message is clear, what could be improved, and if their

understanding of PPD changed after viewing the advertisement. Feedback is taken into

consideration and adjustments are made as necessary.

Program facilitators also review the Mama’s Little Helpers website for appropriateness

and monitor it continuously to gauge its effectiveness. Before launching, Mama’s Little Helpers

website is proofread by a third party to ensure appropriate language (e.g., easy to read, respectful

of trigger warnings, empathetic and non-victim blaming). Website users can contact a technical

support team via phone to address any technical difficulties. To assess the reach of the website, it

is monitored for number of visits per month and number of online sign-ups for the support group.

Goal two. Throughout the 13-week support group, a number of evaluations take place.

Specifically, after each weekly group meeting the facilitators debrief to discuss whether or not

they covered the planned educational materials for that session. Facilitators also discuss their

26


observations of the participants for that week; how each mother engaged with both the

facilitators and other mothers as well as their responses during the prompted discussion time.

Halfway through the 13-week program, there is a one-on-one meeting with facilitator and mother

to check in. This session provides space for a conversation about support group progress and to

determine further barriers or needs to be addressed to make the support group as beneficial to the

mother as possible. This meeting is recorded. These qualitative data are analyzed post-support

group to assess the progress of participants and to identify deficiencies the program could

improve on in the future.

Impact Objectives

Goal one. A quasi-experimental pretest-posttest design measures the overall change in

community and mother awareness of PPD. King County is compared to another county with

similar rates of PPD, who were not exposed to the awareness advertisement. Before the

advertisement airs, as well as one year after it airs, a survey is disseminated via mail to a sample

of community members within both counties. Questions on the survey gauge the participant’s

knowledge of symptoms, impacts, and prevalence of PPD in their county. If the participant is a

new mother (i.e., has a child ages 0-1) the survey asks if mothers know where to find available

resources for PPD.

Additionally, the impact evaluation helps determine if the awareness advertisement

increased new mothers’ motivation to attend support groups. This change in behavior can be

evaluated by asking mothers in a pretest survey how they heard about Mama’s Little Helper’s

support group. These data are analyzed to see if King County residents who were exposed to the

awareness campaign advertisement also had increased knowledge about the effects, symptoms,

treatment, and prevalence of PPD within the first year of the advertisement airing. The goal is to

27


see a 20% increase in awareness in residents of King County compared to residents of the county

not exposed to the advertisement.

Goal two. An evaluation of the support group is conducted using a non-experimental,

pretest-posttest design. A survey is administered to mothers prior to the first meeting and

following the last meeting at 13 weeks. The survey assesses self-efficacy of parenting skills,

individual confidence level, and self-reported PPD symptoms. The exit survey includes a section

for mothers to rate their satisfaction with the support group and if they would recommend the

group to others. The goal is to receive a response of 90% of participating mothers reporting

satisfaction with the support provided by Mama’s Little Helpers.

The mothers fill out the Edinburgh Postnatal Depression Scale (EPDS) with a clinician

before and after support group, which is used alongside the surveys in the pretest-posttest

evaluation. These data are analyzed to see if the goal of 70% of mothers self-reported less

symptoms and scored lower than their initial score on the EPDS scale. To support the

implementation of the program, facilitators also participate in a brief exit interview. Questions

inquire about whether or not the program provided sufficient support and resources.

To determine whether or not Mama’s Little Helpers support group is impactful long term,

there is to be a final survey sent to the participating mothers one year after completing the group.

This survey asks for a self-report of PPD symptoms, if the mothers have accessed further care

from their group exit referrals, and whether or not the self-care tools are being utilized. This

allows for the program to make adjustments to improve future support groups and provide the

best possible long-term outcome to mothers involved.

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Outcome Objectives

Overall, this program seeks to decrease the impact and rates of PPD for at-risk mothers

within King County by 15% within five years. County data are monitored to gauge if rates of

PPD have gone down. Additionally, Mama’s Little Helpers strives to increase community

awareness, and decrease overall stigma through advertising and access to factual information on

Mama’s Little Helpers website. This can be evaluated by tracking traffic on the website, and

distributing surveys to a random sample of community members by mail over the duration of the

next five years.

29


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