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Project

From theory to practice. The development and evaluation of a resilience-enhancing intervention for pregnant women.

The perinatal period is considered a sensitive life-changing experience marked by significant and profound changes in biological, psychological, familial and social domains. Keeping a balance between these different domains may be challenging for (expectant) parents, putting them at greater risk of developing perinatal mental health problems. Maintaining resilience during pregnancy may be crucial for psychosocial adaptation to this life-changing event and plays an important role in the prevention of perinatal mental health problems.

Perinatal mental health refers to the well-being of parents during pregnancy and the first 12 months after childbirth. Problems during this period are considered as a major public health concern, given the significant long-term health consequences on parents and their offspring. In addition to the human cost, perinatal mental health problems are expected to generate significant societal and economic costs. Unfortunately, universal preventive interventions, designed to benefit all pregnant women, are limited, and their effectiveness remains relatively unknown. Our hypothesis is that a preventive intervention focusing on strengthening resilience during pregnancy, integrated into existing perinatal care, can be beneficial for all pregnant women.

The objectives of this dissertation focus on understanding the concept of resilience within the perinatal context, systematically develop an online intervention aiming to enhance perinatal resilience, and evaluating the potential effectiveness and feasibility of the developed intervention.

In Chapter 2, we defined the concept of perinatal resilience through a concept analysis, using the Walker and Avant framework and a two-round Delphi survey. Based on these findings, perinatal resilience can be defined as “a circular process towards greater well-being in the form of personal growth, family balance, adaptation, or acceptance when faced with stressors, challenges, or adversity during the perinatal period”. Five main attributes for perinatal resilience were identified: social support, self-efficacy, self-esteem, sense of mastery and personality. This study offered a theoretical framework for perinatal resilience and insights into ways to enhance resilience during this period.

Chapter 3 retrospectively explored the needs of women whose resilience was challenged during the perinatal period through semi-structural in-depth individual interviews (N=13). Mothers disclosed experiencing a combination of different stressors leading to a decrease in resilience attributes, such as a reduced sense of mastery and self-esteem. Women described a detachment from their feelings, and a decreased belief in their ability to cope with motherhood. Lack of understanding and adequate social support from their support network contributed to feelings of isolation. Despite the perinatal period offering a window of opportunity for identifying reduced resilience and perinatal mental distress, given frequent contact with healthcare providers, these issues often remain under the radar. Perinatal healthcare providers predominantly applied a medical approach, paying little attention to the mental health status of women. An integrated care pathway, focusing on early detection of resilience-related problems and providing adequate social support, may be crucial in the prevention and early detection of perinatal mental health problems.

In Chapter 4 we developed an online intervention through a systematic approach, informed by the Behaviour Change Wheel framework and based on the theoretical model of perinatal resilience (Chapter 2). The development process unfolded in phases. In the first phase, we identified the resources (i.e. COM-B components: capabilities, opportunities, motivations, behaviour) that mothers use or need to cope with stress and challenges, and enhance perinatal resilience. The results highlighted the importance of knowledge, psychological skills, social support, and self-efficacy as important resources. In the second phase, the identified COM-B components were linked to relevant intervention functions, with ‘education’, ‘training’ and ‘enablement’ being the main functions. In the third phase, 18 behaviour change techniques were identified and an online method of delivery was chosen. The development process involved multiple iterations, incorporating insights from an interdisciplinary expert panel, scientific literature, and qualitative input from the target group. Ultimately, this process resulted in a 28-week online intervention to enhance resilience for women in the perinatal period, combining online group sessions, resilience-enhancing exercises, and an online peer-support platform.

In Chapters 5 and 6, we described the evaluation of the developed online resilience-enhancing intervention. Unfortunately, at the same time the Covid-19 pandemic broke out and impacted the evaluation process. The study described in Chapter 5 evaluated the potential effectiveness of the developed intervention through a non-randomised controlled trial. This study employed a quasi-experimental design with assessments at baseline (T0), postintervention (T4) and two follow-ups at six (T5) and 12 months (T6) after childbirth. The intervention group received the online intervention (N=70), while the control group (N=32) received care-as-usual. An important finding of this study was the high adherence rate, postintervention (T4) still 81.4% of participants were actively involved. Overall, our findings showed no statistically significant differences between the intervention and control group regarding resilience and maternal mental health. However, within-group changes were interesting. The resilience of participants in the intervention group remained stable, in contrast to a significant decrease in resilience in the control group. Also, the perceived social support remained stable for women in the intervention group but significantly decreased six months after childbirth, possibly due to the termination of the social support installed by the intervention. Considering the context of the Covid-19 pandemic, the within group changes can be considered clinically significant.

Furthermore, the feasibility of the intervention was tested within the intervention group only (Chapter 6). A total of 70 women enrolled in the intervention group and were grouped per gestational age in 22 groups. Participants demonstrated strong engagement with the online group sessions, with an average completion rate of 85%. The engagement with the resilience exercises, as indicated by the number of submitted Google Forms, was relatively low (10.5%). Also peer-support interactions on the online platform (i.e. closed social learning environment on Facebook) were observed, with an average of 32.71 interactions (likes, comments or posts) per group. After completing the intervention, a satisfaction questionnaire (the Client Satisfaction Questionnaire (CSQ-8)), was assessed (N=40). Moreover, semi-structured individual interviews were conducted with 17 participants from the intervention group. Participants expressed high satisfaction with their participation for various reasons. They underscored the importance of peer-support and the need to explicitly focus on perinatal mental well-being by facilitating an open dialogue about positive and negative emotions, thoughts, and experiences.

This doctoral research confirms the challenges that (expectant) mothers may encounter in finding balance among the profound changes during the perinatal period, increasing their vulnerability to mental health problems. Perinatal resilience and resilience attributes are challenged, and a decrease in resilience can be considered as an initial warning sign of perinatal mental health issues. The current doctoral research significantly contributes to the literature on maternal mental health by providing theoretical insights into perinatal resilience, systematic intervention development, and the evaluation of an online multicomponent intervention. Despite the complexity of the perinatal period, this research suggests that online interventions with human support, specifically targeting perinatal mental health and fostering openness for communication and experience-sharing, show promise in supporting (expectant) mothers and preventing perinatal mental health problems.

Date:1 Jan 2019 →  1 Feb 2023
Keywords:Resilience, Perinatal, Mental health
Disciplines:Health promotion and policy
Project type:PhD project