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Mothers and Babies: Preventing the Onset of Postpartum Depression among Low-Income Latina Populations
Hae Young Park
Welcome to the Maternal and Child Health Research Program Podcast Series. This series features the latest information and findings of investigator-initiated research projects, supported by the R40 MCH Research Program. I'm Hae Young Park, a project officer with the MCH Research Program, which is administered by the Division of Research, Training, and Education, part of the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA). The MCH Research Program has a long and rich history of supporting efforts to address disparities in the health of mothers and children from racial and ethnic minority communities. Today we'll be talking about postpartum depression and prevention efforts in a high-risk community.
I'm very pleased to welcome Dr. Huynh-Nhu "Mimi" Le. Dr. Le was the principal investigator of an R40 research project, Preventing Postpartum Depression in High-Risk Pregnant Latinas: Effects on Maternal and Infant Health. Mimi, thank you so much for joining us today.
Thank you. I'm glad to be here.
Hae Young Park
I wanted to ask you, Mimi, to tell us a little about yourself: your research interests and how you got started as an MCH researcher.
I'm a clinical and community psychologist by training, and I'm currently an associate professor in the Department of Psychology at George Washington University. And I've always been interested in the area of emotion, socialization, and families. As an intern and postdoctoral fellow at the University of California in San Francisco, I was fortunate enough to work with Ricardo Muñoz, who is a prominent psychologist with expertise in the area of preventing depression. And together we developed the Mothers and Babies: Mood and Health program, in which we developed and pilot-tested a cognitive behavioral intervention to prevent perinatal depression. We conducted a pilot study of about 40 women, predominantly low-income Mexican immigrant women. And we tested this Mothers and Babies 12-week cognitive behavioral course, which aimed to teach pregnant women, who were at high risk for depression, mood regulation skills. And the preliminary results were really promising, and that's sort of how I got started in this field.
Hae Young Park
Thank you. Can you tell us about the R40 project? What was the purpose, and why was it so important to you to do the study?
So when I came to George Washington University from San Francisco, I was fortunate to meet and have been collaborating with Dr. Deborah Perry, who's an expert in child development and early mental health consultation to public health systems of care at George Washington University. We were fortunate to receive this 4-year grant from the Maternal and Child Health Bureau, in which I was able to expand the work that I had started with Ricardo Muñoz in San Francisco. With this new grant, we conducted a randomized control trial of 217 low-income women, predominantly Central American women, in the Washington, DC, area.
And we really were interested in focusing on this group for several reasons. One, Latinos are indeed the largest and fastest-growing ethnic group in the U.S. Recent census data, for example, show that more than half of the growth of the U.S. population between 2000 and 2010 was due to the increase of the Latinos. Latinos also have higher birthrates, and these rates are actually higher than other racial/ethnic groups in the U.S. This was also important for us to consider. And finally, there was some evidence that really low-income ethnic-minority women, including poor Latinas, have been found to be at higher risk for developing both symptoms and diagnoses of depression. We also knew from the literature that this particular group either was less likely to have access to evidence-based treatments for mental health, or, whether it's due to stigma or some other structural problems, they did not want to really seek treatment.
So for those reasons, we really wanted to focus more on prevention. So the purpose of the study was to see if we could prevent the onset of postpartum depression by teaching women these mood regulation skills and promoting mother-infant bonding using predominantly cognitive behavioral strategies. And we focused on women who were at high risk for depression, with the long-term goal of hoping to reduce risk in their infants also.
So from San Francisco to here, we shortened the Mothers and Babies course, this intervention, from 12 weeks to 8 weeks to try to really meet more the needs of the Central American women here. And what we found was that they also had this particular unique risk factor, in that many of them have actually left their children behind in their home country. So they have come to the U.S. with the hopes of trying to make a better life for themselves, maybe to bring back money for their own kids and families, but in fact then they became pregnant again. And what we found was that a lot of their current pregnancies were actually unintended and unplanned. Fortunately, though, they were able to receive services from two community-based settings that were culturally and linguistically sensitive to their needs.
Hae Young Park
Thank you, Mimi. The study also involves strong collaboration with community-based organizations where the participants were recruited for the study. Can you describe the partnership with these community-based organizations? Particularly, what were the barriers in working with them, and how did you achieve success?
We were indeed very lucky to be able to partner with these agencies. And I think the importance of establishing community partnerships with this population that you're working with is really trying to figure out how to make that impact. In particular, in working with this low-income perinatal group of Latina immigrant women, there needs to be a lot of trust to develop with these community-based organizations.
And the two agencies we were fortunate to work with were Mary's Center for Maternal and Child Care—and later on we added the Center for Life of Providence Hospital.
And as I mentioned, these relationships take a lot of time to cultivate. And one of the barriers that you had asked about is—and in particular, in one of the community partners, they did not have a good previous experience in conducting research with a university partnership. So we were very careful to take things slow. We were also very careful to say that we were a different group, a different entity from a different part of that university. So I think those things take a lot of time to develop trust between the two partners.
The other thing that was important was to be able to meet and work directly with the frontline staff, who are working with the perinatal women and families whom we work with. And these individuals, these staff members, are certainly committed to working with this population and overloaded in working with this population. And so, one of the things we really had to do was to take some time to engage them; talk about the project; and talk about how ultimately, by participating in the project and helping them help us with this project, they may see kind of longer-term benefits to this, because they may not see the direct benefits from prevention work initially. And part of this—for example, at Mary's Center, we were able to train some of their staff to screen for depression as part of the recruitment of the study, and I think this really aided in our ability to meet our sample size targets for the study.
Hae Young Park
So what did you find out from the study? Was your study successful in preventing postpartum depression?
Half of the women in our study received this 8-week Mothers and Babies course during pregnancy and three booster sessions in the postpartum period. All groups were interviewed up to five times during the course of the study, beginning at pregnancy and going up to the postpartum period. And interestingly, the results indicated that both groups had very low depression rates: about 8 percent in the intervention group and about 10 percent in the usual care control group. So this 8 percent and 10 percent are very, very low rates, but there were really no differences between the two group conditions. So on the one hand, this seemed as if our intervention did not make a difference; however, if you look at the research, we know that in the research in similar high-risk samples, people have found the rates being anywhere between 20 to 50 percent depending on how depression is measured and in what population. So in this sense, we felt like we were actually able to cut that at least by half.
The other thing that we found was that, in the work in my earlier San Francisco study with Ricardo Muñoz, we found that 14 percent of the women in the intervention group developed depression, compared to 25 percent of the women in the usual care group. So our numbers were actually much, much lower, but there were no differences between the two groups. So we were perplexed; we were really trying to figure out why this was the case. And what we decided to do was to conduct exit interviews with a selected group of women, after they completed the entire study, to just further understand their particular perspectives. And we learned a lot from these exit interviews. We found out that women in the intervention group were able to describe the skills that they had learned at this Mothers and Babies course and were actually applying them in their own lives in order to be able to manage their mood and to lower their depressive symptoms.
Those who were in the usual care or control condition also reported that they felt like they became more aware of their mood, in part because we asked them questions about their mood, about their relationships with their babies and their significant others, over an extended period of time, since this was a longitudinal study. What we also found was that women in the usual care or control condition felt that they also benefitted from the study, but in a different way. One, they said that they had developed these relationships and valued the relationships that they had with their research staff so that we had interviewed them up to five times during the perinatal period. And in this longitudinal study, the average time was about 15 months. And so they got to know us very well. We also did a lot of different things to try to recruit and retain these women over time by providing incentives—Mother's Day cards birthday cards—so they were very engaged. I think the other part with the control group was that they, by virtue of listening and answering these questionnaires over time, became much more aware of their mood and their interactions with other people. So what we think happened here is that there were two very different but active interventions going on at the same time, and it highlights the importance of having social support and developing relationships as being very important for, I think, both groups in our study.
Our research staff were, for the most part, bilingual and bicultural and were from some of the same community as the participants. So we tried consciously to make sure that we could ensure—and provided a lot of training for the staff so that they could be sensitive to the needs of these women. And I think that certainly helped in maintaining some of those relationships over time.
In terms of some of the other lessons learned, the importance of creating and maintaining community partnerships, as I have mentioned above, is, I think, very critical to this. I think the other part is the importance of really understanding and knowing who your population is whom you're working with, so not only understanding the context of their lives but also understanding the setting which we're working with. And one of the ways that we did this was to really recognize the importance of having a cultural adaptation process and to develop this process when working with a new population and setting to try to understand the contextual and within-group differences of that particular setting and that particular population. And one of the ways that we did this was to kind of create a five-step iterative process in which we first talked about and tried to identify what the needs are of that particular population and also of that particular setting—of the staff providers, for example; of whom we're working with…. We tried to gather this information through informant interviews/focus groups initially, and they sent some of that information help to really design an adaptation of the intervention that we had originally developed and had found to be promising. And then the importance following that is to try to evaluate and figure out "Does this really work or not for this particular new group, and how do we refine it so that it would potentially work better in the future?" And I think the last step is really thinking a bit more about how to replicate some of this information. And in doing this work, I think, for us, we really learned about the value of mixed methods, in that it's important to collect both qualitative data at the beginning of the study as well as at the end of the study to help to inform what the research is going to be, but also to help to explain potentially what some of the findings are of the research that we actually found.
And then, I think, lastly, the lesson that we learned from this project was more of a focus on prevention rather than treatment. I think there is a bias in our health care system, in that we wait for people to get sick before actually being able to get treatment and help for them. And one of the things that I hope comes through from the research that I've been doing is that it's so important to focus more on preventing something, on prevention research, because it really helps to decrease the negative impact of perinatal depression over a time and also, I think, decrease the stigma in working with these particular populations.
Hae Young Park
I wonder if you could describe some of the impact of your research also at a regional and/or national level.
Yeah, I think one of the main things is thinking about dissemination and how this work has impacted the field from this rich database that we were able to collect over time. We have, to date, 13 peer-reviewed, published papers that have been disseminated into the academic world to increase that impact. We've also been fortunate and have had a number of different presentations, including 8 invited presentations as well as papers or poster presentations that have been presented at regional, national, as well as international conferences—and thinking about that.
Our Mothers and Babies course manual that we've developed has also and is still continuing to be disseminated. We are updating this information at our Web site, which is available to anyone who has access to the Internet, and we're very proud of that. At the University of California, San Francisco Web site, for example, the 12-week Mothers and Babies manual has existed there, and that includes both the participant manual as well as the instructor's manual, both in English and in Spanish.
We've also been very fortunate to think about how our work has been adapted in other research groups. So, for example, Dr. Darius Tandon at Johns Hopkins University has adapted the Mothers and Babies course for low-income African-American mothers who are in home-visiting programs. So he shortened this to a 6-week model, and his initial results have been very, very positive. And they're currently seeking funding to try to expand this to a full-scale randomized control trial. Dr. Alinne Barrera and Dr. Ricardo Muñoz are also conducting currently an online study to evaluate an Internet version of this course, and that's currently in progress right now.
We also know that there have been a number of different agencies throughout the U.S. who are using this in their community-based settings. Some of them have data available, and some of them do not, and we're trying to currently gather and figure out who is using these various versions of the Mothers and Babies course to understand better what that potential impact is. And in my own work currently, I also find that from the Maternal and Child Health Bureau, we are trying to consider "In which particular settings would the Mothers and Babies Course be most sustainable?" and working at this. So we're still working with the Mary's Center here, and we're trying to consider a setting that serves both pregnant women as well as postpartum moms at the same time. And one of the settings that we're working with right now is the Women, Infants, and Children program (the WIC program), in part because they're able to span the services for both pregnancy and the postpartum period, making that very important for us. And so, the idea here is to see if we can integrate both screening for perinatal depression into the WIC program, which historically has only focused on high-risk, more nutrition services and risk, and also see if we can integrate prevention services for this group so that it makes it a more comprehensive, holistic type of services for low-income, at-risk women and families.
Hae Young Park
What is your thought on the ability to sustain prevention services in communities after the study has ended?
This is a big, huge challenge, and the challenge is always about how to sustain this work once the funding goes away or only with limited funding and also recognizing that prevention is important in a more treatment-dominated type of field. But we do know that prevention works and that, in the long run, prevention has a more significant impact on preventing negative consequences that are associated with perinatal depression on the health of women, her partners, her children, and the quality of this relationship. So in thinking about how to do this, I think one of the ways is to really recognize the importance of trying to consider the entire context of integration. And what I mean by that is that it's not just enough to focus on having available prevention and treatment intervention services but also how to integrate the range of these services, beginning with screening, prevention—but also in having these referrals for available, culturally tailored, evidence-based interventions and integrating that into primary care and social services agencies. And if we can sort of figure out that whole system of care that's more integrated, I think that we would be better able to meet the needs of these women and families and hopefully make the most impact.
Hae Young Park
Thank you. HRSA and the MCHB are committed to ensuring a diverse, well-trained public health workforce. In your own education and early research experiences in California, you described some of the work with your colleagues, and it sounded like you had a great mentor and colleague who has influenced your research career tremendously. Earlier, you also mentioned that the R40 grant allowed for many students to be involved in your research. So from your personal experiences, can you tell us about some challenges that you encountered or barriers as you were pursuing your education and early years in research? Also, can you share your pearls of wisdom for students and new investigators who may want to venture into research?
Yeah, it's a huge question [laugh]. I think those are really important questions, Hae Young, and I'm going to try to do my best to address maybe a small part of that. I think that being an Asian-American female researcher conducting prevention research with a vulnerable, high-risk population in community-based settings is challenging but, at the same time, extremely rewarding. And you're right: I was able and very fortunate to have great mentors during the different phases of my academic career who have helped to assess my areas of strengths and weaknesses and, I think, also to improve my own skills over time and figure out further—defining sort of my areas of research and expertise. One of the things I really learned is that you cannot do this work alone—that it's so important to have these mentors, who I continually check in with periodically and still help me figure out what to do next—and also the importance of developing strong collaborations with other researchers, especially community partners.
Based on all of these experiences, I really value the importance of also giving back and hoping to mentor other students, especially, I think, minority students who may have had less exposure to research and to figure out how to provide them with more of these research opportunities over time. Some of these students may also have been the first ones in their families to get a higher education or to get a more advanced degree, and they may have more limited writing skills or research skills or not know how to navigate kind of this research world or academic world. And I am strongly passionate about helping them figure out and navigate this to the best of their abilities.
And so, really through the work at MCHB and through these projects that I've been involved with, we have been very, very fortunate to attract a large number of student volunteers. As I mentioned, this work cannot be done alone. And the funds that are provided are wonderful, but they're not proficient for every single thing. So we have been very fortunate to be able to attract a number of different student volunteers. These have included both undergraduate students and graduate students who have contributed their time in a number of different ways. For example, with this first MCHB grant, we were fortunate to have at least over 30 of these different students. Some of them have gone on to graduate school or medical school. Some of them have been first authors on papers and presentations that have been derived from our Mothers and Babies: Mood and Health project. So it's been an important part of my academic and career life in being able to mentor these students, but also to have had wonderful mentors along the way.
Hae Young Park
Mimi, it has been such a pleasure speaking with you today. I wanted to sincerely thank you so much for your time and sharing all of your very rich and wonderful experiences and information about your R40 grant.
Thank you so much. This has been a great experience, and it provided me with some food for thoughts in some ways. Thank you, Hae Young.
Hae Young Park
Dr. Huynh-Nhu "Mimi" Le is an associate professor of psychology at the George Washington University in Washington, DC.