Moms & Babies Feeling Better Together: Outcomes of a Technology-Assisted,Entertaining,CBT-Based Depression Treatment for Low-Income Perinatal People Served by a Rural Michigan WIC Clinic

Abstract

Rural Americans experience higher rates of perinatal depression (PND) than urban peers yet are less likely to receive treatment. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a potential setting for offering PND treatment. This pilot study examines the impact of Moms & Babies Feeling Better Together (MBFBT), a technology-assisted depression treatment, on perinatal WIC clients’ depressive symptoms, anxiety, and parenting self-efficacy. A one-group pre-/post-test design assessed changes in outcomes over time. Paired-samples t-test results show statistically significant decreases in depression and anxiety and increases in parenting self-efficacy between baseline and post-treatment. Repeated measures analysis of variance demonstrates significant patterns of difference in expected directions across three timepoints for each outcome. Findings provide preliminary support for MBFBT’s effectiveness and its promise for delivery within rural WIC settings.

Keywords

perinatal depression (PND)technology-assisted cognitive behavioral therapy (T-CBT)rural mental health WIC mental health intervention research

Introduction

Perinatal depression (PND) represents a significant public health concern that impacts 10%–17% of pregnant and postpartum people in the United States (Ko et al., 2017; Underwood et al., 2016). Untreated PND has negative, long-term impacts on both perinatal people and their children (Balbierz et al., 2015; Field, 2017; Muzik & Borovska, 2010; O’Hara & McCabe, 2013; Slomian et al., 2019). Perinatal people experiencing depression are significantly less likely to attend prenatal visits, take their infants to well-child visits, immunize their infants, or follow recommended safety practices (Balbierz et al., 2015; Milgrom & Gemmill, 2014; Zajicek-Farber, 2009). In addition, PND is associated with poor cognitive, developmental, and social outcomes and higher rates of emotional and behavioral problems for infants and children (Balbierz et al., 2015; Brand & Brennan, 2009), as well as lower parenting self-efficacy among perinatal people (Bates et al., 2020; Goodman et al., 2022). Furthermore, the economic burden of untreated perinatal mood and anxiety disorders among 2017 births was estimated to be $14 billion from conception through children’s fifth year of life, with the largest costs associated with reduced economic productivity among perinatal people (Luca et al., 2020).

Rural residents and low-income people are more likely to experience PND than non-rural and higher-income peers yet less likely to receive treatment (Mollard et al., 2016; Nidey et al., 2020; O’Hara & McCabe, 2013; Villegas et al., 2011). Persistent barriers, including mental health provider shortages (Ellis et al., 2009; Sawyer et al., 2006), access challenges (e.g., cost, transportation; Gjesfjeld et al., 2015; Proctor et al., 2016; Tickamyer, 2020), and acceptability issues (e.g., stigma, lack of anonymity; Cheesmond et al., 2019; Crumb et al., 2019), impair rural residents’ treatment utilization. Hospital closures and decreased maternity services in rural areas further exacerbate barriers (Mullens et al., 2024; Rayburn, 2017).

We must identify strategies that deliver evidence-supported mental health treatment in non–mental health settings and leverage technology in accessible ways. Cognitive behavioral therapy (CBT), a gold standard psychosocial depression treatment, is based on the interconnection between our behaviors, thoughts, and feelings. CBT posits that changing our behaviors and our thinking also changes our mood (Beck et al., 1987; Dobson & Dobson, 2009). Core elements of CBT for depression include (a) behavioral activation strategies that encourage individuals to take action even when they do not feel like it and assess the impact of taking action on their mood, (b) cognitive restructuring strategies that support individuals in identifying and evaluating the accuracy of unhelpful thoughts and replacing them with more helpful, accurate thoughts, and (c) problem-solving strategies that support individuals to overcome setbacks and take action when challenges arise (Beck et al., 1987; Dobson & Dobson, 2009; Weaver et al., 2014).

CBT is effective when delivered by non-mental health professionals in their usual care settings (e.g., Anvari et al., 2023; Himle et al., 2014; Weaver et al., 2022; Zhang et al., 2019) and via technology (T-CBT; e.g., Andrews et al., 2018; Himle et al., 2022; Karyotaki et al., 2021). Despite the promise of T-CBT, user engagement challenges related to text-heavy, academically-oriented content, and one-size-fits-all approaches, remain (e.g., Barrera et al., 2013; Etzelmueller et al., 2020). There is great potential to increase T-CBT engagement through entertaining content and treatment tailoring.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offer a promising setting for delivering T-CBT for PND. WIC programs serve low-income perinatal people and children between zero and five years of age, providing nutrition education and vouchers for healthy foods and infant formula (United States Department of Agriculture Food and Nutrition Service, 2023). Literature suggests that approximately 20% of WIC clients experience PND symptoms (Giron et al., 2021; Pooler et al., 2013). Furthermore, WIC providers often identify multiple client needs, including mental health concerns, and offer appropriate referrals (e.g., Klawetter et al., 2021; Pooler et al., 2013; Weaver et al., 2023). Perinatal people with depression are less likely to attend health care appointments for themselves or their children than peers without depression (Balbierz et al., 2015; Milgrom & Gemmill, 2014; Zajicek-Farber, 2009). However, perinatal people with depression are likely to prioritize attending WIC appointments, as they often rely on WIC resources to meet their families’ basic needs.

This pilot study examines the impact of an eight-session, entertaining, T-CBT tailored for perinatal people in rural WIC settings, called Moms & Babies Feeling Better Together (MBFBT), on perinatal clients’ depressive symptoms. Given that over 40% of individuals who experience depression in their lifetime also experience comorbid anxiety (Kessler et al., 2015) and literature suggests a bidirectional relationship between PND and parenting self-efficacy (e.g., Goodman et al., 2022), the impact of MBFBT on these secondary outcomes is also examined.

Methods

Participants and Recruitment

Participants were recruited from one WIC clinic in rural Michigan between March 2021 and June 2022. Clients attending pregnancy or postpartum WIC appointments were screened for depression using the Patient Health Questionnaire-2 (PHQ-2; Löwe et al., 2005). Pregnancy and postpartum appointments specifically focus on the perinatal client. Perinatal clients who screened positive for depression or presented with at least mild depressive symptoms (PHQ-2 ≥ 2) received information about MBFBT and the pilot study, along with standard mental health resources. Perinatal clients interested in MBFBT completed an online contact form received by researchers. Eligible participants (a) screened positive for depression or presented with at least mild symptomatology, (b) were not currently receiving psychosocial treatment, (c) had internet access, (d) were English speaking, (e) never completed a course of CBT (≥8 sessions), (f) did not have a psychotic disorder or depression with psychotic features, and (g) did not have prominent suicidal ideation with imminent risk. Individuals deemed ineligible due to acute mental health needs were connected to immediate resources following study protocol.

Moms & Babies Feeling Better Together

MBFBT is an eight-session, entertaining, T-CBT for depression that is tailored for perinatal people and the rural WIC setting. MBFBT is housed on Entertain Me Well (EMW), an online platform for delivering CBT, developed by study authors (Weaver et al., 2021). EMW utilizes a character-driven storyline, video-based educational content, and text-based content (text, images, quotes examples) to deliver CBT. Participants receive an accompanying workbook with exercises to complete during sessions and exercises to practice between sessions.

EMW includes three key innovations: (a) entertaining delivery of CBT content through a character-driven, animated storyline; (b) quick, easy, low-cost treatment-tailoring capabilities while retaining core CBT elements; and (c) simple, straightforward presentation of content that appeals to multiple learning preferences (Weaver et al., 2021). EMW was designed to enhance treatment engagement and flexibility without compromising fidelity to CBT concepts (i.e., behavioral activation, cognitive restructuring, problem-solving).

Our research team utilized a community-engaged, iterative process to tailor EMW’s T-CBT treatment for perinatal people and the rural WIC setting, resulting in MBFBT. WIC staff, peers (prior WIC clients who support existing clients), and researchers engaged in a series of interactive meetings to modify images, text, quotes, and examples in each session, maximizing content relevance and relatability for perinatal clients.

For example, adaptations related to behavioral activation strategies were made to examples of activities for enjoyment and accomplishment that perinatal people could do with their babies and example activities perinatal people could do alone, with a focus on activities that could be done for free, quickly, and easily, in their local, rural community. There was attention to reminding perinatal people to give themselves credit for their accomplishments (e.g., feeding baby, taking a shower, paying bills, going to doctor appointments). In addition, adaptations were made to examples of common unhelpful thoughts that relate to parenting (e.g., I’m a horrible parent, I will never be enough for my baby) and examples of more helpful, accurate thoughts (e.g., I will never be a perfect parent, but I am doing the best I can for my baby. Even on hard days, I am taking care of myself and my baby).

MBFBT is self-paced and completed independently. Participants are asked to complete one session per week. Each session takes between 25 and 30 minutes. Research staff provide brief (5–10 minutes), phone-based check-ins after each session to answer questions and offer support for between-session exercises.

Overview of Pilot Study Design and Procedures

A one-group pre-/post-test design was used to assess change in outcomes over time in the MBFBT program (baseline, post-treatment, 3-month follow-up). Figure 1 presents participant flow during the pilot study. An institutional review board approved all study procedures.

Research staff shared study information with individuals who screened positive for PND or presented with at least mild depressive symptoms at WIC appointments and completed an online contact form. Individuals who remained interested provided informed consent and participated in a baseline assessment. Eligible participants were given access to the MBFBT program.

Research staff with mental health backgrounds, trained to a standard, conducted assessments virtually. Assessments took approximately 30 minutes. Participants were invited to complete post-treatment and 3-month follow-up assessments regardless of treatment engagement. Participants received a $25 incentive for each assessment.

Measures

Psychiatric Diagnoses

The Mini International Neuropsychiatric Interview (MINI) v. 7 was used to assess psychiatric diagnoses. The MINI, a short, semi-structured diagnostic interview tool based on the Diagnostic and Statistical Manual of Mental Disorder (DSM-5), has excellent validity and reliability (Sheehan, 2016).

Primary Outcome: Depressive Symptoms

The Edinburgh Postnatal Depression Scale (EPDS; Cox & Holden, 2003) and PHQ-9 (Kroenke et al., 2001) were used to assess depressive symptoms. The EPDS and PHQ-9 have adequate reliability and validity. Scores on the 10-item EPDS range from 0 to 30, with scores 10 and above indicating a probable major depressive disorder (MDD). Scores on the 9-item PHQ-9 range from 0 to 27, with scores 10 and above indicating probable MDD.

Secondary Outcome: Anxiety Symptoms

The Generalized Anxiety Disorder-7 (GAD-7; Spitzer et al., 2006) was used to assess anxiety symptoms. The GAD-7 has adequate validity and reliability. Scores on the 7-item GAD-7 range from 0 to 21, with scores 10 and above indicating moderate anxiety.

Secondary Outcome: Parenting Self-Efficacy

The Parenting Sense of Competence (PSOC; Ohan et al., 2000) scale contains 17 items assessing parenting self-efficacy. Items are rated on a six-point scale, from 1 (strongly disagree) to 6 (strongly agree), with nine reverse-coded items. Higher scores indicate a higher sense of parenting competence.

Data Analysis

We conducted descriptive analyses to examine sample characteristics and treatment engagement, measured by the number of sessions completed.

Paired samples t-tests were used to assess within-group differences between baseline and post-treatment outcomes. Within-group effect sizes were calculated using a small sample size–corrected Hedge’s g (Cooper et al., 2019). Assumptions for paired samples t-tests, including normality and no outliers, were examined and met. We used Repeated measures analysis of variance (ANOVA) to examine the pattern of difference on outcomes across three time points. Effect size estimates for Repeated measures ANOVA were calculated via the partial eta-square. Assumptions required for repeated measures ANOVA, including normality, no outliers, and sphericity, were assessed and met. All analyses were conducted using SPSS v. 28 (IBM, 2021).

Results

Sample Characteristics

Twenty-four participants completed baseline assessments. Nineteen started the MBFBT program (79.2%), comprising the analytic sample. All participants identified as female. Eight participants (42.1%) were pregnant at the baseline assessment, five participants were postpartum (26.3%), and six participants (31.5%) had a child between one and five years of age. Participants’ average age was 29.2 (SD = 6.47). Over one third of participants identified as Hispanic or Latinx (n = 7; 36.8%). All participants identified as white. The majority of participants (n = 11; 57.9%) reported being married or partnered. Over one quarter of participants (n = 5; 26.3%) reported living with friends or family. Almost 40% of participants (n = 7; 36.8%) indicated having a high school education or less.

Over half of participants (n = 10; 52.6%) reported full-time employment, whereas about one third (n = 6; 31.6%) identified as stay-at-home parents or caregivers. Almost 60% of participants (n = 11; 57.9%) reported annual household incomes less than $40,000.

Treatment Engagement

On average, participants completed 5.79 (SD = 3.03) of 8 sessions. Thirteen participants completed five or more sessions (68.4%). Eleven participants (57.8%) completed all eight sessions. Three participants completed one session (15.8%).

Treatment Effect

Participants’ depressive symptoms and anxiety significantly decreased between baseline and post-treatment assessments (see Table 1). Participants’ parenting self-efficacy significantly increased over time.

Table 1.

Bivariate Differences and Repeated Measures Analysis of Variance (n = 19).

Paired samples t-test (n = 12)	Baseline		Post-treatment		—		t	p	Hedge’s g
	M	SD	M	SD
EPDS	14.8	4.62	8.17	5.86			3.66	.004	.983
PHQ-9	13.2	5.84	5.83	5.44			4.08	.002	1.10
GAD-7	11.2	5.22	6.08	5.35			2.74	.019	.737
PSOC	57.2	12.4	65.2	8.80			−2.70	.021	−.724
Repeated measures ANOVA (n = 11)	Baseline		Post-treatment		3-Month follow-up		F	p	Partial eta-squared
	M	SD	M	SD	M	SD
EPDS	15.3	4.45	8.45	6.06	7.45	4.76	12.9	<.001	.564
PHQ-9	13.2	6.13	6.09	5.63	5.82	4.17	12.7	<.001	.558
GAD-7	11.4	5.66	6.50	5.80	5.50	4.30	5.16	.017	.364
PSOC	59.8	9.60	65.4	9.70	70.5	7.11	9.61	.001	.516

Repeated measures ANOVA demonstrated statistically significant patterns of difference in expected directions across baseline, post-treatment, and follow-up time points on each outcome (see Table 1).

Seven of 12 participants who completed baseline and post-treatment assessments (58.3%) experienced a decrease of 50% or more in their PHQ-9 score. Eight of 12 (66.7%) had PHQ-9 scores indicating probable MDD at baseline; two (16.7%) had scores indicating probable MDD at post-treatment.

Discussion

Findings suggest rural WIC programs offer a promising setting for delivering T-CBT for PND. This is important from a health equity perspective as rural WIC clients represent a marginalized group of perinatal people who often lack access to mental health treatment.

Implications for Practice

Results of this study offer preliminary support for MBFBT, an engaging, low-cost T-CBT for depression delivered in a rural WIC clinic, as an accessible, effective PND treatment. Our findings suggest that perinatal clients are open to engaging in depression treatment offered by their WIC clinic. The persistent shortage of mental health providers and the closure of hospitals providing maternity services in the rural United States continues (Ellis et al., 2009; Mullens et al., 2024; Rayburn, 2017; Sawyer et al., 2006), leaving perinatal people in rural areas with extremely limited mental health treatment options. Providing MBFBT in rural WIC clinics presents a critical opportunity to build capacity and increase access to PND treatment in underserved rural communities. Furthermore, offering MBFBT through WIC at no cost to clients likely reduces barriers to care associated with cost and insurance status that are salient among rural residents. Perinatal people using MFBFT also did not have to consider the transportation burden associated with seeking—typically distant—mental health care.

In addition, participants experienced significant improvements in depressive symptoms over time upon participating in MFBFT. This finding is consistent with meta-analytic reviews of T-CBTs for depression (e.g., Andrews et al., 2018; Karyotaki et al., 2021). However, our findings also suggest that MBFBT was highly engaging. Our participants completed 72.4% of sessions, on average, whereas a review of internet-based CBT for depression suggests that participants, on average, complete 62.6% of sessions (Etzelmueller et al., 2020). It is likely that MBFBT’s design, specifically its entertaining approach, community-based tailoring for perinatal WIC clients and the rural context, and brief, human support contributed to increased engagement (Karyotaki et al., 2021; Richards & Richardson, 2012). This requires further research.

Our findings demonstrating a significant improvement in parenting self-efficacy over time in MBFBT is consistent with a small but growing literature suggesting that CBT is a promising treatment for parenting self-efficacy, maternal adaptation, and parenting satisfaction (Goodman et al., 2022; Kim & Kim, 2015; Ngai et al., 2019). Although the mechanisms of change require investigation, it may be that MBFBT provided participants with strategies and tools to identify and replace their unhelpful thoughts, which often related to parenting. Thinking more accurately about their parenting may have increased their self-efficacy. Furthermore, through behavioral activation, participants likely engaged in activities for enjoyment and accomplishment with their infants, which may have provided evidence that they are capable parents and increased their parenting self-efficacy. As low parenting self-efficacy is associated with poor infant and child outcomes that can have impacts into adulthood, including self-regulation (Bates et al., 2020), it is imperative to further examine the impact of CBT for PND on parenting self-efficacy.

Limitations

This study has limitations that must be acknowledged. First, this was a pilot study focused on a small sample of perinatal people served by one WIC clinic. Although results are promising, they must be interpreted with caution and require replication with larger, more diverse samples. Second, although overall treatment engagement was high, participants who dropped out before completing all eight sessions were lost to follow-up. Furthermore, a relatively small proportion of clients with positive PND screens enrolled in the program. Future studies of MBFBT require enhanced focus on recruitment and retention. Third, our pre-experimental design has threats to internal validity. The one-group pre-/post-test design does not randomize participants to conditions but rather allows WIC clients to self-select into the treatment, which may result in participants who were more motivated to address their depressive symptoms or to be more receptive to a technology-assisted treatment approach. In addition, the one-group pre-/post-test design does not have a control group, which inhibits our ability to assess a causal relationship between the MBFBT program and improved participant outcomes. Therefore, research using more rigorous designs, such as randomized controlled trials, to test the effect of MBFBT is warranted. Fourth, research associates conducted brief, weekly check-ins. This was appropriate for a pilot study; however, WIC staff’s ability to support check-ins is unknown.

Conclusion

This pilot study suggests rural WIC clinics offer a promising site for increasing access to PND treatment among underserved perinatal people. Offering the MBFBT program through WIC, an established and trusted community service, likely extended treatment to perinatal people who otherwise would not have received mental health care. Partnering with WIC presents an opportunity to deliver MBFBT in a way that can be replicated and scaled across the national network of WIC clinics, building capacity to address mental health needs in underserved rural communities. Further research testing MBFBT with larger, more diverse populations and with WIC staff support is needed.

Footnotes

Disposition editor: Cristina Mogro-Wilson

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article: The authors received financial support from the Eisenberg Family Depression Center at the University of Michigan and the Michigan Department of Health and Human Services for the research presented in this article.

ORCID iDs

Addie Weaver

Stephanie V. Hall

Tahani Al-Shamari

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