Personalized Mobile Health-Enhanced Cognitive Behavioral Intervention for Maternal Distress: Examining the Moderating Role of Adverse Childhood Experiences

Abstract

Background: Maternal history of trauma is a risk factor for distress during pregnancy. The purpose of this paper was to examine the theorized differential impact of a cognitive behavioral intervention (Mothers and Babies Personalized; MB-P) on maternal distress and emotional regulation for those with ≥ 1 adverse childhood experiences (ACEs; vs no ACEs) from pregnancy to 3 months postpartum.

Methods: Between August 2019 and August 2021, eligible pregnant individuals aged ≥ 18 years, < 22 weeks' gestation, and English-speaking were recruited from 6 university-affiliated prenatal clinics. Participants (N = 100) were randomized to MB-P (n = 49) or control (n = 51). Analyzable data were collected for 95 participants. Analyses tested progression of change (slope) and at individual timepoints (panel analysis) for perinatal mental health outcomes.

Results: The majority of participants (n = 68, 71%) reported experiencing > 1 ACE (median = 1, range: 0-11). Participants demonstrated significant differential effects for depressive symptoms in absence of ACEs (standardized mean differences [SMD] = 0.82; 95% confidence interval [CI] = [0.13-1.51]) vs in presence of ACEs (SMD = 0.39; 95% CI = [-0.20 to 0.97]) and perceived stress in absence of ACEs (SMD = 0.92; 95% CI = [0.23-1.62]) vs in presence of ACEs (SMD = -0.05; 95% CI = [-0.63 to 0.53]). A panel analysis showed significantly reduced depressive symptoms postintervention and increased negative mood regulation at 3 months postpartum for individuals with ACEs.

Conclusions: Findings support effectiveness of the MB-P intervention to reduce prenatal distress for all pregnant individuals. Preliminary exploration suggests the possibility that individuals with ACEs may benefit from enhanced trauma-informed content to optimize the effects of a perinatal intervention.

Keywords: adverse childhood experiences; emotional regulation; maternal distress; perinatal intervention; primary prevention; randomized controlled trial.

Figure 1:

Forest plot of the standardized mean difference of the effect size in the slopes between the intervention and control groups for participants with an absence or presence of ACEs. Effect size differences for depression, perceived stress, and anxiety were reversed from negative to positive to demonstrate improvement, ensuring that all of the scales were pointing in the same direction. The between-group statistical significance is indicated in bold, whereas the differential effect between ACEs absence vs presence for depressive symptoms and perceived stress is indicated with an asterisk. ACE = Adverse Childhood Experience; CI = confidence interval; PROMIS = Patient-Reported Outcomes Measurement Information System; SMD = standardized mean differences.

Figure 2:

Panel analysis of adjusted marginal means for PROMIS Depression, PSS, and SAI for individuals with ACEs absence or presence. Decreasing scores indicate improvement. Time points are designated as: 1 = baseline; 2 = postintervention; 3 = 1 month postnatal; 4 = 3 months postnatal. ACE = Adverse Childhood Experience; PROMIS = Patient-Reported Outcomes Measurement Information System; PSS = Perceived Stress Scale; SAI = State Anxiety Index.

Figure 3:

Panel analysis of adjusted marginal means for NMR Scale and BADS for those with ACEs absence and presence. Increasing scores indicate improvement. Time points are designated as: 1 = baseline; 2 = postintervention; 3 = 3 month postnatal. ACE = Adverse Childhood Experience; BADS = Behavioral Activation for Depression Scale; NMR = Negative Mood Regulation.