Investigating the effects of having access to a perinatal psychologist (PEPO) in perinatal care on children’s birth outcomes

According to the World Health Organisation (WHO) 15-20% of all births worldwide are low birth weight (<2500 g) and more than 1 in 10 children are born preterm (<37 weeks gestation) (Bilgin et al 2028; Voit et al. 2022). These adverse birth outcomes are known to be associated with lifelong consequences, such as an increased risk of disability, health issues, neurocognitive impairment, and mental health problems (Voit et al. 2022; Bilgin et al. 2018; Talge et al 2010). While this has led to the WHO aiming to decrease low birth weight by 30% in 2025, the related risk factor of maternal mental health has not been properly addressed as an important focus for prevention (Dadi et al. 2020). Research shows that poor maternal mental health during pregnancy is a risk factor for preterm birth and low birth weight in offspring (Voit et al. 2022; Dadi et al. 2020). Postpartum MMH problems are also linked to decreased care-giving behavior, mother-infant bonding, and earlier discontinuation of breastfeeding (Field 2010, Slomian et al. 2019, Dubber et al. 2015). Moreover, maternal mental health (MMH) symptoms have previously been related to impaired physical and mental child development in the short- and long-term (Kingston et al.2012; Slomian et al. 2019).

The potential impact of improving MMH is substantial, as 1 in 5 women from community populations experience clinically relevant MMH problems such as anxiety, stress and depression (Browne et al. 2020). As these problems still frequently go unnoticed, only 15% of women experiencing MMH problems receive sufficient treatment or support (Browne et al. 2020). For some of the women receiving no treatment these symptoms will increase, possibly developing into psychiatric disorders with far-reaching consequences for both mother and child. Maternal mental health problems and their associated consequences also have an impact on society as a whole, as a study in the United Kingdom (UK) showed that perinatal anxiety, depression and psychosis add up a total cost for society of 8.1 billion pounds per year. This amounts to a little under 10.000 pounds for each birth (Bauer et al. 2016). This study also showed that 60% of these costs were related to child outcomes (Bauer et al. 2016). Early prevention and treatment of MMH problems is therefore both efficient and of large societal value.

Previous research on (early) prevention and treatment of MMH problems show promising outcomes in reducing perinatal mental health problems (Kohlhoff et al. 2023; de Graaff et al. 2020; Werner et al. 2024; Haga et al. 2019; Lau et al. 2022). However, the overall quality of evidence found in the various studies was low (Lau et al. 2022), and while there is sufficient evidence for the effectiveness of these interventions for women at risk and women with severe psychological symptoms, effectiveness of these interventions for universal perinatal populations remains unclear (Missler et al. 2021). Bauer et al (2016) estimate that the cost of perinatal mental health problems is 5 times higher than it would be if the services to reduce perinatal mental health problems were improved. However, they also state that research on the effectiveness of interventions aimed at improving perinatal mental health to reduce long-term effects on child outcomes are sparse (Bauer et al. 2016).

This study aims to investigate the effects of having access to a perinatal psychologist (PEPO; in Dutch ‘PErinatale Psychische Ondersteuner’) in standard perinatal care. This PEPO is a newly developed professional. The roles of this PEPO entail an introductory meeting at 18-20 weeks pregnancy, and screening for mental health problems using short screening questionnaires at three times in the peripartum period (at 13 weeks and 32 weeks pregnancy and at 6 weeks postpartum). Moreover, if needed, the PEPO offers support in the form of psychoeducation, evidence-based supportive care, and referrals to more specialized care, and if the pregnant woman agrees, communicating with the other professionals in the perinatal care to offer more personalized care. These roles and the working method of the PEPO were specified during focus groups with all stakeholders involved. Based on the outcomes of these focus groups a protocol with the roles and working methods of the PEPO was specified.

This current intervention study used a two-period cross-over design to investigate whether belonging to the PEPO intervention group as compared to care-as-usual (CAU) resulted in better birth outcomes. Specifically, we will look at potential effects on gestational age, birth weight and the 5-min Apgar score. In addition, we will investigate whether, within the intervention group, women receiving actual PEPO care, meaning at least one session after the introductory meeting, compared to women receiving CAU, give birth to children with better birth outcomes. Finally, we will determine whether potential effects are moderated by demographics (ethnicity, marital status, socio-economic status, and parity), and characteristics of PEPO care (number of prenatal sessions, online or in-person sessions, and the person carrying out the PEPO role).

根据世界卫生组织（World Health Organisation, WHO）的数据，全球范围内15%至20%的新生儿为低出生体重儿（出生体重＜2500g），超过十分之一的儿童为早产儿（妊娠时长＜37周）（Bilgin等，2028；Voit等，2022）。此类不良妊娠结局已被证实与终身健康风险相关，包括残疾、躯体健康问题、神经认知损伤以及精神健康障碍（Voit等，2022；Bilgin等，2018；Talge等，2010）。尽管世界卫生组织曾设定目标，要在2025年前将低出生体重儿比例降低30%，但孕产妇心理健康这一相关风险因素尚未被作为重要的预防重点得到妥善应对（Dadi等，2020）。

研究表明，妊娠期孕产妇心理健康（maternal mental health, MMH）状况不佳是子代早产和低出生体重的风险因素（Voit等，2022；Dadi等，2020）。产后孕产妇心理健康问题还与照料行为减少、母婴联结减弱以及母乳喂养提前终止相关（Field，2010；Slomian等，2019；Dubber等，2015）。此外，孕产妇心理健康症状已被证实会在短期和长期内损害儿童的身心发育（Kingston等，2012；Slomian等，2019）。

改善孕产妇心理健康所能带来的潜在影响十分显著，因为社区人群中每5名女性就有1名存在临床意义上的孕产妇心理健康问题，如焦虑、压力和抑郁（Browne等，2020）。这类问题往往难以被及时发现，仅有15%出现心理健康问题的女性能够获得足够的治疗或支持（Browne等，2020）。对于未接受治疗的部分女性而言，其症状可能会加重，甚至发展为精神障碍，对母婴双方均造成深远影响。孕产妇心理健康问题及其相关后果还会对整个社会产生影响：英国的一项研究显示，围产期焦虑、抑郁和精神病每年给社会造成的总成本高达81亿英镑，平均每例分娩相关成本接近1万英镑（Bauer等，2016）。该研究同时指出，其中60%的成本与儿童结局相关（Bauer等，2016）。因此，对孕产妇心理健康问题进行早期预防和治疗，既具有经济性，也具备重大的社会价值。

过往针对孕产妇心理健康问题（早期）预防与治疗的研究显示，相关干预措施在改善围产期心理健康问题方面取得了颇具前景的成果（Kohlhoff等，2023；de Graaff等，2020；Werner等，2024；Haga等，2019；Lau等，2022）。不过，多项研究的证据整体质量偏低（Lau等，2022）；尽管已有充分证据证实此类干预对高危女性及存在严重心理症状的女性有效，但针对全人群围产期群体的干预效果仍不明确（Missler等，2021）。Bauer等（2016）估算，围产期心理健康问题造成的社会成本是改善相关服务后成本的5倍。但他们同时指出，针对改善围产期心理健康以降低儿童长期不良结局的干预措施有效性的研究尚且匮乏（Bauer等，2016）。

本研究旨在探讨在标准围产期护理中加入围产期心理咨询师（PEPO，荷兰语全称为"PErinatale Psychische Ondersteuner"）所带来的影响。PEPO是一类新兴的专业岗位，其工作职责包括：在妊娠18-20周时开展首次见面咨询，在围产期的三个时间点（妊娠13周、32周以及产后6周）使用简短筛查问卷对心理健康问题进行筛查；若有需要，PEPO将为孕产妇提供心理教育、循证支持性护理，并转诊至更专业的医疗机构；若孕产妇同意，PEPO还可与围产期护理团队中的其他专业人员沟通，以提供更个性化的护理。PEPO的工作职责与工作流程是通过与所有利益相关方开展焦点小组讨论确定的，并基于这些讨论结果制定了明确PEPO职责与工作流程的实施方案。

本项干预性研究采用两阶段交叉设计，旨在对比PEPO干预组与常规护理（care-as-usual, CAU）组的妊娠结局差异，具体考察指标包括妊娠时长、出生体重以及5分钟阿普加评分（Apgar score）。此外，本研究还将分析干预组内，接受过至少一次首次见面后咨询服务的PEPO护理孕产妇，与接受常规护理的孕产妇相比，其新生儿是否拥有更优的妊娠结局。最后，本研究将探究人口统计学特征（种族、婚姻状况、社会经济地位以及产次）以及PEPO护理相关特征（产前咨询次数、线上或线下咨询、PEPO的执行主体）是否会对干预效果产生调节作用。