The feasibility and acceptability of implementing simplified cognitive behavioral therapy approaches to support postpartum mental health and address associated social and behavioral barriers to postpartum family planning in Amhara, Ethiopia: a qualitative study.

Background: Poor mental health can negatively impact health outcomes across diverse health areas, including in the first year postpartum. Yet, the intersection of postpartum mental health and postpartum family planning (FP) is understudied. Cognitive Behavioral Therapy (CBT) is an evidence-based practice that has proven helpful for improving mental health and supporting positive behavior change across health areas, including in low-resource settings. Drawing on existing CBT tools, we created and piloted an intervention called Mothers Time, designed to be delivered in three sessions by a community health worker (CHW) to small groups of postpartum women experiencing depression or anxiety symptoms and an unmet need for FP. Our objective was to assess the feasibility and acceptability of Mothers Time in rural Amhara, Ethiopia.

Methods: We recruited and trained four CHWs to deliver the intervention. We recruited 16 postpartum women experiencing mild to moderate anxiety and depressive symptoms to participate. We conducted in-depth interviews with women and CHWs before, during and after the intervention. We used a framework approach to analyze data. To assess acceptability, we analyzed data from mothers, probing to understand whether they found the intervention accessible, engaging, and relevant for the challenges they were experiencing postpartum. To assess feasibility, we explored CHWs ability to deliver the intervention and analyzed their capacity to deliver it at consistent quality. Interviews with CHWs and other health actors provided additional data on the feasibility of adding simplified CBT to CHWs' current package of services.

Results: Mothers perceived Mothers Time to be acceptable and to provide helpful tools for navigating the postpartum period. Prior to the intervention, many women felt isolated, and the group sessions supported social connection. Vignettes demonstrating simple CBT concepts engaged mothers, provoking reflection on how anxious or sad thoughts can impact behaviors that are important for informed FP use (such as care seeking, spousal communication and planning for the future) and sparked discussions on how mothers can support their own mental and physical health. Homework (explained by CHW in sessions and completed independently between sessions) helped women prioritize caring for themselves and social connection. Overall, we found that it was feasible for CHW to learn and deliver Mothers Time. CHW understood that mental health could create challenges for mothers and were able to use the simplified materials to share information about basic mental health concepts. Limited time was the biggest challenge; CHWs would benefit from additional training, and women would likely benefit from additional sessions.

Conclusion: This research may be useful to practitioners looking to integrate mental health and postpartum FP in low-resource settings. These findings can be used as a foundation for future research and pilot interventions to support all women to meet their postpartum and FP needs, including those living with symptoms of depression and anxiety.