Significance

The postpartum period is a critical time for the health of women and infants, yet many women feel disempowered during the postpartum period and acknowledge there is a lack of knowledge about and preparation for the postpartum experience. The United States maternal mortality rate is the highest among other developed, high-income countries, and Black women are 3–4 times more likely to die during postpartum than white women. Joyuus is an online tool designed to address the self-care needs of underserved postpartum women. In this pilot evaluation, Joyuus showed promise as a digital intervention which can be easily and widely distributed.

Objectives

The United States (US) maternal mortality rate is the highest among other developed, high-income countries, and has nearly doubled in the past 20 years (Berg 2010; Burris et al., 2021; Essien rt al., 2019; Howell et al., 2005; Hutto et al., 2011; Louis et al., 2015; Ruiz et al., 2015; Zaharatos et al., 2018). Amongst the US birthing population, Black women are three to four times more likely to die during postpartum than white women (Louis et al., 2015; Zaharatos et al., 2018). After giving birth, many women experience postpartum depression and anxiety which have been steadily increasing over the past decade. Black women are at higher risk for postpartum depressive symptoms and related negative outcomes than their white counterparts (Howell et al., 2005; Hutto et al., 2011). Medical complications, including cardiovascular disease and hypertensive disorders, contribute to pregnancy-related deaths impacting minority women at higher rates, with systemic and structural racism contributing to these rates (Burris et al., 2021; Essien et al., 2019). Factors such as intimate partner violence and substance abuse also play a role in poor maternal outcomes but are often overlooked (Collier & Molina, 2019). Negative clinical outcomes are exacerbated by the high cost and limited access to quality healthcare in the US placing greater burden on those with lower incomes (Schneider et al., 2021). Policies restricting in-person access to care during the COVID-19 pandemic increased social isolation, creating another potential barrier during a period when seeking urgent care may be lifesaving (Riley et al., 2021). Beyond medically urgent health considerations, women undergo changes physically, emotionally, and socially once they return home after giving birth. Being home with a newborn is often compounded by financial, housing, or employment challenges particularly during a pandemic and economic crisis (Friedline et al., 2020; Thayer & Gildner 2021). Combined with mental health challenges, many women experience physical problems including breast engorgement, sore nipples, mastitis, prolonged bleeding, and urinary tract infections (Keppler & Roudebush, 1999; Miller et al., 2011). The many health challenges women are presented with post-birth are exacerbated by systemic racism, pandemic-amplified disparities, and limited in-person care due to COVID-19 social distancing protocols (Bryant et al., 2010; Grooms et al., 2020).

The postpartum period is a critical time for the health of women and infants, yet once women are discharged from medical care after birth, between 20 and 40% of women do not return for a follow-up visit (Consensus Development Conference 2016). Women in the postpartum period receive less attention from healthcare professionals than during pregnancy and are often lost to follow-up after delivery (ACOG, 2018; Tully et al., 2017). Up to 40% of women experiencing their first pregnancy do not return for a follow-up appointment postpartum (ACOG, 2018) and the rate of missed postpartum appointments increased during the COVID-19 pandemic (Sakowicz et al., 2021). Reasons cited for missed visits are often related to lack of childcare, transportation, maternity leave, other support, and recently, safety concerns and change in access because of the COVID-19 pandemic (Corrigan et al., 2015; Sakowicz et al., 2021). When women do return for a postpartum visit, the visit typically focuses on the physical aspects of care including breastfeeding and contraception (Fowles et al., 2012). During the pandemic, the switch to virtual care shortened the duration of many postpartum visits (Blue Cross Blue Shield, 2020). For minority women, evidence suggests that even when postpartum care is sought, it is suboptimal, and symptoms may be disregarded (Bond et al., 2021). Ineffective postpartum care for minority women is a symptom of the broader, deeply rooted, structural inequalities pervasive across the reproductive health journey (Taylor, 2020). These inequities require targeted interventions to reduce the unacceptably high rates of morbidity and mortality for women of color (Crear-Perry et al., 2021; Tully et al., 2017).

Many women feel disempowered during the postpartum period and acknowledge there is a lack of knowledge about and preparation for the postpartum experience (Howell 2010; Howell et al., 2010). Women are not finding adequate resources to match their postpartum needs, yet reducing barriers to postpartum care is an important component in linking women to necessary health services. Eighty-five percent of women own a smartphone, and the childbearing age group is more likely to be smartphone-dependent than other forms of access (Pew Mobile Fact Sheet, 2021). There is important mHealth work being conducted for postpartum women, with the most robust pool of programs focusing on postpartum depression (Kocak et al., 2021; Saad et al., 2021, Zhou et al., 2022). More needs to be done to ensure the mHealth efforts are accessible, comprehensive and evidence-based (Tucker et al., 2021). The Joyuus web application is designed to provide a comprehensive mHealth experience, accessible through a web browser rather than an Apple or Google App paywall, to address the self-care needs of postpartum women. It provides actionable self-care information, knowledge, and skills to improve postpartum health. As well, the prototype identifies symptoms that may require additional medical attention and are presented as Red Flag topics with relevant resources for when self-care shifts to seeking care. Joyuus is culturally diverse, meaning prior to and throughout the development of the prototype, the study team involved women with perspectives from varied social, geographic, economic, cultural, racial, and ethnic backgrounds. The purpose of our evaluation was to assess the effects of a prototype of the Joyuus tool in a limited sample to assess the key domains and trends related to treatment effect. The study tested five outcome domains (social support, resilience, depression, anxiety, and COVID-19 mental health impacts) in our participant population.

Methods

This study was a proof-of-concept mixed-methods multiphase design to evaluate the Joyuus prototype, including a pre-post evaluation with pregnant and postpartum women (N = 87) to assess social and behavioral health outcomes at baseline and after using the tool for a one-month period. Outcomes included social support, resilience, depression, anxiety, and COVID-19 mental health impacts. The analysis focused on estimation of treatment effect (via 95% confidence intervals). We also tested for correlation between stress, anxiety, and depression measures in the EPDS, STAI and COVID-19 measures. For all results presented, P-values are exploratory. All research activities were conducted in accordance with prevailing ethical principles and were reviewed and approved by the New England Research Institutes Institutional Review Board and an independent Safety Monitoring Committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Participants were eligible for the study if they were an expectant or new mother (at least 28 weeks/6 months pregnant up to 1-year post-birth); aged 18 or older; and identified as non-white. Participants had to be able to read, write, and speak English as all research and product development activities were conducted in English at this stage. Research activities were conducted via smartphone with internet access which was also a requirement of participation. The goal of Joyuus is wide accessibility, therefore no restrictions were placed on phone model, type of Wi-Fi, bandwidth, or where participants accessed Joyuus.

Participants were recruited using a multi-pronged approach, including collaboration with healthcare providers; partnership with Health Equity Zones, the Rhode Island Department of Health, and other local community health centers and community organizations; and directly through advertising on private Facebook groups specifically for new Black and Latina mothers.

It was expected that a sample of 68 participants with analyzable data would provide 90% power to detect a medium effect size of 0.4 at a 5% significance level, assuming the correlation between the pre-and-post measures was 0.5. We planned to recruit 85 participants to yield 68 subjects with analyzable data, assuming an attrition rate of 20%. We enrolled 87 participants in a 2-week recruitment period during June 2021.

During the study, 73 completed a survey about visual identity (look and feel, colors, branding) and 75 completed a survey on content (tone, level, voice). Overall, 79 participants (91%) completed the post-test with 8 participants lost to follow-up. Study participation was completed by August 2021. Interested participants were sent a link to complete an online screening form. If eligible, they completed an electronic informed consent form and baseline questionnaire. All participants gave their informed consent prior to their inclusion in the study. Pregnant and postpartum women contributed demographic data at baseline. Following baseline assessment, all participants were assigned the Joyuus prototype to use for one month and completed a post-test after one month of accessing the tool. Engagement with the mobile tool was evaluated using two real-time experience surveys while using the tool (visual identity and content). Experience survey links were sent at week 2 and week 3 of participation via text message and only one user response per link was possible. A diagram of study methods is referenced in Fig. 1.

Fig. 1
figure 1

Diagrammatic representation of participant data collection points

Mobile tool usage statistics were captured in the post-test survey. Data collection, including screening, informed consent, and surveys was conducted in Qualtrics. Study communications were conducted through text message using SimpleTexting (SimpleTexting.com), a mobile messaging service. Participants were asked to complete online questionnaires within 2 weeks of receipt, and up to three text message reminders were sent at each timepoint. Participants were compensated at each round of data collection.

Joyuus Prototype

The Joyuus prototype was programmed in InVision (invisionsapp.com), a software program that simulates the hands-on version of a mobile web application for beta testing, without the costly requirements of coding and building out a complete mobile web tool. This approach allowed for rapid prototyping, validation of the strategic design direction, identification of critical issues, and overall user experience without costly re-working. Content and coding were frozen during the study period to ensure all participants had access to the same information. The prototype included a home screen and onboarding process to demonstrate how to sign up and customize the user experience through sample surveys on areas of interest based on the stage of postpartum. The tool also shared detailed outlines of the four sections (Body, Feelings, Real Life, Red Flags) which make up the base of our information architecture. For example, we provided participants with the topic of sleep to demonstrate how content would be displayed and how it connects to other topic areas within the tool. All content was evidence-based and reviewed by our research team and clinical expert. Initially, this includes articles, stories, tips, and resources and will expand in the complete program to include videos, expert and peer interviews, and graphic stories.

Outcome Measures

Resiliency was measured with the Connor-Davidson Resilience Scale (CD-RISC 10). It is a 10-item scale used with a variety of populations, including across a wide range of languages, racial/ethnic, and cultural groups. It has been shown to have strong psychometric properties (Mollard et al., 2021; Levey et al., 2021). Each item has a minimum score of 0 and maximum score of 4. Total scores range from a minimum of 0 to a maximum of 40, and total scores are calculated by summing all ten items. A higher score indicates higher resilience (Connor & Davidson, 2003).

Depressive symptoms were measured by the Edinburgh Postnatal Depression Scale (EPDS), a reliable, valid, and widely used scale that measures the presence and intensity of depressive symptoms (Cox et al., 1987). The 10-item scale has high internal consistency, test–retest reliability, and construct validity in community and psychiatric samples. Items are scored 0–3, with some items reverse-scored, and total scores are calculated by summing all ten items. The maximum score is 30, with possible depression indicated by a score of 10 or greater. Item 10 on suicidal thoughts is also a separate indicator.

Anxiety was measured with the State-Trait Anxiety Inventory (STAI), a commonly used measure of trait and state anxiety. It has 20 items for assessing trait anxiety and 20 for state anxiety. In this study, we used the Trait Form only. Studies have shown that it is a sensitive predictor of caregiver distress over time and that it can vary with changes in support systems (Gunning et al., 2010; Spielberger, 1983). Response options range from 1 to 4, with the summary score calculated by summing all 20 items. Some items are reverse scored. Higher scores indicate greater anxiety.

Social support was measured using the MOS Social Support Scale, a 19-item instrument comprising four subscales and one overall summary index (Sherbourne Stewart, 1991). The instrument is scored by obtaining the mean item response for each subscale as well as the overall mean of all items. Higher score reflects higher level of social support.

COVID-19 impact was assessed with the COVID-19 and Mental Health Impacts Scale, which includes 12 items with response options ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate greater concern for impact of COVID-19. The overall summary score is the sum of all items (PhenX Toolkit, 2021).

While social support and COVID-19 impact were not formal endpoints, a descriptive analysis of these measures was conducted.

Results

Participants had a mean age of 30 years, with nearly equal distribution of married (55%) and not married (44%), and above (47%) and below (46%) annual income of $60 K. All identified as female and 99% as Black, with some mothers identifying as more than one race. The sample was geographically dispersed in the United States, with participants from 27 states [Table 1/Figure 2].

Table 1 Pilot Demographics
Fig. 2
figure 2

Sample by US regions

Across the key measures, we saw significant improvement from pre-study (mean = 26.44, SD = 5.39) to post-study (mean = 28.29, SD = 5.26) on the Connor-Davidson Resilience Scale (p < 0.001), trends for improvement related to Depression (EPDS) (p = 0.624) and Anxiety (STAI) (p = 0.286), and no meaningful change on MOS Social Support or COVID-19 Mental Health Impacts [Table 2].

Table 2 Summary scores: Mean changes from baseline at 30-day follow-up (N = 79)

Findings from subgroup analyses related to income and education included trends suggesting women with a bachelor’s degree or above were more likely to score higher on aspects of social support (p = 0.099 affectionate support, p = 0.041 positive social support). Women with higher income (> $60 K) also scored significantly higher in overall social support (p = 0.039) and social support sub-scales (p = 0.058 emotional/information support, p = 0.006 affectionate support), as well as on the resilience measure (p = 0.090), and women with lower income (< $60 K) scored higher on the STAI (p = 0.91).

Data focusing on user experience using the Joyuus prototype for one month suggested that participants found the tool easy to use (96%); felt like the sample content was written for them (94%); and were able to use the information presented in their daily routine (76%). Nearly all participants (99%) reported that they would use or share the fully developed tool when available.

Conclusions for Practice

Joyuus shows promise as a digital intervention that can be easily and widely distributed to pregnant and postpartum women. This pilot study demonstrates that a self-care mobile tool has the potential to address significant health outcomes related to maternal morbidity and mortality. By providing a continuously available companion, Joyuus addresses physical concerns, mental health challenges, and real-life social and interpersonal questions. Women reflected that having scientifically backed comprehensive information in a relatable format created a connection during postpartum when mothers can feel overwhelmed or isolated.

This tool is being developed to provide self-care, in addition to providing resources for women seeking care, because of existing gaps in comprehensive, continuous, accessible, and coordinated care. There are a growing number of web-based programs along with state and national policies that are prioritizing postpartum, which this tool could integrate with to provide broader access to information. Many of these programs and policies are specifically addressing the gap in quality care for women of color. By considering and including insights from diverse perspectives of postpartum women as noted above, Joyuus delivers self-care resources to women recognizing cultural differences and audience diversity. The tool is also delivered in digital format so they can more effectively access important, timely, and relevant knowledge for any stage of the postpartum period they are experiencing.

With the threat of negative health outcomes increasing for women post birth in the US, there is no more important time to be providing information on postpartum self-care to new mothers. This is particularly relevant considering the shift to virtual care, increased social isolation, economic stressors, and renewed awareness of the prevalence of systemic racism as a result of the pandemic. Our study supported evidence that comprehensive self-care resources directed to women's mental health, physical health, and real-life challenges up to 12 months postpartum are desired. As summarized in the words of one participant: “I think it was just really helpful and I think it’s awesome that it’s being put together in one space for women to access. And I definitely would be interested in using the full version and sharing that with friends of mine. I think the fact that it’s going to be in, like an app is, you know, super accessible and I think that’s going to be really helpful.”

Because this prototype evaluation was designed to assess only a subset of a complete program and includes a relatively small sample, this pilot was not designed to provide definitive evidence of a meaningful treatment effect on clinical or behavioral health outcomes. Despite this limitation, participants had significant improvement across key measures from pre-to-post on the Connor-Davidson Resilience Scale, and showed trends for improvement (not statistically significant) for Depression (EPDS) and Anxiety (STAI). While we interpret these results cautiously due to the small sample size and scope of the prototype, this study suggests that the Joyuus tool could improve health outcomes during the postpartum period through improved resilience, and potentially for anxiety and depression when comprehensive unbiased care is otherwise inaccessible. Future studies, including the development and clinical validation study of the comprehensive Joyuus tool, should assess the impact of mHealth on medical complications, including cardiovascular disease and hypertensive disorders. As well, future interventions developed to address postpartum health of underserved women must consider the influence of system and social variables when developing digital or community-based programs. As with Joyuus, conducting formative research at the start of a study can greatly inform the development of interventions for impacted populations. Further development and testing of this tool will include a rigorous randomized controlled trial to evaluate the strength of this relationship.