title: Improving population-level maternal health: a hard nut to crack? Long term findings and reflections on a 16-community randomised trial in Australia to improve maternal emotional and physical health after birth [ISRCTN03464021].
abstract: BACKGROUND
  Community level interventions to improve maternal and child health have been supported and well evaluated in resource poor settings, but less so in developed countries. PRISM--Program of Resources, Information and Support for Mothers--was a primary care and community-based cluster-randomised trial in sixteen municipalities in Victoria, Australia, which aimed to reduce depression in mothers and improve their physical health. The aim of this paper is to report the longer term outcomes of PRISM and to reflect on lessons learned from this universal community intervention to improve maternal health.
  
  
  METHODS
  Maternal health outcome data in PRISM were collected by postal questionnaire at six months and two years. At two years, the main outcome measures included the Edinburgh Postnatal Depression Scale (EPDS) and the SF-36. Secondary outcome measures included the Experience of Motherhood Scale (EOM) and the Parenting Stress Index (PSI). A primary intention to treat analysis was conducted, adjusting for the randomisation by cluster.
  
  
  RESULTS
  7,169/18,424 (39%) women responded to the postal questionnaire at two years -3,894 (40%) in the intervention arm and 3,275 (38%) in the comparison arm. Respondents were mostly representative on available population data comparisons. There were no differences in depression prevalence (EPDS≥13) between the intervention and comparison arms (13.4% vs 13.1%; ORadj = 1.06, 95%CI 0.91-1.24). Nor did women's mental health (MCS: 48.6 vs 49.1) or physical health scores (PCS: 49.1 vs 49.0) on the SF-36 differ between the trial arms.
  
  
  CONCLUSIONS
  Improvement in maternal mental and physical health outcomes at the population level in the early years after childbirth remains a largely unmet challenge. Despite the lack of effectiveness of PRISM intervention strategies, important lessons about systems change, sustained investment and contextual understanding of the workability of intervention strategies can be drawn from the experience of PRISM. Trial Registration. Controlled-Trials.com ISRCTN03464021.
authors.affiliation: Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
authors.forename: Rhonda
authors.initials: R
authors.lastname: Small
authors.affiliation: Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
authors.forename: Lyndsey
authors.initials: L
authors.lastname: Watson
authors.affiliation: Department of General Practice, University of Melbourne, Carlton, Victoria, Australia.
authors.forename: Jane
authors.initials: J
authors.lastname: Gunn
authors.affiliation: School of Nursing and Midwifery, Griffith Health Institute, Griffith University, Southport, Queensland, Australia.
authors.forename: Creina
authors.initials: C
authors.lastname: Mitchell
authors.affiliation: Healthy Mothers Healthy Families Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Brown
mesh_terms: D001315:Australia; D005260:Female; D006304:Health Status; D006801:Humans; D008429:Maternal Welfare; D008603:Mental Health; D011181:Postnatal Care; D011247:Pregnancy; D012944:Social Support; D011795:Surveys and Questionnaires