title: An integrated web-based mental health intervention of assessment-referral-care to reduce stress, anxiety, and depression in hospitalized pregnant women with medically high-risk pregnancies: a feasibility study protocol of hospital-based implementation.
abstract: BACKGROUND
  At prevalence rates of up to 40%, rates of depression and anxiety among women with medically complex pregnancies are 3 times greater than those in community-based samples of pregnant women. However, mental health care is not a component of routine hospital-based antenatal care for medically high-risk pregnant women.
  
  
  OBJECTIVE
  The purpose of this study is to evaluate the effectiveness and feasibility of the hospital-based implementation of a Web-based integrated mental health intervention comprising psychosocial assessment, referral, and cognitive behavioral therapy (CBT) for antenatal inpatients.
  
  
  METHODS
  This study is a quasi-experimental design. Pregnant women are eligible to participate if they are (1) <37 weeks gestation, (2) admitted to the antenatal inpatient unit for >72 hours, (3) able to speak and read English or be willing to use a translation service to assist with completion of the questionnaires and intervention, (4) able to complete follow-up email questionnaires, (5) >16 years of age, and (6) not actively suicidal. Women admitted to the unit for induction (eg, <72-hour length of stay) are excluded. A minimum sample of 54 women will be recruited from the antenatal high-risk unit of a large, urban tertiary care hospital. All women will complete a Web-based psychosocial assessment and 6 Web-based CBT modules. Results of the psychosocial assessment will be used by a Web-based clinical decision support system to generate a clinical risk score and clinician prompts to provide recommendations for the best treatment and referral options. The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6-8 weeks postrecruitment. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence at 3-months postpartum; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. All women will complete email questionnaires at 6-8 weeks postrecruitment and 3-months postpartum. Qualitative interviews with 10-15 health care providers and 15-30 women will provide data on feasibility and acceptability of the intervention.
  
  
  RESULTS
  The study was funded in September, 2014 and ethics was approved in November, 2014. Subject recruitment will begin January, 2015 and results are expected in December, 2015. Results of this study will determine (1) the effectiveness of an integrated Web-based prenatal mental health intervention on maternal and infant outcomes and (2) the feasibility of implementation of the intervention on a high-risk antenatal unit.
  
  
  CONCLUSIONS
  This study will provide evidence and guidance regarding the implementation of a Web-based mental health program into routine hospital-based care for women with medically high-risk pregnancies.
authors.affiliation: University of Alberta, Edmonton, AB, Canada. dawn.kingston@ualberta.ca.
authors.forename: Dawn
authors.identifier: http://orcid.org/0000-0002-7183-2803
authors.initials: D
authors.lastname: Kingston
authors.forename: Selikke
authors.identifier: http://orcid.org/0000-0003-2888-2562
authors.initials: S
authors.lastname: Janes-Kelley
authors.forename: Janie
authors.identifier: http://orcid.org/0000-0001-5341-036X
authors.initials: J
authors.lastname: Tyrrell
authors.forename: Lorna
authors.identifier: http://orcid.org/0000-0003-4540-2196
authors.initials: L
authors.lastname: Clark
authors.forename: Deena
authors.identifier: http://orcid.org/0000-0001-8943-2165
authors.initials: D
authors.lastname: Hamza
authors.forename: Penny
authors.identifier: http://orcid.org/0000-0003-3941-7113
authors.initials: P
authors.lastname: Holmes
authors.forename: Cheryl
authors.identifier: http://orcid.org/0000-0001-5867-0101
authors.initials: C
authors.lastname: Parkes
authors.forename: Nomagugu
authors.identifier: http://orcid.org/0000-0001-7652-9689
authors.initials: N
authors.lastname: Moyo
authors.forename: Sheila
authors.identifier: http://orcid.org/0000-0002-5950-7098
authors.initials: S
authors.lastname: McDonald
authors.forename: Marie-Paule
authors.identifier: http://orcid.org/0000-0002-6957-0656
authors.initials: MP
authors.lastname: Austin
keywords: Web-based; anxiety; cognitive behavior therapy; depression; pregnancy; psychological stress; quasi-experimental studies; screening