Background and development
Maternal ill-health – a significant public health issue
PRISM was the culmination of almost a decade of research beginning in 1989 that mapped the experiences of Victorian women as they became mothers, and documented concerning levels of maternal physical and emotional ill-health after childbirth.
This research included:
1989 Survey of Recent Mothers
A population based statewide postal survey exploring women's views of maternity care and assessing the prevalence of maternal depression after birth.
Follow-up Study of Women's Emotional Well-being and Experiences of Motherhood
Personal interviews with 90 women, half of whom had been depressed 8-9 months after childbirth.
1994 Survey of Recent Mothers
A second statewide postal survey with additional emphasis on physical health problems after birth.
Life as a Mother Project (LAMP)
Telephone interviews more than 200 women concerning the first nine months of life with a new baby.
Mothers in a New Country (MINC) Study
A cross-cultural interview study with Vietnamese, Turkish and Filipino women assessing their views of maternity care and exploring physical and emotional health issues after birth.
The evidence and knowledge gained from this work informed the strategies implemented and evaluated in PRISM. In summary:
- Depression affects around one in six or seven women following the birth of a baby - 10,000 women in Victoria every year.
- 95% of women report one or more health problems in the first six months after childbirth, with the most common problems being exhaustion, backache, perineal pain, sexual problems and urinary incontinence.
- These problems are common in both Australian-born and immigrant women and often go undetected, despite frequent contacts with primary health care services.
- Women often find it hard to find someone to talk to about these issues and few women actively seek help from health professionals.
- Women who do find someone who listens with empathy describe this as very helpful.
- Isolation, lack of support and few opportunities for time out from infant care are key issues for women experiencing depression and other health problems.
A variety of publications [PDF 235KB] arose from the previous descriptive studies that led to PRISM.
The evidence for interventions to improve maternal health
The development of PRISM was also informed by the accumulating evidence from randomised trials - conducted in Australia and elsewhere - to reduce maternal depression and improve physical health in the year after birth.
At the time PRISM commenced, the evidence in support of the approach taken in PRISM can be summarised as follows:
- The importance of community-based interventions in mental health had been argued by Regier et al.(1) because only a minority seek professional help for mental health problems, when they do they turn to the primary health sector; even when help is sought mental health problems are under-recognised in primary care. These arguments were reinforced by the difficulties of identifying women at high risk of depression after birth.(2)
- The effectiveness of 'active listening' and non-directive counselling in depression after birth by staff equivalent to maternal and child health nurses had been demonstrated in three small randomised trials in the UK and Sweden. (3-5) A subsequent dissemination project identified greater confidence in dealing with maternal depression, and a decrease over time in their need to refer to other agencies, as well as reduced levels of depression. (6) The effectiveness of teaching 'empathic' listening skills to GPs for improved care of patients with depression and anxiety had been similarly demonstrated. (7) This strategy - providing someone to talk to - was the primary advice which Victorian women who had been depressed would give to other women with depression. (8)
- Extended community midwifery care and support to reduce maternal physical and emotional problems in the first 6 months after birth was being tested in 2 randomised trials of new models of service delivery in the UK. (9) Results form these trials have now been published. (10,11)
- Systematic reviews, summarised by Davis, (12) showed that changing GP knowledge, skills, and confidence requires multifaceted interventions. These findings informed the development of the GP interventions.
- Social support interventions for new mothers were supported by limited trial evidence at the start of PRISM (13) and whole community natural helping interventions were largely supported by case study evidence only. (14)
- The effectiveness of 'time out' for maternal health and well-being had not been studied within a randomised trial but taking 'time out' was the other key strategy put forward by Victorian women who had been depressed. (8)
- The provision of mothers' information kits, and the establishment of mothers' groups to reduce depression were being evaluated in a randomised (factorial design) trial in the Grampian region of Scotland, at the time PRISM commenced. The results have now been published. (15)
1. Regier D et al. The NIMH depression awareness, recognition and treatment program Am J Psychiatry 1988; 145:1351-57.
2. Appleby L et al. Screening for high risk of postnatal depression. J Psychosom Res 1994: 38: 539-45
3. Holden JM, Sagovsky R, Cox JL. Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. Br Med J, 1989, 298, 223-26.
4. Wickberg B, Hwang C.P. Counselling of postnatal depression: A controlled study on a population based Swedish sample. J Affect Disorders, 1996, 39, 209-16.
5. Appleby L, Warner R, Whitton A, Faragher B. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. Br Med J, 1997, 314, 932-36.
6.Gerrard J et al. A trainer's perspective of an innovative programme teaching health visitors about the detection, treatment and prevention of postnatal depression. J Adv Nursing 1993;18:1825-32
7. Gask L. Teaching psychiatric interviewing skills to general practitioners. In: Jenkins R et al. The prevention of depression and anxiety the role of the primary care team. London: HMSO, 1992, 39-45.
8. Small R, Brown S, Lumley J, Astbury J. Missing voices: what women say and do about depression after childbirth. J Reprod Inf Psychol 1994, 12, 89-103.
9. Henderson C. (ed) Women's health after birth: what's happening in postnatal care? [Supplement] Br J Midwifery 1997; 5: 608-622
10. Morrell CJ, Spiby H, Stewart P, Walters S, Morgan A. Costs and effectiveness of community postnatal support workers: randomised controlled trial. Br Med J 2000; 321: 593-598.
11. MacArthur C, Winter HR, Bick DE, Knowles H, Lilford R, Henderson C, Lancashire RJ, Braunholtz DA, Gee H. Effects of redesigned community postnatal care on women's health four months after birth: a cluster randomised trial. Lancet 2002;359:378-385.
12. Davis DA et al. Changing physician performance. JAMA 1995; 274: 700-705.
13. Johnson Z et al Community mothers program: a randomised trial of a non professional intervention. BMJ 1993;306:1449-1452
14. Lay health advisors: a critical link to community capacity building. Health Ed Qly (Special issue) 1997;24(4):407-522.
15. Reid M, Glazener C, Murray GD, Taylor GS. A two-centres pragmatic randomised controlled trial of two interventions of postnatal support. BJOG. 2002 Oct;109:1164-70.
Systematic reviews of relevant trials have been completed and published, summarising the current evidence about:
- Interventions to reduce maternal depression. Lumley J, Austin M-P. What interventions may reduce postpartum depression. Curr Opin Obstet Gyneol 2001;13:605-611
- Antenatal screening for prevention of postnatal depression. Austin M-P. Lumley J. Antenatal screening for postnatal depression: a systematic review. Acta Psychiatr Scand 2003;107:10-17
- Intervening to reduce postnatal depression. A systematic review of the randomized trials. Lumley J, Austin M-P, Mitchell C. Int J Technol Assess Health Care 2004;20:128-144
Summary tables [PDF 140KB] provide information about the design and intervention of the trials reviewed in the paper, and a reference listing [PDF 96KB] shows all the trials, up-to-date at 23 March 2004.
Read more about the background to PRISM in a comprehensive overview of the study rationale and evolution [PDF 448KB], including our efforts to obtain funding for the conduct of the trial.
Design of PRISM
PRISM was designed as a cluster randomised trial, meaning that participating communities accepted a 50:50 chance of being an intervention community (implementing PRISM strategies to support mothers) and a 50:50 chance of being a comparison community (continuing with usual postnatal care for women).
'Cluster' randomised means that it was whole communities, in this case municipalities, which were randomised rather than individuals.
Sixteen communities have participated in PRISM: eight in the Melbourne metropolitan area and eight in rural areas of Victoria. Four Melbourne and four rural municipalities are intervention communities, and four Melbourne and four rural municipalities are comparison communities.
The important benefit of the randomised trial design is that it allows us to answer the question – does the PRISM intervention work? – with confidence.
More about the design of PRISM
A paper describing the design in full - the trial protocol - has been published.
PRISM (Program of Resources, Information and Support for Mothers) Protocol for a community randomised trial [ISRCTNO3464021] Lumley J, Small R, Brown S, Watson L, Gunn J, Mitchell C, Dawson W. The paper is available at http://www.biomedcentral.com/1471-2458/3/36
A second paper describing design issues in PRISM was published in 2004.
PRISM: Mounting a community randomised trial: sample size, matching, selection and randomization issues. Watson L, Lumley J, Small R, Brown S, Dawson W. Controlled Clinical Trials 2004;25:235-250
Evaluation in PRISM
Evaluation has involved:
- Process and impact evaluation (assessing implementation of PRISM key elements, stakeholder views, program impacts);
- Health outcome evaluation (maternal depression and physical health outcomes); and
- Context evaluation (mapping State and Commonwealth activity on maternal health; and assessment of activity in comparison areas).
Read more detailed information about the evaluation strategies in PRISM [PDF 90KB].
Getting started: establishing partnerships with local government
There were a number of steps in getting started in PRISM. Perhaps the most important were those taken to gather information about local government areas in Victoria, to inform eligible municipalities about the trial, to invite expressions of interest in participation and then to provide more in-depth project briefings in each interested municipality concerning the rationale for PRISM, what participation would involve and to answer questions about the trial - prior to a formal Memorandum of Understanding being signed.
Information gathering about municipalities in Victoria
Thirty-three of the 78 municipalities in Victoria were eligible to participate in PRISM on the basis that their annual numbers of births fell between 300 and 1500. A range of information about these 33 eligible communities was collected prior to our approaches to local councils. This included compilation of publicly available information about each local government area (such as Council Annual Reports, Municipal Public Health Plans, Community Service Directories and organisational charts identifying key decision makers), documentation of relevant health service activity (Maternal and Child Health Services, special outreach programs for mothers and babies and General Practice Division projects focused on pregnancy, birth and the postnatal period). Australian Bureau of Statistics data on each local government area were also compiled to provide a socio-demographic profile of each community, and the most recent data on numbers of births in each municipality was requested from the Victorian Perinatal Data Collection Unit, within the Department of Human Services.
An information package for local government about PRISM
The 33 eligible local government authorities, comprising 17 rural and 16 metropolitan areas of the state, were all sent a letter of invitation accompanied by an information package [PDF 309KB] about the trial and a form for expression of interest in a formal project briefing. This invitation package was sent to the Mayor, the Chief Executive Officer and the Community Services Manager in all 33 municipalities.
Briefing meetings in municipalities around Victoria
Twenty-six municipalities submitted written expressions of interest in receiving a more detailed briefing [PDF 100KB] about PRISM with the Research Team. All briefings were held in local communities, mostly at municipal offices. The briefings were interactive sessions which enabled not only the presentation of more detailed information about the trial, but also provided an opportunity for local government participants to ask questions and for the research team to develop further understanding of service provision and local issues in each municipality.
Memorandum of Understanding (MoU)
At the end of each local briefing session, a proposed joint Memorandum of Understanding [PDF 270KB] between the University and each local government area agreeing to participate was discussed. Subsequently, 21 municipalities submitted signed MoUs to the University.
Selection of the final set of 16 participating communities
A number of considerations affected the selection of sixteen communities for participation in PRISM, including ensuring an adequate sample size, program costs and available resources, concern to minimise contamination across adjoining local government boundaries between intervention and comparison areas, and capacity to match communities in pairs on a limited number of criteria (geographic size, number of births and levels of infrastructure support and activity).
Importantly, we included the minimum number of communities that would enable us to detect with confidence a meaningful effect on depression prevalence and the maximum number of communities our budget/resources would allow. A detailed description of the selection process employed is included in the PRISM design paper (reference available here soon).
A public launch of PRISM [PDF 83KB] at which the randomisation of the sixteen communities was undertaken, took place in Melbourne in June 1998. As part of a commitment to public discussion of the rationale for conducting PRISM as a community randomised trial and to provide a forum for discussion of evaluation of social interventions, representatives of all participating areas were invited to take part in a half-day workshop, preceding the randomisation.
More about establishing partnerships to implement PRISM
A paper describing in more detail our approaches to local government and the process of establishing partnerships to implement PRISM has been published.
Mounting a community-randomised trial. Establishing partnerships with local government. Small R, Brown S, Dawson W, Watson L, Lumley J. Aust N Z J Public Health 2004;28:471-475.