Introducing the Postpartum Toolkit: An Examination of the Feasibility, Acceptability and Pilot Efficacy of an Online Clinical Tool to Enhance Postpartum Functioning and Emotional Wellbeing

Abstract

During the postpartum period, a birth parent’s level of functioning (ability to perform the activities and roles required to maintain wellbeing) is critical in determining the health of parents and their infants. However, existing approaches to support postpartum parents are insufficient, especially in the United States, and these individuals face barriers to care. The utilization of internet-based intervention may be an effective solution allowing access to resources for this population. In this study, we developed a patient-centered online tool to bolster postpartum functioning, and collected data on the feasibility, acceptability, and initial impact of this tool on functioning and emotional wellbeing. Data collection took place between February and June 2021 from a sample of 124 individuals who were within the first ten months postpartum and living in the US. Results suggest that the tool is acceptable, though there are barriers to feasibility of use. Additionally, pilot-efficacy data suggest that this tool may be effective in improving postpartum emotional wellbeing, though further controlled testing is warranted. A future iteration of the tool that incorporates participant feedback to improve feasibility of use could prove an effective means of delivering support to an at-risk population.

1. Introduction

A birth parent’s level of functioning—their ability to perform the activities and roles required to maintain health and wellbeing—is of high importance in determining parent/child health outcomes during the first postpartum year. Note: we use the term “birth parent” (rather than “mother”) to refer to individuals who are carrying, birthing, and caretaking for their infants. It was taken from a handbook created at Australian National University which suggests the term “birthing/birth parent” should be used as a default, particularly in academic settings, in place of “mother” [1] to promote inclusion and lessen feelings of isolation that can stem from gendered language surrounding childbearing [2]. This is not to suggest that individuals cannot identify as a mother; rather, the assumption of gender should not be made prior to an individual expressing their preferences. This is particularly important as previous work with pregnant transmen has demonstrated that institutional erasure functions as a barrier to routine perinatal care [3]). Birth-parent postpartum functioning is important for determining infant health, as birth parents are generally the principal performers of infant care during the postpartum period, and this is the time in which infants have the greatest need [4,5]. The interaction and care provided to the infant during this time also has implications for later development [6,7]. Postpartum functioning also plays a key role in parent recovery from childbirth, as the postpartum year is a time of increased vulnerability to physical health concerns [8] and is the time period in which individuals assigned female at birth are most likely to develop depression and anxiety compared to any other time in their lives [9]. This vulnerability is so serious that the postpartum period has been determined to have the highest risk of birth-parent and infant death [10]. Therefore, ensuring that birth parents are achieving optimal functioning during this time, and are thus able to address both their own physical and emotional needs, as well as their infant’s needs, is an important health goal.

Importantly, the field has seen recent gains in the measurement and understanding of postpartum functioning. First, with the creation of the Barkin Index of Maternal Functioning (BIMF), the field now possesses a patient-centered means of assessing postpartum functioning across the seven domains of social support, adjustment to new motherhood, infant care, responsibility management, self-care, psychological wellbeing, and mother-child interaction [11,12,13]. Additionally, qualitative work with experts on the postpartum experience, i.e., postpartum birth parents themselves, has revealed key factors that birth parents indicated were most influential in determining their level of functioning during the postpartum year [14].

Despite the recognition that the postpartum year is a vulnerable and important time, existing approaches to support postpartum birth parents are insufficient, especially in the United States [15,16]. Prenatal education, a commonly available initiative, does not appear to consistently prepare birth parents for postpartum adjustment [17,18]. There is also an observed gap between what is desired by birth parents and what is offered by providers during the postpartum period [19,20,21,22], which is an important consideration given that patient-centered approaches have proven influential in delivering effective postpartum mental healthcare [23]. Additionally, a recent review called for better clarification of the dimensions of health that promote holistic birth-parent wellbeing and functioning in the postpartum year, beyond commonly researched topics such as depression and breastfeeding/chestfeeding [24].

Further, postpartum birth parents are a uniquely difficult population to reach. They face many barriers to postpartum healthcare-visit attendance, including the parent reported barrier of being too busy with their new baby and other responsibilities [5,25]. Postpartum birth parents often neglect their own self-care needs, which can reduce postpartum healthcare utilization and engagement in key health-promoting behaviors [26]. Additionally, birth-parent discomfort with disclosing their feelings, often reinforced by their support network’s failure to respond to their needs, can be a barrier to help-seeking behavior [27,28].

Particularly in the realm of mental health care, while some services exist to address postpartum mood and anxiety disorders, screening rates for these disorders are inconsistent and low among healthcare professionals [29] and evidence suggests there are many barriers to addressing mental health in maternal–child health-care settings [30]. This is problematic, as medical providers are positioned to play a key role in connecting patients with mental health care [31]. Research also suggests that birth parents of less-privileged backgrounds, who are at the highest risk for postpartum depression, must contend with attitudinal and instrumental barriers that prevent them from seeking professional mental-health support [32,33,34].

Birth parents in the United States also face systematic barriers, as resources and opportunities such as health insurance, paid parental leave, and nurse home-visiting programs are not universally available [35,36], in addition to a sorely lacking standard of postpartum care compared to “peer” nations. Postpartum health care in the United States generally consists of a single poorly attended six-week postpartum visit, though efforts are being made to move towards a paradigm of more individualized and ongoing care [37]. These obstacles further worsen outcomes for an already at-risk population.

One solution to the issue of resource access for this population is the utilization of mobile health and internet-based intervention. The Pew Research Center has found that internet usage in the US is nearly ubiquitous [38]. A recent meta-analysis found therapist-supported internet-based cognitive behavior therapy to be effective in reducing stress, anxiety, and depressive symptoms among postpartum birth parents [39]. Another recent meta-analysis found social media and mobile health apps to be effective at promoting physical health, mental health, and knowledge during pregnancy and postpartum [40]. Additionally, a recent study that tested the efficacy of a self-guided web-based intervention to improve postpartum mental health, found that this intervention led to significant increases in positive mental-health outcomes [41], demonstrating that interaction with a professional is not necessary in order to confer benefits. Therefore, decreasing barriers to care by allowing for virtual engagement via the internet or a mobile health device shows great promise for delivering support to postpartum birth parents. Additionally, techniques such as individually tailoring virtual interventions have been associated with effective behavior change, and can further increase the impact of such interventions [42].

To address these issues, the current study sought to test the feasibility, acceptability, and pilot efficacy of a newly developed online tool, The Postpartum Toolkit (see Section 2.1 for a detailed description of the tool), based upon qualitative findings uncovered with postpartum birth parents [14]. The Postpartum Toolkit provides postpartum birth parents with personalized resources to bolster functioning in the form of written feedback. Follow-up data was collected six weeks after participant’s received their individual feedback. Feasibility was assessed through participant reports of resource use, and acceptability was assessed through participant ratings of the resource matching the need and usefulness of the resources. Pilot efficacy was assessed by examining pre-post change in score on postpartum functioning (primary outcome), as well emotional wellbeing (stress, anxiety and depression; secondary outcomes).

2. Materials and Methods

The study utilized online survey data collection on a secure platform that was designed for this study. IRB approval was obtained by Drexel University.

2.1. The Postpartum Toolkit

The personalized resources presented by the tool are determined based off of each participant’s unique response pattern on “The Postpartum Toolkit Checklist” (see Appendix A), which features 24 items representing factors that birth parents identified as most influential to functioning in previous qualitative work [14]. Participants were asked to rate the degree to which each item is a strength for them (selecting from “This is a strength for me”, “This is going ok for me, but could be better” or “I would like help with this”; participant options for responses were based on the Canadian Self-Care Program for Mothers with Postpartum Depression and Anxiety [43]). For each item not endorsed as a strength (i.e., the participant selected “this could be going better for me” or “I would like help with this”), the resources mapped to that item were automatically selected to appear in individualized feedback that was presented to the participant upon submission of the baseline survey. Appendix B includes the text of the resources; each resource is given its own letter (e.g., Resource “H” provides emotion-regulation tools), and Appendix C shows the mapping of resources to checklist items (i.e., which lettered resources would appear for each item on the checklist when not endorsed as a strength). The resources were a mix of information and links to empirically backed educational content. Of note is that efforts were made to include links and recommendations to materials that are low or no cost, not geographically restricted (most commonly online resources), and reflect population diversity. The resources were organized so that the most indicated resources appeared first. Specifically, the resources that corresponded to items on which the participant endorsed “I’d like help with this” appeared before those that corresponded to “This is going ok for me, but could be better.” Of note is that participants were emailed a PDF copy of their feedback for reference and the feedback was calculated to be written at an 8th–9th grade reading level using the Flescher Kincaid criteria [44].

It is important to note that this tool was designed as a flexible and personalized intervention. Depending on the profile of strengths and growth edges of each individual, the tool served different purposes. For some participants, who were indicating areas of growth that called for self-guided intervention (deep-breathing exercises, information about accessing low-cost material resources), this tool could work on its own as an intervention. In some cases, the growth areas endorsed called for resources such as mental-health counseling or specialist care such as postpartum occupational therapy. In these cases, the tool functioned a first step towards getting connected to more intensive support by providing education about services and how to access them.

It is additionally important to note that, prior to pilot testing the tool, we sought consultation from a multidisciplinary group of experts (consisting of: a nurse with expertise in parent/child health, four perinatal-mental-health specialists, an obstetrician-gynecologist, a marriage and family therapist, and two occupational therapists with perinatal expertise) on both the user experience as well as the completeness of the checklist and resource mappings. The experts were presented with documents outlining the content of the tool (see Appendix A, Appendix B, and Appendix C) as well as a description of the user flow. Specifically, they were asked:

• Whether the checklist of items produced from the qualitative data appear theoretically complete. If it does not appear complete, what items should be added?
• Whether there are additional resources that should be incorporated into the feedback to address checklist items?
• What if anything about the way the checklist and feedback is presented (phrasing of information, means of delivering the feedback, etc.) could be improved upon to increase the inclusivity of this tool and/or generally improve the tool?

Feedback from the experts was incorporated into the tool before finalizing it for pilot testing. This feedback included suggestions for more inclusive and sensitive phrasing, more attention to the birth parent’s physical recovery from birth, and adjusting resource offerings to increase accessibility (e.g., including information about accessing doula services for folks of limited financial means).

2.2. Participants

Eligible participants were individuals who had given birth in the past ten months (including cisgender females, trans men and non-gender-binary individuals) who live in the United States and had access to the internet. These individuals, additionally, were required to be at least 18 years of age, and both literate and fluent in English, given that all measures were presented in English. Participants also agreed to participate and completed an electronic consent form. Participants were considered ineligible if they were not a cohabitating caretaker for their infant or infants. In an effort to collect feedback from as universal a population as possible, no additional exclusion criteria were imposed.

We planned to recruit 72 completers of the study, as determined by the power analyses. To account for attrition, we planned to enroll up to 150 participants [45]. Ultimately, 125 participants completed all study time points. Overall, 215 individuals expressed interest in the study, 158 of which were assessed for eligibility. Fifty-seven were not assessed for eligibility for the following reasons: 34 never responded to outreach from the study team after they expressed initial interest in participating, and 23 expressed interest after study recruitment was complete. Of the 158 assessed for eligibility, 14 were excluded (9 because they were more than twelve months postpartum, 3 because they were living outside of the US, 1 because they had experienced pregnancy loss, and 1 because they were still pregnant at the time of outreach). Of the 144 individuals who were enrolled, 19 were lost to follow up (10 did not complete the baseline survey, 9 did not complete the follow-up survey). Of note is that 124 individuals were included in the outcome analysis. One individual was excluded from these analyses as they endorsed all strengths on The Postpartum Toolkit Checklist and thus were not presented with resources. See Figure 1 for participant flow information.

2.3. Data Collection and Procedure

Recruitment occurred between February and April 2021, and data collection took place between February and June 2021. Participants were recruited online, via postings on online support communities and social-networking websites (e.g., Facebook). Virtual recruitment materials directed interested participants to contact the study team directly or complete the Qualtrics form and a study team member would reach out to interested individuals. Following contact with the study team to confirm that they met inclusion criteria, participants were sent a baseline survey link via email or text (depending upon participant preference) featuring a sociodemographic questionnaire created for the study, the Barkin Index of Maternal Functioning (BIMF) [11], the Perceived Stress Scale 10 (PSS-10) [46], the Hospital Anxiety and Depression Scale (HADS) [47], and The Postpartum Toolkit Checklist, which determined individualized resources provided in participant feedback (as discussed in Section 2.1). Immediately upon submitting the baseline survey, participants were presented with their individualized feedback and resources on the screen of their device (phone or computer). In addition, a study team member checked the data-collection platform daily and emailed PDF versions of the feedback (for reference) to any individuals who had completed the baseline within the past 24 h. Three weeks after the baseline, participants were sent a brief two-item survey by email or text survey inquiring if they have used any of the resources (dichotomous yes or no response), and, if they have used at least one resource, how helpful they found that resource (on a scale 1–10; 10 being most helpful). Six weeks after baseline, participants were sent a final follow-up survey via email or text featuring the BIMF, PSS-10, HADS and a feasibility and acceptability questionnaire created for the study. Participants were asked a series of eleven questions that were created to assess the feasibility and acceptability of The Postpartum Toolkit. Specifically, they were asked:

• The degree to which the resources that they were given matched their needs (rated 1–10 with a higher rating indicating a better match).
• The degree to which the resources that they were given were found to be useful (rated 1–10 with a higher rating indicating a higher level of usefulness).
• Whether they used the resources (dichotomous yes/no options for response; if participants responded “yes” a checklist of the resources they were given in their feedback appeared and they were asked to select which resources were used).
• Whether there are resources which they have not yet used but intend to use (dichotomous yes/no options for response; if participants responded “yes” a checklist of the resources they were given in their feedback appeared and they were asked to select which resources have not yet been used but they intend to use).
• How often they referenced their feedback (there were multiple choice options for response).
• If they did not use the resources, what got in the way (there were multiple choice options for response and participants could select all that applied).
• Whether there are other factors which should be included in the checklist (items were listed for participant reference and participants were given a dichotomous yes/no option for response; if they responded “yes” a textbox appeared in which they could specify suggested additions).
• Whether there is anything else that could be included in the feedback/resources (dichotomous yes/no options for response; if they responded “yes” a textbox appeared in which they could specify suggested additions).
• Whether there were other resources which the participant used which were not featured in the feedback list (if they responded “yes” a textbox appeared in which they could specify the resource(s) used).
• Whether participants would have been more likely to use these resources if they had a person introducing them to the resources rather than guiding themselves through feedback that was provided automatically (dichotomous yes/no options for response).
• Other suggestions to improve the tool (dichotomous yes/no options for response; if they responded “yes” indicating they had suggestions, a textbox appeared in which they could specify suggested additions).

This questionnaire was calculated to be written at a 6th-grade reading level using the Flescher Kincaid criteria [44]. Of note is that individuals who endorsed all checklist items as strengths were not asked to provide feedback on their resources, but were asked for feedback on The Postpartum Toolkit Checklist. After completion of their six-week follow-up survey, participants were compensated with a USD 20 gift card.

2.4. Statistical Analyses

Data were analyzed using SPSS 28.0 statistical package. Initial descriptive analyses were conducted to examine the characteristics of the participants and to examine primary variables. Given the generally privileged background of our sample overall, we examined the baseline characteristics of the less-privileged subgroup of the sample to see if the characteristics of this sample seemed to differ from the overall sample. The individuals included in this subgroup were those who filled at least one of the following criteria: were of a non-White racial background, did not possess an advanced degree (individuals whose highest degree was at college or lower), and were of lower income (less than $75,000 estimated annual income given that this was the median US income as of 2018 [48]). In addition, as research on the experience of transgender parents is lacking [49], we examined the data collected from the two participants who did not identify as female (both identified as male). Descriptive statistics were also calculated on the feasibility and acceptability data in addition to qualitative analysis of the open-ended textbox responses on the feasibility and acceptability measure. To assess pilot efficacy, a series of four matched pairs t-tests examining mean difference in score from baseline to six-week follow-up were performed on the following variables: the BIMF (primary outcome), the PSS-10, the anxiety subscale score on the HADS, and the depression subscale score on the HADS (secondary outcomes). Assumptions were also tested prior to conducting analyses. For the purposes of statistical evaluation, “completers” were defined as individuals who completed every question in both the baseline and follow-up surveys. Additionally, an exploratory mixed ANOVA was performed to examine if there were significant differences in outcome measures (BIMF, PSS-10, HADS anxiety, HADS depression) between individuals who reported using the resources compared to those who did not report using the resources. In addition, as mentioned, one individual was not included in the outcome analyses as they endorsed all items in The Postpartum Toolkit Checklist as strengths and thus were not presented with resources. Thus, 125 individuals (“completers”) are included in the descriptive statistics of the sample, but 124 are included in outcome analyses.

3. Results

3.1. Participant Characteristics

Descriptive statistics for all socio-demographics of the sample were examined (see

Table 1. Participant sociodemographics, reproductive history, and psychiatric history.

	Total (n = 125)
Race	n (%)
Asian	9 (7.2)
Black or African-American	3 (2.4)
Multiracial	3 (2.4)
Other	3 (2.4)
Prefer not to report	5 (4.0)
White	102 (81.6)
Ethnicity
Hispanic or Latinx	10 (8)
Non-Hispanic or Latinx	115 (92)
Gender
Female	123 (98.4)
Male	2 (1.6)
Marital Status
Married	117 (93.6)
Partnered but not married	7 (5.6)
Single	1 (0.8)
Access to support with infant care
No	10 (8)
Yes	115 (92)
Religious Identity
Buddhist	3 (2.4)
Christian	71 (56.8)
Jewish	10 (8)
Not religious	36 (28.8)
Other	5 (4)
Education
College graduate	47 (37.6)
Graduate degree	70 (56)
Did not complete high school	1 (0.8)
High school graduate/GED	4 (3.2)
Other	3 (2.4)
Employment
Employed	102 (81.6)
Homemaker/stay at home	16 (12.8)
Other	7 (5.6)
Income
Less than USD $25,000	3 (2.4)
USD $25,000–USD $74,999	23 (18.4)
USD $75,000–USD $124,999	37 (29.6)
USD $125,000–USD $174,999	22 (17.6)
More than USD $175,000	40 (32)
Participant age (years)
18–25	5 (4)
25–35	85 (68)
35–45	34 (27.2)
46 or older	1 (0.8)
Age of youngest infant at baseline
0–3 months	32 (25.6)
3–6 months	42 (33.6)
6–9 months	28 (22.4)
9–12 months	23 (18.4)
Mode of delivery
Caesarean section	36 (28.8)
Vaginal	89 (71.2)
Whether mode of delivery proceeded as planned
Yes	111 (88.8)
No	14 (11.2)
Youngest infant singleton or multiple
Singleton	123 (98.4)
Multiple	2 (1.6)
Number of children
1	67 (53.6)
2	49 (39.2)
3	6 (4.8)
4	2 (1.6)
More than 4	1 (0.8)
Whether pregnancy of youngest infant was planned
Yes	108 (86.4)
No	17 (13.6)
Infant born at term
At term	119 (95.2)
Preterm	6 (4.8)
Whether youngest infant was hospitalized in a Neonatal Intensive Care Unit
No	109 (87.2)
Yes	16 (12.8)
Whether participant experienced postpartum re-hospitalization
No	119 (95.2)
Yes	6 (4.8)
Whether participant received treatment for infertility to conceive youngest infant
No	109 (87.2)
Yes	16 (12.8)
Participant history of stillbirth or miscarriage
History of stillbirth or miscarriage	34 (27.2)
No history	91 (72.8)
Participant psychiatric history
Negative history of psychiatric or psychological condition	87 (69.9)
Positive history of psychiatric or psychological condition	38 (30.4)
Experienced a medical condition complicating pregnancy
No	74 (59.2)
Yes	51 (40.8)
Medical conditions experienced during pregnancy
Asthma in pregnancy	12 (9.6)
Diabetes related	12 (9.6)
High blood pressure during pregnancy	18 (14.4)
Obesity in pregnancy	14 (11.2)
Other medical condition a	12 (9.6)

^a Reported medical conditions included: cerebral spinal fluid leak, cholestasis, hyperemesis, hypothyroidism, intrahepatic cholestasis of pregnancy, kidney disease, pelvic girdle pain, preeclampsia, preterm labor at 32 weeks, rheumatoid arthritis, Hashimoto’s thyroiditis, suspected cavernous hermangioma of the uterus, Von Willebrand disease, and mild hemophilia.

). Of the 125 participants, the majority of the participants were White (n = 102; 81.6%), Non-Hispanic or Latinx (n = 115; 92%); identified as female (n = 123; 98.4%); were married (n = 117, 93.6%); reported access to support for infant care (n = 115, 92%); identified as Christian (n = 71, 56.8%); possessed an advanced degree (n = 70, 56%); were employed (n = 102, 81.6%); had an estimated annual income above $75,000 (n = 77, 61.6%); and were between the ages of 25 and 35 (n = 85, 68%).

Descriptive statistics for participant reproductive and psychiatric history were also calculated (see Table 1). Of the 125 participants, the majority had an infant or infants aged 3–6 months at baseline (n = 42, 33.6%), though there was fairly good representation across the first postpartum year. The majority had delivered vaginally (n = 89, 71.2%); delivered in their planned mode of delivery (n = 111, 88.8%); had given birth to a singleton infant (n = 123, 98.4%); had given birth at term (n = 119, 95.2%); had a planned pregnancy (n = 108, 86.4%); and were primiparous (n = 67, 53.6%). The majority of participants were not diagnosed with medical conditions complicating their pregnancy (n = 74, 59.2%). The majority of participants also did not have an infant who experienced neonatal intensive care unit (NICU) hospitalization (n = 109, 87.2%); had not been re-hospitalized during the postpartum period themselves (n = 119, 95.2%); had not received fertility treatment (n = 109, 87.2%); and had no history of infant loss (n = 91, 72.8%). Lastly, the majority of the sample had a negative psychiatric history (n = 87, 69.9%).

3.1.1. Less-Privileged Subgroup Analysis of Baseline Characteristics

It was found that this subgroup was similar to the overall sample in terms of demographics as well as reproductive and psychiatric history. Of the 51 participants in this subgroup, the majority were married (n = 45, 88.2%); had access to childcare support (n = 47, 92.2%); and were employed (n = 38, 74.5%). In terms of reproductive history, the majority had a planned pregnancy (n = 41, 80.4%); had an infant 3–6 months old at baseline (n = 16, 31.4%); delivered vaginally (n = 35, 68.6%); delivered in the mode they had planned (n = 45, 88.2%); were primiparous (n = 31, 60.8%); had an infant born at term (n = 49, 96.1%); did not experience NICU hospitalization (n = 44, 86.3%); did not experience a medical condition complicating pregnancy (n = 30, 58.8%); did not experience postpartum rehospitalization (n = 50, 98%); did not have a history of pregnancy loss (n = 40, 78.4%); and did not receive treatment for fertility (n = 48, 94.1%). Additionally, the majority had a negative psychiatric history (n = 39, 76.5%). However, it was found that that this subgroup was slightly younger than the overall sample, with the majority reporting to be between the ages of 25 and 35 (n = 42, 82.4% compared to n = 85, 68% of the overall sample) and only 11.8% (n = 6) reporting to be in the 35–45 age range (compared to n = 34, 27.2% of the overall sample.

3.1.2. Male-Identifying Subgroup Analysis

With regard to sociodemographic factors for this subsample, they were similar to the majority of the sample in most respects (identified as White, were between the ages of 25 and 35, had a college degree, were employed, married, and of above average income). However, with regard to reproductive history, they differed from the majority of the sample. While the majority of the sample (87.2%) did not experience NICU hospitalization, both of these participants’ newborns spent time in the NICU.

3.2. Feasibility of The Postpartum Toolkit

Descriptive statistics were calculated on both the mid-study report of resource utilization as well as the follow-up survey report of resources utilization (see

Table 2. Participant report of feasibility and acceptability.

		Total (n = 124) a
Did you use any of the resources?		n (%)
Yes		70 (56.5)
No		54 (43.5)
How often did you refer to/look at the feedback that was sent to you?
A few times		56 (45.2)
I only looked at it once		54 (43.5)
Often		2 (1.6)
Several times		12 (9.7)
If you did not use these resources, what got in the way? b
Didn’t find the resources appealing		17 (13.7)
Didn’t have time		50 (40.32)
Forgot about it		42 (33.87)
Other		17 (13.7)
COVID-19 made use difficult		3 (2.42)
Cost		4 (3.23)
Resources not useful		6 (4.8)
Formatting made difficult to access		6 (4.8)
Would you have been more likely to use these resources if you had a person introducing them to you rather than looking into things yourself?
Yes		72 (58.1)
No		52 (41.9)
	M ± SD	Range
On a scale from 1–10 how much did you feel the feedback matched your needs (with 10 being the best match)?	7.42 ± 2.0	1–10
On a scale from 1–10 how helpful did you find your personalized resources (with 10 being the most helpful)?c	6.96 ± 2.35	1–10

^a A total of 125 participants completed the study, 1 of which was not presented with resources as they did not endorse any weaknesses in The Postpartum Toolkit Checklist and thus were not presented with resources. ^b Participants could select multiple options. ^c Participants were asked for a rating of helpfulness at both the mid-study timepoint (three weeks after baseline) and at the final study timepoint (six weeks after baseline). The results seen here are ratings of helpfulness from the final six-week timepoint.

). At the midpoint, 69 participants (55.6% of the sample) reported having utilized at least one resource that was provided in their individualized feedback generated by The Postpartum Toolkit. At follow-up, 70 participants (56.5% of the sample) reported having utilized at least one of their personalized resources. Additionally, at follow-up, most participants reported referencing their resources “a few times” (n = 56, 45.2).

The most-commonly endorsed barrier to resource utilization was insufficient time (n = 50, 40.32%), followed by forgetting about the resources (n = 42, 33.87%). When asked if they would have been more likely to engage with the resources if they had been guided through them as opposed to guiding themselves through the resources, most participants (n = 72, 58.1%) reported that they would have preferred a guide.

Table A1. Report of resource offering and use.

	Total (n = 124) a
Average Percentage of Reported Use Across all Resources	24.29
Resource 1: Address Physical Pain and Discomfort	n (%)
Number of participants to whom the resource was offered	40 (32.3)
Number of participants offered the resource who reported using the resource or the intention to use the resource	12 (30)
Resource 2: Calm your baby and yourself through crying spells
Number of participants to whom the resource was offered	72 (58.1)
Number of participants offered the resource who reported using the resource or the intention to use the resource	25 (34.72)
Resource 3: Consider a postpartum doula
Number of participants to whom the resource was offered	93 (75)
Number of participants offered the resource who reported using the resource or the intention to use the resource	5 (5.38)
Resource 4: Consider joining a support group
Number of participants to whom the resource was offered	91 (73.4)
Number of participants offered the resource who reported using the resource or the intention to use the resource	19 (20.9)
Resource 5: Consider seeking professional mental health support
Number of participants to whom the resource was offered	122 (98.4)
Number of participants offered the resource who reported using the resource or the intention to use the resource	29 (23.77)
Resource 6: Find someone to talk to
Number of participants to whom the resource was offered	39 (31.45)
Number of participants offered the resource who reported using the resource or the intention to use the resource	6 (15.38)
Resource 7: Gain some tools to help you manage strong emotions
Number of participants to whom the resource was offered	89 (71.8)
Number of participants offered the resource who reported using the resource or the intention to use the resource	24 (26.3)
Resource 8: Get some distance from your thoughts
Number of participants to whom the resource was offered	122 (98.4)
Number of participants offered the resource who reported using the resource or the intention to use the resource	25 (20.16)
Resource 9: Get trustworthy information
Number of participants to whom the resource was offered	36 (29)
Number of participants offered the resource who reported using the resource or the intention to use the resource	5 (13.9)
Resource 10: Increase self-compassion
Number of participants to whom the resource was offered	110 (88.7)
Number of participants offered the resource who reported using the resource or the intention to use the resource	43 (39.09)
Resource 11: Increase the power of positive emotions
Number of participants to whom the resource was offered	52 (41.9)
Number of participants offered the resource who reported using the resource or the intention to use the resource	8 (15.38)
Resource 12: Know your rights as an employee
Number of participants to whom the resource was offered	49 (39.5)
Number of participants offered the resource who reported using the resource or the intention to use the resource	6 (12.24)
Resource 13: Learn about asking for help
Number of participants to whom the resource was offered	72 (58.1)
Number of participants offered the resource who reported using the resource or the intention to use the resource	20 (27.78)
Resource 14: Learn about baby care
Number of participants to whom the resource was offered	6 (4.8)
Number of participants offered the resource who reported using the resource or the intention to use the resource	0 (0)
Resource 15: Learn about bonding with your baby
Number of participants to whom the resource was offered	21 (16.94)
Number of participants offered the resource who reported using the resource or the intention to use the resource	4 (19.05)
Resource 16: Learn about community support resources
Number of participants to whom the resource was offered	67 (54.03)
Number of participants offered the resource who reported using the resource or the intention to use the resource	12 (17.91)
Resource 17: Learn about resources to help you have a safe and healthy home
Number of participants to whom the resource was offered	8 (6.45)
Number of participants offered the resource who reported using the resource or the intention to use the resource	1 (0.81)
Resource 18: Learn about setting a routine for baby
Number of participants to whom the resource was offered	62 (50)
Number of participants offered the resource who reported using the resource or the intention to use the resource	21 (33.87)
Resource 19: Learn about some tips for effective time management
Number of participants to whom the resource was offered	68 (54.84)
Number of participants offered the resource who reported using the resource or the intention to use the resource	20 (29.41)
Resource 20: Learn about the resources around you
Number of participants to whom the resource was offered	5 (4.01)
Number of participants offered the resource who reported using the resource or the intention to use the resource	0 (0)
Resource 21: Learn the ‘language’ of your baby
Number of participants to whom the resource was offered	46 (37.1)
Number of participants offered the resource who reported using the resource or the intention to use the resource	19 (41.3)
Resource 22: Limit social media scrolling
Number of participants to whom the resource was offered	78 (62.9)
Number of participants offered the resource who reported using the resource or the intention to use the resource	29 (37.18)
Resource 23: Make sleep a priority
Number of participants to whom the resource was offered	58 (46.77)
Number of participants offered the resource who reported using the resource or the intention to use the resource	22 (37.93)
Resource 24: Question self-blame
Number of participants to whom the resource was offered	87 (70.16)
Number of participants offered the resource who reported using the resource or the intention to use the resource	22 (25.29)
Resource 25: Take a break
Number of participants to whom the resource was offered	92 (74.19)
Number of participants offered the resource who reported using the resource or the intention to use the resource	40 (43.48)
Resource 26: Take care of yourself
Number of participants to whom the resource was offered	98 (79.03)
Number of participants offered the resource who reported using the resource or the intention to use the resource	44 (44.9)
Resource 27: Take some time to reflect
Number of participants to whom the resource was offered	81 (65.32)
Number of participants offered the resource who reported using the resource or the intention to use the resource	18 (22.22)
Resource 28: Use positive affirmation
Number of participants to whom the resource was offered	98 (79.03)
Number of participants offered the resource who reported using the resource or the intention to use the resource	41 (41.84)

^a 124 participants were used in outcome analysis as one individual responded to The Postpartum Toolkit Checklist endorsing all strengths and thus was not presented with resources.

(see Appendix D) displays the number of participants who were recommended each of the 28 possible resources, as well the number of participants who reported that they had either used or intend to use the resource. The most-commonly recommended resources were “Resource 5: Consider seeking professional mental health support” and “Resource 8: Get some distance from your thoughts”, which were both included in the personalized feedback of 122 participants (98.4%). It should be noted that both of these resources were mapped to multiple checklist items (which is not the case for all resources; see Appendix C for resource-to-checklist item mapping), which increased their likelihood of recommendation. The resource with the highest percentage of reported use or intended use by those who were recommended it was “Resource 26: Take care of yourself”, which was included in the feedback of 98 participants (79.03%) and was reported used or intend to use by 44 of the participants (44.9%) to whom it was recommended. The least-recommended resource was “Resource 20: Learn about the resources around you,” which was included in the feedback of five participants. This resource, alongside “Resource 14: Learn about baby care” (recommended to six participants) were the-least used resources. Both were reported used or intend to use by zero participants. The average percentage of use was 24.29%, meaning that the average percentage of individuals who reported that they had used or intend to use a resource was about a quarter of the individuals to whom the resource was recommended.

Relatedly,

Table A2. Frequency counts of responses to The Postpartum Toolkit checklist items.

	Total (n = 125)
1. When things don’t go well, I don’t blame myself.	n (%)
This is not an issue for me.	38 (30.4)
This is going ok for me, but could be better.	66 (52.8)
I’d like help with this.	21 (16.8)
2. When trying new things, I do all of the following: I am patient with myself and don’t expect myself to get things right away I feel comfortable pushing myself beyond my comfort zone I can be flexible with my plans and expectations.
This is a strength for me.	27 (21.6)
This is going ok for me, but could be better.	77 (61.6)
I’d like help with this.	21 (16.8)
3. My baby and I are bonding.
This is going well for me.	104 (83.2)
This is going ok for me, but could be better.	19 (15.2)
I’d like help with this.	2 (1.6)
4. Most of the time my baby’s crying doesn’t overwhelm me.
This is a strength for me.	53 (42.4)
This is going ok for me, but could be better.	60 (48)
I’d like help with this.	12 (9.6)
5. Most of the time I am able to calm myself down when I have strong emotions (such as stress, worries, anger) or distressing thoughts.
This is a strength for me.	36 (28.8)
This is going ok for me, but could be better.	67 (53.6)
I’d like help with this.	22 (17.6)
6. I have people in my life that help to make sure I’m taking care of myself. For example, people in my life check-in with me about taking care of myself, or they help me to take care of myself by doing things like watching the baby.
This is going well for me.	65 (52)
This is going ok for me, but could be better.	46 (36.8)
I’d like help with this.	14 (11.2)
7. I am able to get the materials I need to take care of the baby and myself (such as diapers and food).
This is not an issue for me.	120 (96)
This is going ok for me, but could be better.	4 (3.2)
I’d like help with this.	1 (.8)
8. I am getting more experienced with taking care of my baby.
This is going well for me.	119 (95.2)
This is going ok for me, but could be better.	6 (4.8)
I’d like help with this.	0
9. When I do things well, I am able to give myself credit for it.
This is a strength for me.	73 (58.4)
This is going ok for me, but could be better.	48 (38.4)
I’d like help with this.	4 (3.2)
10. If you have people in your life who help and support you: when I am talking to people in my life who help or support me, I do all of the following: I can be open and honest I can trust people to help me I can ask for help and take help when it is offered
This is a strength for me.	53 (42.2)
This is going ok for me, but could be better.	61 (48.8)
I’d like help with this.	11 (8.8)
11. I have been able to get my baby into a routine.
This is going well for me.	63 (50.4)
This is going ok for me, but could be better.	49 (39.2)
I’d like help with this.	13 (10.4)
12. When I have a question about parenting or early motherhood, I know how to get an answer that I trust.
This is going well for me.	89 (71.2)
This is going ok for me, but could be better.	32 (25.6)
I’d like help with this.	4 (3.2)
13. I am involved in activities outside of the house (such as friendships, hobbies, professional or volunteer work).
This is going well for me.	33 (26.4)
This is going ok for me, but could be better	69 (55.2)
I’d like help with this.	23 (18.4)
14. I know myself (when I need to ask for help, what I need, what makes me feel better when I feel down, worried, or stressed).
This is a strength for me.	44 (35.2)
This is going ok for me, but could be better.	64 (51.2)
I’d like help with this.	17 (13.6)
15. My home environment is safe and stable. This is not an issue for me.	117 (93.6)
This is going ok for me, but could be better.	7 (5.6)
I’d like help with this.	1 (.8)
16. I know that taking care of myself is important, and guilt does not get in the way of taking care of my own needs.
This is a strength for me.	27 (21.6)
This is going ok for me, but could be better.	71 (56.8)
I’d like help with this.	27 (21.6)
17. I am able to sleep at night when my baby is sleeping.
This is going well for me.	67 (53.6)
This is going ok for me, but could be better.	45 (36)
I’d like help with this.	13 (10.4)
18. When thinking about social pressures, I don’t do any of the following: feel like I have to reach the expectations of others worry about other people’s judgments of me compare myself to others.
This is a strength for me.	47 (37.6)
This is going ok for me, but could be better.	64 (51.2)
I’d like help with this.	14 (11.2)
19. I plan and manage time well.
This is a strength for me.	57 (45.6)
This is going ok for me, but could be better.	51 (40.8)
I’d like help with this.	17 (13.6)
20. I have people in my life that I can talk to openly and honestly about my feelings and experiences.
This is not an issue for me.	86 (68.8)
This is going ok for me, but could be better.	33 (26.4)
I’d like help with this.	6 (4.8)
21. I have people to help me with childcare and household management (cooking, cleaning, shopping, etc.).
This is not an issue for me.	58 (46.4)
This is going ok for me, but could be better.	50 (40)
I’d like help with this.	17 (13.6)
22. I understand what my baby is trying to tell me (through their cries, body language, etc.).
This is a strength for me.	79 (63.2)
This is going ok for me, but could be better.	43 (34.3)
I’d like help with this.	3 (2.4)
23. If you or your co-parent are currently working: my workplace/my partner’s workplace has been understanding and flexible since I have had my baby.
This is not an issue for me.	76 (60.8)
This is going ok for me, but could be better.	42 (33.6)
I’d like help with this.	7 (5.6)
24. I am not experiencing physical pain or discomfort.
This is not an issue for me.	85 (68)
This is going ok for me, but could be better.	29 (23.2)
I’d like help with this.	11 (8.8)

(see Appendix E) shows the frequency counts of responses to The Postpartum Toolkit Checklist items. The item with the highest percentage of participants who endorsed it as an area not requiring extra support was item seven: “I am able to get the materials I need to take care of the baby and myself (such as diapers and food)” (96% reported it as a strength). This was followed by item eight: “I am getting more experienced with taking care of my baby” (95.2% reported it as a strength), and item 15: “My home environment is safe and stable” (93.6% endorsed this as a strength). The items with the least percentage of participants endorsing it as a strength were item two: “When trying new things, I do all of the following: I am patient with myself and don’t expect myself to get things right away, I feel comfortable pushing myself beyond my comfort zone, I can be flexible with my plans and expectations”, and item 16: “I know that taking care of myself is important, and guilt does not get in the way of taking care of my own needs” (21.6% of the sample endorsed each of these as a strength). This was followed by item 13: “I am involved in activities outside of the house (such as friendships, hobbies, professional or volunteer work)” (26.4% endorsed this as a strength).

Less-Privileged Subgroup Analysis of the Feasibility of The Postpartum Toolkit

The less-privileged subgroup (n = 51) was found to be similar to the overall sam-ple, with the majority of participants reporting that they used the resources (n = 28, 54.9%), and referencing their resources “a few times” (n = 24, 47.1%). However, a higher percentage of this subgroup would have preferred having a person introduce resources to them rather than guiding themselves (n = 35, 68.6% of the subsample compared to n = 72, 58.1% of the overall sample). Additionally, like the overall sample, this subgroup reported that the most frequent obstacle to use was not having enough time (n = 23, 54.1%), though the percentage of individuals in the subgroup endorsing this was higher than the overall sample (overall sample: n = 50, 40.32%).

3.3. Acceptability of the Postpartum Toolkit

Descriptive statistics were calculated on both the mid-study report of resource helpfulness as well as the follow-up survey report of resources utilization (see Table 2 for follow-up results). At the midpoint, the average helpfulness rating (on a 1–10 scale with 10 being most helpful) was 7.35 (SD = 1.62). At follow-up, the average 1–10 rating of the degree to which the resources matched the participant’s needs (10 representing best match) was 7.42 (SD = 2.0), and the average 1–10 rating of the degree to which the resources were found to be helpful (10 representing most helpful) was 6.96 (SD = 2.35).

Less-Privileged Subgroup Analysis of Acceptability of The Postpartum Toolkit

Subgroup (n = 51) acceptability ratings were found to be slightly lower than the overall sample, with an average rating of helpfulness of 6.9 (SD = 2.46) and match to needs of 7.39 (SD = 2.1).

3.4. Pilot Efficacy of The Postpartum Toolkit

Table 3. Results of pre/post analysis for quantitative self-report measures.

Measure	Baseline Score		Follow-Up Score		t (123)	Two-Sided p	Cohen’s d
	M	SD	M	SD
Barkin Index of Maternal Functioning (BIMF) a	87.88	12.28	92.38	12.55	−5.07	<0.001	0.46
Perceived Stress Scale-10 (PSS-10) c	18.16	6.29	16.26	5.96	4.07	<0.001	0.37
Hospital anxiety and Depression Scale-Anxiety Subscale (HADS-A) b	7.99	4.16	7.12	3.73	3.18	0.002	0.29
Hospital Anxiety and Depression Scale-Depression Subscale (HADS-D) b	5.44	3.33	4.6	3.24	3.6	<0.001	0.32

^a Scores to the right of 80 on a number line indicate ideal functioning. ^b Scores of 8 or higher on either subscale indicate clinically elevated symptoms. ^c The population norm is a score of 13.7.

shows the results of the pilot-efficacy analyses. Prior to analyzing differences in mean BIMF score from baseline to follow-up (primary outcomes of interest), a BIMF change score variable was computed and tested for normality. BIMF change score was found to be normally distributed, as assessed by a Shapiro–Wilk’s test (p = 0.258) as well as by visual inspection of a histogram and normal Q-Q plot of the BIMF change score. A matched pairs t-test was then performed, and results indicated that participant mean score on the BIMF was significantly higher at follow-up (M = 92.38, SD = 12.55), compared to baseline (M = 87.88, SD = 12.28); t (123) = −5.07, p < 0.001, and d = 0.46, indicating an improvement in functioning. To examine if there were particular functioning items that were driving this change, item level averages for BIMF score at baseline and follow-up were calculated (see Appendix F). These descriptive findings do not seem to highlight any particular item as seeming to drive the change, though scores on item 6 (“There are people in my life that I can trust to care for my baby when I need a break”) increased the most from baseline to follow-up.

Prior to analyzing differences in mean PSS-10, HADS-A, and HADS-D score from baseline to follow-up (secondary outcomes of interest), a change score variable was computed for each measure and that change variable was tested for normality. All change scores were determined to be normal by visual inspection of a histogram and normal Q-Q plot. Matched pairs t-tests were then performed for all four outcome variables. Results indicated that participant mean score on the HADS-A was significantly lower at follow-up (M = 7.12, SD = 3.73) compared to baseline (M = 7.99, SD = 4.16); t(123) = 3.18, p = 0.002, and d = 0.29. For the HADS-D, results revealed that participant mean score on the HADS-D was significantly lower at follow-up (M = 4.6, SD = 3.24) compared to baseline (M = 5.44, SD = 3.33); t(123) = 3.6, p < 0.001, and d = 0.32. Results for the PSS-10 revealed that participant mean score on perceived stress was significantly lower at follow-up (M = 16.26, SD= 5.96) compared to baseline (M = 18.16, SD = 6.29); t(123) = 4.07, p < 0.001, and d = 0.37.

Additional Exploratory Efficacy Analysis

In order to provide additional information about The Postpartum Toolkit’s effectiveness, a mixed ANOVA was conducted that examined change in outcome variables (BIMF, PSS-10, HADS anxiety, HADS depression) for individuals who reported use of the tools vs. those who reported they had not used the tools.

Table 4. Descriptive statistics for outcome measures by resource-use condition (used vs. not).

	Used Resources (n = 70)	Did Not Use Resources (n = 54)
BIMF Baseline M ± SD	86.7 ± 12.61	89.41 ± 11.78
BIMF Follow-Up M ± SD	92.63 ± 12.55	92.06 ± 12.66
PSS-10 Baseline M ± SD	18.46 ± 6.8	17.78 ± 5.61
PSS-10 Follow-Up M ± SD	15.69 ± 5.84	17.00 ± 6.09
HADS Anxiety Baseline M ± SD	8.46 ± 4.59	7.39 ± 3.48
HADS Anxiety Follow-Up M ± SD	7.33 ± 3.85	6.85 ± 3.59
HADS Depression Baseline M ± SD	5.41 ± 3.45	5.46 ± 3.20
HADS Depression Follow-Up M ± SD	4.19 ± 3.01	5.15 ± 3.46

BIMF = Barkin Index of Maternal Functioning; PSS-10 = Perceived Stress Scale-10; HADS = Hospital Anxiety and Depression Scale.

displays descriptive statistics of outcome measures.

For the BIMF, there was a significant main effect of time (i.e., a significant improvement in score from baseline to follow-up): F (1,122) = 23.38, p < 0.001, and ηp² = 0.161, but there was not a significant main effect of condition (i.e., whether participants reported using the tools): F (1,122) = 0.266, p = 0.607, and ηp² = 0.002. There also was not a significant time by condition interaction effect: F (1,122) = 3.42, p = 0.067, and ηp² = 0.027.

For the PSS-10, there was a significant main effect of time (i.e., a significant improvement in score from baseline to follow-up): F (1,122) = 14.58, p < 0.001, and ηp² = 0.107, but there was not a significant main effect of condition (i.e., whether participants reported using the tools): F (1,122) = 0.10, p = 0.754, and ηp² = 0.001. However there was a significant time by condition interaction effect: F (1,122) = 4.6, p = 0.034, and ηp² = 0.036. Comparisons using paired sample t-tests revealed that participants who endorsed using the resources in The Postpartum Toolkit had significantly lower stress scores at follow-up compared to baseline: t (69) = 4.99, p < 0.001, and d = 0.60. However, for individuals who did not report using the resources, there was no significant difference between stress score at baseline and stress score at follow-up: t (53) = 1.00, p = 0.320, and d = 0.14.

For the HADS-Anxiety, there was a significant main effect of time (i.e., a significant improvement in score from baseline to follow-up): F (1,122) = 9.09, p = 0.003, and ηp² = 0.069, but there was not a significant main effect of condition (i.e., whether participants reported using the tools): F (1,122) = 1.37, p = 0.244, and ηp² = 0.011. There also was not a significant time by condition interaction effect: F (1,122) = 1.15, p = 0.286, and ηp² = 0.009.

For the HADS-Depression, there was a significant main effect of time (i.e., a significant improvement in score from baseline to follow-up): F (1,122) = 11.24, p = 0.001, and ηp² = 0.084, but there was not a significant main effect of condition (i.e., whether participants reported using the tools): F (1,122) = 0.85, p = 0.358, and ηp² = 0.007. However, there was a significant time by condition interaction effect: F (1,122) = 3.94, p = 0.049, and ηp² = 0.031. Comparisons using paired sample t-tests revealed that participants who endorsed using the resources in The Postpartum Toolkit had significantly lower depression scores at follow-up compared to baseline: t (69) = 3.95, p < 0.001, and d = . 47. However, for individuals who did not report using the resources, there was no significant difference between depression score at baseline and depression score at follow-up: t (53) = 0.99, p = 0.35, and d = 0.13.

3.5. Participant Suggestions for Improving the Postpartum Toolkit

Participants had excellent suggestions with regard to ways in which the tool could be improved to increase engagement. Many of these suggestions centered on the format in which the tools were presented, as several participants reported that the text-based format was not found to be user-friendly and in fact, in several cases, was reported as “overwhelming.” Alternative formatting suggested by participants included the following: spreading out information (dividing the resources into “chunks”), using a podcast format, breaking up the text with more images or graphics, or delivering the information in the form of something like an Instagram post.

As part of their feasibility and acceptability questionnaire, participants were asked about additions they believe ought to be added to The Postpartum Toolkit Checklist (the measure used to determine which resources are presented to participants in their personalized feedback). Participants suggested adding items inquiring about the following: how far into the postpartum the individual is, baby health (e.g., chronic health diagnosis; NICU hospitalization), non-baby-related stressors (e.g., partners looking for jobs, COVID-19), “giving self grace”, preparation before baby arrives, and relationship with partner.

In addition, as part of their feasibility and acceptability questionnaire, participants were asked about resources they believed ought to be added to toolkit resources. Participant suggestions concerned the following: relationship functioning with romantic partners and other family members, COVID-19 (specifically, the negative impact of COVID-19 on employment), breastfeeding, local resources (midwives, counselors, lactation consultants), support groups, and tools for understanding a baby’s development.

Additionally, participants were asked in the feasibility and acceptability questionnaire about other resources they were using that were not included in their toolkit resources. Twenty-four participants (19.2% of the sample) endorsed using other resources. When asked to specify the resources used, participants cited the following: support groups, therapists, audiobooks, online resources, meditation, pelvic floor exercises, police/lawyer, parenting classes, pediatrician, and baby-milestone apps.

4. Discussion

In this study, data on the feasibility, acceptability, and pilot efficacy of an online tool based upon qualitative work conducted with the population of interest was collected.

Overall, The Postpartum Toolkit was found to be acceptable, with average ratings of both match with needs as well as usefulness (with 10 indicating a better match/higher degree of usefulness) reaching close to 7 out of 10, a metric used in comparable examinations of acceptability in other interventional work [50]. The majority (56%) of the 124 completers reported using at least one resource. As mentioned, insufficient time and forgetting about the resources were the most common barriers to use. On average, about 25% of the participants offered a resource reported that they used or intend to use that resource, though the resource with the highest percentage of use or intended use concerned self-care, reinforcing previous findings that self-care is an area of unmet need for the postpartum population [51]. This is further bolstered by the statistic that two of the checklist items with the lowest percentage of endorsed strengths related to self-care and involvement in activities outside of the home (see Table A2, Appendix E). Conversely, one of the least-used resources concerned infant-care education, which is noteworthy, as much prenatal education focuses on this topic. Perhaps these findings indicate that participants already had access to infant-care education, or it may be further evidence of a gap between patient and provider opinion on what training or information is most relevant in preparing for the postpartum transition. Additionally, despite prior evidence that self-guided interventions are efficacious [41], participants seemed to prefer having more interaction and guidance. Thus, in summary, the tools were deemed useful and a match to participant need, but participants reported barriers to utilization of the resources.

Self-report ratings of function, stress, and symptoms of depression and anxiety were statistically significantly different at follow-up compared to baseline. As mentioned, changes in all measures was in the direction that would indicate improved wellbeing (average score on function went up, average score on symptoms of stress, anxiety, and depression went down). For comparison, a Visiting Moms intervention (a preventative program providing social support to new birth parents) observed an average change of about 16 points on the BIMF over the course of about a year of visits [52]. The Visiting Moms study was conducted in a similar population to the current study (both were conducted in a sample endorsing minimal to mild depressive symptomatology), and the current study observed nearly a third of this change (average change of about five points on the BIMF) over the course of only six weeks. The Postpartum Toolkit also has the advantage of increased accessibility and flexibility (the parents can engage with the resources in their own time and the scheduling of additional appointments is not required). In addition, as described above, an additional exploratory analysis comparing change in outcome measures for individuals who reported use of resources provided by the tool compared to those who did not report using the resources provided by the tool was performed. Individuals who reported using the resources provided by the tool were found to have significantly lower stress and depression scores at follow-up compared to baseline. Individuals who did not report using the tool’s resources did not have significantly lower stress and depression scores at follow-up compared to baseline measurements. Though this analysis is confounded by the fact that the group who did not report using the tool’s resources is not a true control group (both groups received the intervention), it is an additional signal of the efficacy of The Postpartum Toolkit.

With regard to participant suggestions for improving The Postpartum Toolkit, it is interesting to note that several of these suggestions for additional resources (local resources, breastfeeding resources, statements normalizing the transition to parenthood, support groups, information about baby’s development) were included in the toolkit resources (see Appendix B). It is possible the individuals suggesting these additions were not presented with these resources in their feedback (suggesting that our mapping of resources could perhaps be improved), or perhaps barriers to engagement and issues with user-friendliness led participants to miss the presentation of these resources. It is also possible the users were providing these suggestions with others in mind, though they themselves did not endorse that they would like support with these things (and, thus, they were not presented with these resources and were unaware that they were already included in the tool).

Limitations and Future Directions

There are several limitations to this project that bear mentioning. First, while these findings are promising, there are several considerations to take into account when interpreting these results. First, effect sizes for the analyses were small to moderate, and change in average score from baseline to follow-up was less than one point on both the HADS-A and the HADS-D. Thus, the clinical significance of the change is rather small. In addition, while the average level of perceived stress decreased from baseline to follow-up, average score of stress in the sample remained high at follow-up compared to the general population (the average PSS-10 score at follow-up was 16.5, and population norm is 13.7). Additionally, as mentioned, given that over half the sample was in the first six months postpartum when they enrolled in the study, this change may be explained by the natural history of postpartum adjustment, which remains largely unstudied. An efficacy trial using a randomized controlled trial design to better control for factors such as the natural history of postpartum adjustment would provide more convincing evidence of the efficacy of the tool to impact postpartum functioning and emotional wellbeing. If efficacy was proven following testing in a randomized controlled trial, the tool could be made available to postpartum birth parents, perhaps through hosting it on a website or through a mobile health application.

Additionally, it is important to acknowledge the larger cohort effect of the COVID-19 pandemic, as these data were collected between February and June 2021. Thus, there are other factors related to the pandemic that may have been impacting scores on outcome measures of emotional distress, such as adjustment to the restrictions of quarantine, or the lifting of restrictions.

Third, our sample was rather homogenous, and, in general, of a more privileged background. Thus, it would be important for future work to seek feedback and pilot data on this tool from a more diverse sample of birth parents. Given restrictions in place to manage the spread of the COVID-19 pandemic, recruitment for the study took place almost entirely online. General population-level research suggests that this recruitment venue may have influenced the sample, as social media users are more likely to possess a higher income and levels of education [53]. Additionally, the first author’s prior experience with recruiting for a qualitative project in the population of postpartum mothers found that using both in-person and online methods seemed to inadvertently target different demographic groups (those who were recruited through a remote means were majority White and reported higher estimated household income) [14]. A subgroup analysis of the less-privileged subgroup of participants was performed to examine whether baseline characteristics, feasibility, and acceptability differed. Overall, the sample and the sub-groups were statistically indistinguishable from one another. However, it will be especially beneficial for future work to seek out the perspective of a more diverse population, including transgender birth parents, given the dearth of research in this population. The importance of studying transgender birth parents was underlined by the finding that both parents who identified as male reported spending time in the NICU. Though the sample size was extremely small, this finding is noteworthy given the current dearth of research on birth outcomes for transgender men and previous findings that institutional erasure functions as a barrier to receiving routine perinatal care [3]. This leads one to wonder whether barriers to care might have impacted these participants’ pregnancy and birth experiences, ultimately leading to their infants’ NICU hospitalizations.

In addition to recruiting a more diverse sample, it would also be important for future work to involve integrating participant feedback into the tool to improve feasibility of use. Given feedback suggesting that changing resource formatting could increase user friendliness, it would be particularly important to consider altering the text-based format in order to improve resource engagement with a future iteration of the tool.

5. Conclusions

In conclusion, postpartum functioning is of critical importance to birth parents and their infants throughout the postpartum year. However, despite recognition of the importance of the postpartum year, birth parents face many barriers in accessing healthcare and relevant support resources. To address this, the feasibility, acceptability, and pilot efficacy were tested of an online tool based upon qualitative work with postpartum birth parents that provided parents with personalized, tailored resources to bolster functioning. The Postpartum Toolkit was found to be acceptable, but participants reported barriers to use, and made suggestions for improvement, including altering the text-based format to increase user-friendliness. Additionally, pilot-efficacy data suggests that this tool may be effective in improving postpartum functioning and emotional wellbeing. Therefore, a future iteration of the tool that incorporates participant feedback from a diverse population of birth parents could prove an effective means of delivering helpful support to an at-risk population, particularly in the era of a global pandemic, when in-person engagement is limited and the need for mental-health support is heightened.