Discussion
depression, depressive symptoms
Compared to the participants assigned to the usual care group, those assigned to the mHealth group—where they could use mHealth consultation services according to their needs free of charge—had a lower risk of elevated postpartum depressive symptoms three months after delivery. Women assigned to the mHealth group tended to display higher parenting self-efficacy, lower levels of loneliness, and fewer perceived barriers to healthcare access. No differences were observed in the number of medical facilities used between the groups. Among the participants in the mHealth group, those who consulted with midwives and those who used the chat consultations tended to have a decreased risk of elevated postpartum depressive symptoms. Importantly, despite the general concerns that new technology may expand the socioeconomic disparity in health and healthcare use [The difference between our findings and those of a recent study indicating mixed results on the effect of mHealth-based prevention for PPD may be attributed to the features of timeliness [Compared to these studies, the most remarkable advantage of our intervention was the timeliness and appropriateness of the consultation, as the services provided technology-based interactive, synchronous communication. Although reservations were necessary for consultations, women could consult even after a few minutes when they needed help if a professional was available. After childbirth, women could consult with midwives through text-based chatting without reservation or time limitations. A participant in the mHealth group commented in an open-ended questionnaire asking about the study participation, at three months post-delivery, that, “When I had concerns or something I did not know about childcare, I researched these things by myself, but I could not judge whether the results I found suited me or determine what I should do. At that time, it was very reassuring to be able to consult with healthcare professionals immediately through mHealth service.” (All comments related to the intervention were listed in Additional file Removing psychological barriers to healthcare may be another critical mechanism for preventing postpartum depressive symptoms. Using the mHealth app can be a strategy to overcome fear of stigma or judgment in vulnerable populations [Other potential mechanisms include enhanced parenting self-efficacy [This study has several limitations. First, the generalizability of our findings is limited given that our study participants were only Japanese speakers having Internet access and almost all participants were over 20 years of age with a partner. The lack of clear standardized procedures during consultations also limits generalizability. When implementing similar services that this study evaluated, the content should be arranged according to the setting in which they are implemented. We also note that the effect size of the service shown in this study may vary depending on the setting. As our study participants had a higher percentage of elevated depressive symptoms at baseline compared to the previous review, partially due to the COVID-19 pandemic, the intervention effect may differ in situations outside the pandemic. Second, the attrition rate (13%) may lead to biased results, although sensitivity analysis with multiple imputations showed nearly the same results. Third, we did not use a formal clinical diagnosis of PPD as the primary outcome; however, the EPDS is a well-validated scale for the diagnostic interview for depression around the world [