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International Journal of
Women’s Health and Wellness
Original Article: Open Access
ClinMed
International Library
Citation: Fontein-Kuipers Y, van Limbeek E, Ausems M, de Vries R, Nieuwenhuijze M (2015)
Using Intervention Mapping for Systematic Development of a Midwife-Delivered Intervention
for Prevention and Reduction of Maternal Distress during Pregnancy. Int J Womens Health
Wellness 1:008
Received: November 26, 2015: Accepted: December 19, 2015: Published: December 22, 2015
Copyright: © 2015 Fontein-Kuipers Y, et al. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original author and source are credited.
Fontein-Kuipers. Int J Womens Health Wellness 2015, 1:2
Using Intervention Mapping for Systematic Development of a Midwife-
Delivered Intervention for Prevention and Reduction of Maternal
Distress during Pregnancy
Yvonne Fontein-Kuipers*, Evelien van Limbeek, Marlein Ausems, Raymond de Vries and
Marianne Nieuwenhuijze
Midwifery Education & Studies Maastricht, ZUYD University, The Netherlands
*Corresponding author: Yvonne Fontein-Kuipers, Midwifery Education & Studies Maastricht, Research Centre for
Midwifery Science, ZUYD University, PO Box 1256, 6201 BG Maastricht, The Netherlands, Tel: +31 33 2584656,
Fax: +031 43 3885400, E-mail: j.a.c.a.fontein-kuipers@hr.nl
Abstract
The authors describe how Intervention Mapping was used to
develop a midwife-led intervention to prevent or reduce maternal
distress during pregnancy. An extensive needs assessment showed
that both pregnant women and midwives needed to be taught to
recognise the vulnerability for developing maternal distress during
pregnancy and how to identify maternal distress when it occurs.
In addition to these mutual learning needs, women needed to
learn to disclose their problems, how to handle maternal distress
in their daily lives, and the value of seeking help when necessary.
Midwives needed to prepare themselves to provide (collaborative)
care for maternal distress. Screening and psycho-education were
pathways to support self-disclosure, self-management, mobilizing
support and treatment of maternal distress. Theory-based methods
- such as tailoring, communicative support, individualization,
advance organisers, cultural similarity, consciousness raising,
elaboration, and cue altering - were built into a web-based tailored
program for women. Information processing, intergroup dialogue
training, verbal persuasion, providing cues, facilitation of means,
and structural organization were the theory-based methods that
were built into a training program and a toolbox for the midwife-
delivered program. The program was introduced by means of the
training given to midwives from 17 midwife-led practices in the
Netherlands and proved to be effective. Finally, process and effect
evaluations were planned.
Keywords
Intervention, Intervention mapping, Maternal distress, Preventative
measures
life [4-7]. It varies in severity from stress, worry, and concerns to
more serious feelings of unhappiness, anxiety and/or depression
and disturbed psychological functioning [8]. Maternal distress has
shown to have adverse consequences for women, children, including
obstetric complications, severe long-term maternal mental health
problems and neuro-behavioural and cognitive development
problems in children [2,9,10]. e worldwide prevalence of maternal
distress varies from 10 to 41% [11]. Given the prevalence and severe
consequences of maternal distress it is imperative that caregivers
have an eective strategy for managing maternal distress.
A recent meta-analysis of antenatal interventions to reduce
maternal distress showed that only a few were eective [3]. e results
showed that preventive interventions targeted at pregnant women
without symptoms of maternal distress did not have a signicant
eect in reducing maternal distress. However, women suering
from maternal distress and women that were more vulnerable for
maternal distress as a result of predisposing factors were helped by
an intervention [3]. Given the paucity of eective interventions, we
have begun to work on developing an evidence-based intervention
focused on screening and support of pregnant women in midwife-led
care more likely to develop or experiencing maternal distress. In the
Netherlands the primary caregiver for most pregnant women is the
midwife [12].
We used ‘intervention mapping’- a stepwise approach for
theory and evidence-based program development, implementation,
and evaluation - to guide the development of our intervention.
Intervention mapping combines theoretical evidence with practical
information from stakeholders (e.g. pregnant women, midwives,
psychologists) [13]. is way, program materials are not only tailored
to the target group (pregnant women), but also to the needs, abilities
and possibilities of the program implementers (midwives) [14]. is
seems especially important since midwives dier in willingness and
perceived self-ecacy regarding management of maternal distress
[15]. Intervention mapping [13] describes the processes involved in
Introduction
Maternal distress is a major concern for perinatal health [1,2].
We dene maternal distress as a spectrum consisting of a variety of
psychological constructs that occur during the antenatal period [3].
Maternal distress can be the result of pregnancy or birth or other
non-pregnancy related experiences in a woman’s past or present
• Page 2 of 10 •
Fontein-Kuipers. Int J Womens Health Wellness 2015, 1:2
planning an intervention in six steps including a needs assessment
that oers an extensive description of the problem, selecting methods
and generating implementation and evaluation plans.
e aim of this article is to describe how intervention mapping
was used to the development of WazzUp Mama?!, an intervention for
the prevention and reduction of maternal distress among pregnant
women in midwife-led care. We present the content of each of the
steps, describing how we carried out the development of the WazzUp
Mama?! intervention.
Intervention Mapping Steps 1-6 in the Development
of Wazzup Mama?!
Step 1: Needs assessment
A needs assessment is the rst step in the development of
an intervention. e aim is to gain a clear understanding of the
health problem, impact on women’s and children’s quality of life,
behavioural and environmental causes, and the determinants of
these causes [13,16]. We conducted the needs assessment using an
integrative review and two additional studies among samples of
Dutch women and midwives.
Application: e integrative review that we conducted included
samples of healthy Western women and showed that maternal
distress is a multi-dimensional concept that refers to a range of
psychological complaints and symptoms during pregnancy, birth
and the postnatal period [17]. e most oen mentioned constructs
used to assess maternal distress were depression, stress, anxiety and
pregnancy-related anxiety with variety in occurrence between 2% to
31% during pregnancy. e possible short-term eects of maternal
distress included fear of childbirth, longer labour duration and
fetal growth restriction and reduced birth weight in neonates and
in post partum maternal depression, stress and anxiety. Long-term
consequences were identied as physical, emotional, behaviour and
cognitive problems in infants, children and adolescents and long-
term ill mental health in women [17].
We also gained preliminary insight into factors that inuenced
the occurrence of maternal distress such as women’s personal
characteristics (e.g. history of psychological problems), personal
circumstances (e.g. daily stressors), behaviour (e.g. negative coping
styles), environmental factors (e.g. partner, family, healthcare
professionals) and predisposing (e.g. knowledge of coping), reinforcing
(e.g. partner support, rapport midwife, relaxation) and enabling
factors (support network including self-management facilities and
psycho-education) [17].
In addition, we conducted a cross-sectional survey among
pregnant women eligible for Dutch midwifery care [7]. In a sample
of 458 healthy Dutch pregnant women we found that 21.8% of the
respondents had heightened levels of maternal distress. We identied
the following factors as predictors of maternal distress: history of
psychological problems, having young children, daily stressors,
avoidant coping, somatisation, and negative feelings towards
upcoming birth. e determinants self-disclosure and help-seeking
were eective coping-styles in preventing maternal distress [7].
When developing an intervention to address maternal distress,
it is necessary to understand the behaviour of those who deliver care
[13,16]. Because in the Netherlands the primary and most important
caregiver in pregnancy is the midwife [12], we conducted semi-
structured interviews among Dutch midwives giving us preliminary
insight in their beliefs about maternal distress [18]. We subsequently
conducted a survey among 112 Dutch midwives, exploring their
behavioural intentions regarding antenatal management of maternal
distress and the determinants inuencing those intentions [15]. e
ndings indicated that supporting women in self-disclosure in order
to screen for the vulnerability of maternal distress and assessment of
signs and symptoms of maternal distress, supporting women in self-
management of maternal distress, and supporting women in help-
seeking were important elements of care. ese elements of care were
positively associated with midwives’ experience, condence, beliefs
or interest in maternal distress [15].
To maximise the value of the ndings for practice we discussed
the importance and clinical relevance for midwifery practice with the
stakeholders. Interpreting and discussing the ndings emphasized
the necessity for an antenatal intervention. e ndings helped us
to identify the factors relevant for screening for maternal distress -
emphasising women’s individuality - as well as the factors related to
midwives’ screening behaviour, both of which needed to be addressed
by the intervention. e ndings also helped us to recognise the
importance of an individual approach addressing individual needs
of women but also showed us that an intervention with interaction
between midwives and women was required.
Step 2: Dene program goals by specifying performance and
change objectives
e second step of intervention mapping is the determination
of who and what will change as a result of the intervention. is
includes an explicit description of the target population’s preferred
behaviours, stated in ‘performance objectives’, and the personal and
external determinants of those behaviours. Identication of what the
target group needs to learn - regarding every determinant - is used to
create ‘change objectives’. e result of this step is a matrix of change
objectives specifying how the environment will be changed and what
individuals need to learn in order to change their current behaviour
[13].
Application: Given the needs assessment we identied specic
performance objectives (POs). ese were formulated at two dierent
levels: the individual level (pregnant woman) and the interpersonal
level (midwife-pregnant woman). We dierentiated between women
that are more prone to develop maternal distress and who will benet
by selective prevention, and those already suering from maternal
distress benetting by indicated prevention methods [19]. erefore
we determined the objectives by taking the found women’s individual
and behavioural factors as starting-points and indicated what women
must learn and change in order to prevent and reduce maternal distress
(Table 1). Firstly, women should learn to be conscious of the factors
in their life that make them more vulnerable for maternal distress
in order to undertake preventive actions. Secondly, women should
learn to self-disclose about their feelings and emotions and to handle
maternal distress in their daily lives if present. In addition, they should
learn when and where to seek help or support. e found personal
factors and behavioural determinants were all relevant and therefore
potential components for an intervention that sought to support
and sustain women in reaching the POs. Knowledge concerned
the origins of the predisposing factors but also the dierentiation
between psychological mood states that belong to pregnancy and
there were emotions deviate. Knowledge also concerned practical
knowledge about how to optimise emotional wellbeing or how to
cope with maternal distress. Attitude reected women’s perception
of the importance of sharing their emotions and seeking help when
they needed this. Risk-perception expressed women’s awareness of
predisposing factors in their lives but also the necessity and positive
and negative consequences of self-disclosure and help-seeking. Self-
ecacy reected the condence of undertaking preventive actions for
maternal distress or dealing with it when it occurs. In addition we
chose to address social inuence from the woman’s partner, relatives
and friends as well as the midwife because these have been found to
be the most important environmental factors [7,17].
ere were parallels between women’s individual and behavioural
factors and midwife’s care behaviour and therefore we determined
what midwives must learn and change in order to promote self-
disclosure of pregnant women, to support women in self-management
of maternal distress and to implement, monitor and coordinate care
for maternal distress (Table 2). e found behavioural intentions’
determinants of midwives were all modiable and therefore potential
targets for the implementation and sustainability of the intervention.
Midwives’ knowledge concerned content knowledge of maternal
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Fontein-Kuipers. Int J Womens Health Wellness 2015, 1:2
Table 1: Change objectives for all pregnant women (PO1 is a selective prevention method; PO2, PO3 and PO4 are indicated prevention methods).
Knowledge Attitude Risk- perception Self- Efcacy Social Inuence
General Self-disclosure Help- seeking Social
support
Professional
support midwife
Social norm
PO1.
Pregnant
women
identify
factors that
trigger MD
Point out which
factors can
trigger MD
Express that
personal
life issues
can have an
impact on
emotional
wellbeing
during
pregnancy
Explain which
factors in their
personal life (can)
trigger MD during
pregnancy
Express
condence
in identifying
factors in their
life that trigger
MD
Express feeling
supported by
their friends
and relatives
in identifying
factors in their
life that trigger
MD
Identify their
midwife as a
trustworthy
professional to
consult regarding
factors that
trigger MD
Identify their
midwife as a
trustworthy
professional
source of
information
regarding factors
that trigger MD
Express feeling
supported by
their midwife in
identifying factors
that trigger MD in
their own life
Explain that
identifying
pregnant
women that
are at-risk for
MD is a task
of the midwife
PO2.
Pregnant
women
decide to
express
that they
experience
MD (self-
disclosure)
Explain that
self-disclosure
can reduce
MD during
pregnancy
Report that
having a sense
of meaning/
purpose can
contribute to
self-disclosure
of MD during
pregnancy
Express that
their own
wellbeing,
that of their
baby and
family, are
meaningful
reasons to
disclose to
others when
experiencing
MD
Report the
importance
of sharing
problems and
signs and
symptoms of
MD with others
Report that
professional
help as a
consequence
of self-
disclosure is
positive
Report the
positive and
negative
consequences of
self-disclosure
Report personal
reasons to self-
disclose
Express
condence in
disclosing to
others when
experiencing
MD
Express feeling
supported by
their friends
and relatives
in disclosing
to them when
experiencing
MD
Express feeling
supported by
their midwife
in disclosing
to her when
experiencing MD
Explain that
encouraging
women in
talking about
MD is a task
of the midwife
PO3.
Pregnant
women
actively
handle MD
in their daily
life (self-
management)
Explain
effective and
ineffective
coping
mechanism
to deal with
MD during
pregnancy
Report that
having a sense
of purpose
can contribute
to self-
management
of MD during
pregnancy
Express the
importance
of effective
coping
(skills) with
MD during
pregnancy
Report the
importance
of sharing
problems and
symptoms and
signs of MD
with others
Report the
importance
of asking for
support
Express that
support in
coping with
MD is positive
Express
condence
in self-
managing/
coping with
MD
Express feeling
supported by
their friends
and relatives
in coping with
MD
Express feeling
supported by
their midwife in
coping with MD
Explain that
coaching
women in
the self-
management
of MD is a
task of the
midwife
PO4.
Pregnant
women seek
professional
support for
MD when
needed (help-
seeking)
Report the
availability
of different
screening
instruments
to determine
appropriate
support for MD
Explain different
professional
support options
and resources
for MD
Report that
having a
purpose can
contribute to
self-disclosure
Express
positive
aspects of
seeking
professional
support for
MD
Express the
importance
of seeking
professional
support for
MD
Report whether
professional
support involves
positive and/
or negative
consequences
for MD and their
daily functioning
Express
condence
in nding
appropriate
professional
support for
MD
Express feeling
supported by
their friends
and relatives
in seeking
appropriate
professional
support for MD
Express that
their personal
environment
provides
support when
seeking
professional
support
Express feeling
supported by
their midwife
when discussing
professional
support for
Express feeling
supported by
their midwife
when exploring
appropriate
professional
support for MD
Explain that
advising
pregnant
women about
professional
support of MD
is a task of
the midwife
Explain that
referring
pregnant
women
suffering from
MD to other
caregivers is
a task of the
midwife
* MD: Maternal Distress
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Fontein-Kuipers. Int J Womens Health Wellness 2015, 1:2
addressed the mothers’ condence and sense of control, both of which
serve a protective function for maternal distress [28]. To inuence
both attitude and self-ecacy we chose ‘cultural similarity’ [13]. Since
pregnant women identify with other pregnant women and are more
receptive to their experiences [27] we used images of pregnant women
from various cultures and in various states of mind. Furthermore we
used stories (narratives) of ‘everyday’ women reecting variations of
maternal distress. Finally ‘individualization’ was selected to change
risk-perception, attitude and social inuence [13]. Individualization
is concerned with providing opportunities for personalised answers
or to receive instructions that are paced with individual progress
[13]. As part of the tailored advice we asked women about personal
circumstances and issues in their lives. Advice given reected their
need for support and included self-management, practical help,
self-disclosure to a friend or midwife and professional support. We
oered a range of supportive resources on both individual and group
level, depending on the woman’s individual wishes.
Application for midwives: To enable midwives to (a) promote
self-disclosure of pregnant women, (b) support self-management,
and (c) coordinate care for women suering from maternal distress
(Table 2) we called upon several methods. ‘Information processing’
was chosen as a general method [13]. It was used to address
all identied determinants of midwife behaviour. Information
processing helps midwives learn about the relevance of the
intervention, the functioning principles behind the intervention, and
how to use the intervention, all of which increase the likelihood of
adopting the innovation [29]. Because it is important for learners to
identify with the educator [30] we chose for a practising midwife to
lead the training session. In the training session we used ‘intergroup
dialogue training’ as an important method to address social norm and
skills management in relation to the midwife’s role, competencies and
tasks [20,31]. In the training session we also used ‘verbal persuasion’
to convince midwives that they are capable to screen for maternal
distress [13]. Midwives are familiar with screening for various risk
behaviours (e.g. smoking) and are aware that addressing sensitive
psychosocial issues (e.g. sexual abuse) is part of their scope of practice
[20]. However, they need to realize that they can apply their existing
screening abilities to a new area of health behaviour within midwifery
practice i.e. maternal distress.
Additional methods were ‘facilitation of means’ [13] that allowed
us to address the self-ecacy and management of skills needed
to create a change in practice, and to reduce the barriers to action.
Midwives feel inadequate to screen for maternal distress when they do
not know when to refer and which professional is most appropriate
to a woman’s specic needs [32]. erefore we provided midwives
with a practical guideline for screening, a clinical pathway for care,
and an overview of regional healthcare providers for consultation and
referral. ‘Providing cues’ [13] - was used to remind midwives of the
content of the training session. ey received a set of pocket cards
with information that was coloured coded per topic, similar to the
topics discussed in the training, to use as an ‘aid’ during their daily
practice. Finally we used ‘structural organization’ [13] as a method for
helping midwives to share client information with other professionals
in a clear, complete, concise and structured format, all of which
improve communication eciency and accuracy. In addition this
approach enhances the use of structural organization to improve a
midwife’s management of skills.
Table 3 presents the main methods and strategies used for the
development of the WazzUp Mama?! An overview of all methods and
strategies can be obtained from the rst author.
Step 4: Program production
is planning step combines the practical strategies in a program
and develops materials that guide the program production. In our case
we organized the strategies described above into a deliverable program
with specied components, designing a plan for the production and
delivery of the program, and producing program materials. In this
process we also pre-tested the program and materials to ensure that
distress, knowledge about screening instruments and the meaning
and implications of parameters, knowledge about options and sources
for help and support and about communication pathways with other
healthcare professionals. Attitude reected midwives’ positiveness,
their willingness and sense of importance and relevance regarding
the management of maternal distress. Self-ecacy expressed the
condence midwives perceived in assessment of maternal distress
and its predisposing factors. Skills management concerned the
competencies regarding assessment, psycho-education, mobilizing
social support and the coordination and referral of care. Additionally,
we chose to address the midwife’s social norm because this involves
the dierent roles within the midwife’s professional scope [20]. We
have given examples of change objectives for women (Table 1) and
midwives (Table 2). e complete matrices of change objectives can
be obtained from the rst author.
Step3: eory-based intervention strategies
e focus of this third step is to select theoretical change methods
and to formulate practical strategies [13]. Methods are theoretical-
based techniques that can inuence behavioural change [21] and are
translated into strategies [13]. e objective is to base all the decisions
for the WazzUp Mama?! intervention on scientic evidence and
theory [13].
Application for pregnant women: We used ‘tailoring’ as
one of our general methods for change that we found suitable for
almost all of the relevant determinants of behaviour [13]. Tailoring
is prescribed when information given is matched to previously
measured characteristics, individual problems, feelings and emotions,
experiences, wishes, needs and abilities of the woman [22]. It provides
opportunities for women to have their personal questions answered
and to receive advice that aligns with their individual progress
[22]. In order to full this need pregnant women frequently use the
Internet for support and antenatal advice [23]. Our second general
method involved ‘supportive communication’, [13]. Supportive
communication with the midwife inuences the way women appraise
their uncertainties and desires during pregnancy and it facilitates
eective coping [24].
Additional methods were the use of ‘advance organizers’ and
‘elaboration’ to improve women’s understanding of the complex
nature of maternal distress and to enable them to access relevant
information [13,25,26]. Women select a (pre-dened) situation,
like feeling emotionally unbalanced, which is then followed by a
tailored response generated with a ‘narrative advance organizer’. To
alter women’s knowledge of and attitude toward self-disclosure and
help-seeking we chose ‘elaboration’. Elaboration intends to increase
women’s motivation to process information and adds meaning to
the information [13]. We encouraged women to identify present
or past sources for maternal distress (e.g. miscarriage, negative
birth experience) and guided them through the experience by
asking how they felt, the coping mechanisms they used (e.g. self-
disclosure, worrying, help-seeking) and then linking the information
by rehearsing and summarising the previous information. We used
’imagery’ in the pictures of pregnant women to create stronger
memories [13]. To target risk-perception we chose ‘consciousness
raising’ [13]. Risk-perception involves increased awareness about
one’s vulnerability to, the consequences of, and the solutions for
maternal distress [13]. Using an inventory of risk factors for maternal
distress (e.g. past history of psychological problems, daily hassles)
and applying scores for impact and perceived burden of these risk
factors, women verbalized their personal risk(s) and gained insight
into their severity. e use of an inventory was followed immediately
by evaluative and descriptive advice based on a woman’s reported
severity [27]. To enable women to identify risk situations for maternal
distress in advance of exposure to them we chose ‘cue altering’ [13].
Cue altering increases self-ecacy of mothers who tend to relapse
into inadequate coping. Women had to outline their usual coping
responses to dicult situations (e.g. “my response to daily hassles is
to worry about them”), and were provided with practical advice to
anticipate and adequately respond to risk situations. In this way we
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Fontein-Kuipers. Int J Womens Health Wellness 2015, 1:2
Table 2: Change objectives for midwives.
Knowledge Attitude Self-efcacy in
screening for MD
Skills Management Social norm
PO1. Midwives
utilize
assessment
(including
screening) of MD
(to promote self-
disclosure)
Dene maternal distress
Dene psychopathology
Report that assessment
of MD promotes self-
disclosure of pregnant
women
Report the barriers that
affect the midwife’s
approach in assessment
of MD
Report risk groups
for MD (within their
population)
Report the appropriate
times for screening for
MD within antenatal care
Report methods to
screen for MD during
pregnancy
Report how screening
results must be
interpreted
Dene which screening
parameters are relevant
for consultation or
referral to other
healthcare professionals
Report the risk factors
in a woman’s (medical)
history or current
personal circumstances
for developing MD
Report the risk factors
during pregnancy and
birth for developing MD
Report which personality
traits are risk factors for
developing MD
Express their motivation
regarding assessment
and screening of MD
Argue the relevance of
prevention regarding
assessment and
screening of MD
Argue that midwives
are the appropriate
caregivers for MD
assessment and
screening
Argue that pregnancy is
a ‘window of opportunity’
to assess and screen
for MD
Express the importance
of assessment and
screening of MD in
order to adequately
refer to other healthcare
professionals
Express condence
in assessment and
screening of MD
Express competence
in assessment and
screening of MD
Express competence
in asking the right
questions in assessment
of MD
Express that their
experience in
assessment increases
their condence
in asking the right
questions
Express competence
in managing women
that self-disclose after
assessment or screening
Demonstrate
assessment and
screening for MD
Demonstrate correct
interpretation of the
screening results
Demonstrate when
consultation or referral
is indicated based on
assessment or screening
results
Demonstrate discussing
the answers regarding
MD and the results
of MD screening with
pregnant women
Acknowledge that assessment and
screening is part of the midwife’s
role as coach and counsellor and as
medical professional
PO2. Midwives
advice women in
coping with MD
Report the effect of
advising women in
coping with MD
Report the three effective
coping mechanisms
(self-disclosure,
acceptance, help-
seeking)
Report the three
ineffective coping
mechanisms (avoidance,
drinking, smoking)
Report a minimum of 5
practical tips for pregnant
women aimed at coping
with MD in daily life
Express their motivation
to advice women in
coping with MD
Report the relevance to
advice women in coping
with MD
Report the importance to
advice women in coping
with MD
Demonstrate advising
women experiencing MD
how to inuence stress-
factors
Demonstrate advising
women experiencing MD
how to positively cope
with MD
Acknowledge that advising women in
dealing with MD is part of the midwife’s
role as coach and counsellor and
advisor
Acknowledge their position involving
condentiality
Acknowledge their non-judgmental
position regarding MD
PO3. Midwives
support pregnant
women in
nding self-help
initiatives and
professional
support for MD
Report the effect of
supporting pregnant
women in seeking
self-help initiatives and
professional support
for MD
Report the local self-help
initiatives and resources
for professional support
for MD (including content
and scope)
Express their motivation
to guide pregnant
women in nding self-
help initiatives and
professional support
for MD
Report that supporting
pregnant women
in nding self-
help initiatives and
professional support
promotes reduction of
MD
Demonstrate
informing pregnant
women in nding self-
help initiatives and
professional support
for MD
Demonstrate
constructing a map of
local self-help initiatives
and resources for
professional support
for MD
Demonstrate correct
thresholds when to
support pregnant
women in choosing
self-help initiatives and
professional support
for MD
Acknowledge that guiding pregnant
women using self-help initiatives and
professional support for MD is part
of the midwife’s role as coach and
counsellor and as advisor
*MD: Maternal Distress
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Fontein-Kuipers. Int J Womens Health Wellness 2015, 1:2
they were comprehensive, understandable, and acceptable to the
implementers and the participants [13].
e title of our program WazzUp Mama?! reects our interest
in how a pregnant woman feels, both positively and negatively.
Wazzup?! - meaning: how are you? - was ocially added to the
Dutch dictionary in 2013 [33] and we used this Dutch neologism to
emphasize the importance of a mother’s experiences of pregnancy.
Wazzup Mama?!’s dierent components were pre-tested for user
friendliness, design, understandability and comprehensiveness
among pregnant women, young mothers, practising midwives,
midwifery lecturers, psychologists, scholars, and student midwives.
When necessary we adapted program elements. Among the pregnant
women and young mothers who helped with the pre-test were women
who (had) experienced maternal distress during pregnancy.
Application for pregnant women: e program part for women
aims to identify the vulnerability of, or the presence and severity of
maternal distress during pregnancy. When maternal distress is absent
or vulnerability is identied, the program is designed to prevent it from
developing. When maternal distress is present, the program aims to
reduce it. e program included a web-based tailored program (Table
4), consisting of (i) a homepage with three self-directed pathways, (ii)
a process for collecting personal information, and (iii) personalized
feedback based on the data collection in ii. e self-directed pathways
addresses dierent topics of emotional wellbeing: (1) mood changes
as a result of pregnancy, (2) identifying factors that unbalance and
disturb emotional wellbeing, and (3) identication of (levels of)
maternal distress. Self-direction is based on recognition of a situation
presented at the starting point.
e rst pathway focuses on the signs and symptoms of maternal
distress and determines if the respondent’s emotions belong to the
Table 3: Theoretical Methods and Practical Strategies for the WazzUp Mama?! Intervention
Pregnant Women
Determinant Theoretical Method Strategies Conditions
Communicative support Encourage and stimulate women to disclose private
and sometimes sensitive information
Requires a relationship of trust and supportiveness with the
midwife
Tailoring Tailor information to the woman’s needs and her
actual situation: Offer important general knowledge
about the situation. Let the woman link the general
knowledge to maternal distress
Requires that information is responsive to the woman’s
needs, concerns personal factors that are relevant to her
and her situation, and relates to behaviour.
Midwives
Determinant Theoretical Method Strategies Conditions
Social norm Intergroup dialogue training Stimulate to share experiences, which permit
the interplay of character and personality and
recognising the benets to provide care for maternal
distress.
Requires a relationship of openness, trust and
supportiveness among colleague midwives
Knowledge
Skills management
Information processing Provide midwives with awareness-knowledge,
how-to knowledge and principle-knowledge about
maternal distress
Stimulate to share experiences, which permit
the interplay of character and personality and
recognising the benets to provide care for maternal
distress
Requires information that is responsive to the midwives’
level of explicit and tacit knowledge and practical needs
Requires a relationship of openness, trust and
supportiveness among colleague midwives
Table 4: WazzUp Mama?! Web-based tailored program for pregnant women.
Homepage Self-directed pathways or starting points:
(1) Mood changes - Emotional dips
(2) Mapping risk factors - Are you in balance?
(3) Emotional wellbeing - I don’t feel well
Information collection (1) First name
(2) Midwifery practice or post code
(3) Results of screening tests addressing:
- Personal history and circumstances
- Emotional wellbeing - case-nding questions*
- Emotional stamina or perceived burden
- Maternal distress
- Coping mechanisms
Personalised feedback (1) Advice for daily life: a variety of practical tips and tricks [42], including relaxation exercises
(2) Advice about positive ways of coping and alternative ways of effective coping, based on most frequently used coping
styles [43-46]
(3) Overview of all relevant caregivers and health initiatives aimed at psychological and emotional wellbeing:
- Self-management resources
- Local individual and group support:
(i) lay
(ii) professional
(iii) alternative
Synopsis
*Whooley questions - (1) During the past month, have you often been bothered by feeling down, depressed or hopeless? (2) During the past month, have you often
been bothered by little interest or pleasure in doing things?
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physiological process of pregnancy or if they are a deviation from that
process. e respondent is asked to score the burden of her emotions
on a visual analogue scale from 0 to 10, increasing in severity, in order
to identify the level of severity of their burden. Scores above set cut-
o points lead to the second pathway. e second pathway focuses on
identifying (potential) stress factors, problems or dicult situations in
the past or present that may contribute to the development of maternal
distress. e respondent is asked to score their level of emotional
stamina on a visual analogue scale from 0 to 10, increasing in level of
diculty of coping with the situation. Scores above set cut-o points lead
to the third pathway. We used visual analogue scales in these rst two
pathways as an accurate way to rule out women for maternal distress
and to nd that larger proportion of women who are struggling with
emotional complications that would otherwise go undetected [34,35].
Cut-o points for these scales were based on the ‘Distress thermometer’
and these cut-o points indicated women’s needs for self-management
and for additional support [36]. e third pathway is a measurement of
maternal distress operationalized by means of the Edinburgh Depression
Scale (EDS), derived from the Edinburgh Postnatal Depression Scale
(EPDS) [37]. Scores above dened cut-o points identied the severity
of maternal distress [38,39] and were used as indicators for support. e
Edinburgh Depression Scale was incorporated because this is validated
to measure depression and anxiety simultaneously [40] and is recognised
for its user-friendliness and compact size [41].
e results of the information collection and screening tests led to
personalized feedback from the screening tests including advice and
a synopsis of all the advice given. e respondent was encouraged
to print it out and discuss it with her healthcare provider or use it
as a reminder when necessary. e tone of voice of the personalized
feedback was non-judgmental and reective. Women were addressed
by their rst names in the tailored feedback, and feedback was
made personal by women’s self-reported reasons for change. e
starting points of the website and the dierent mood states included
dierent images of women reecting that particular mood. Narratives
supported the dierent mood states of maternal distress.
Application for midwives: Because midwives appreciate clear
guidelines and supportive material and are, in general, willing to
provide care for maternal distress [15] the program part for midwives
included a toolkit. e toolkit included six components and are
presented in table 5. All materials were designed to be recognizable
parts of the Wazzup Mama?! program and were introduced by means
of an accredited training.
Step 5: Program implementation
Step 5 of the Intervention Mapping protocol focuses on adoption
and implementation of the intervention. is step is intended to
inuence the behaviour of individuals who will make the decision
about adopting and implementing the intervention. erefore,
the production of the intervention must be closely linked to the
implementation planning [13].
Table 5: Toolkit WazzUp Mama?! For midwives.
Guideline (1) Clinical pathway for consultation and referral
(2) Case-nding questions* to be used throughout the whole antenatal care period.
(3) Scoring system of perceived burden or emotional stamina (according the same cut-off points as the web-based program
for women)
Regional healthcare map All relevant caregivers and health initiatives aimed at psychological and emotional wellbeing:
(1) Self-management resources
(2) Local individual and group support:
(i) lay
(ii) professional
(iii) alternative
Posters for practices (for waiting and
consultation rooms)
Advertising the tailored website
Credit card-sized cards To hand out to women with the URL of the web-based tailored program
A set of pocket cards Functional format and convenient size (credit card-size) including:
(1) Clinical pathway
(2) Case-nding questions*
(3) Scoring system of perceived burden or emotional stamina (according the same cut-off points as the web-based program
for women)
(4) Card to write down relevant phone numbers
Training - Prevalence and causes
- Predisposing factors maternal distress
- Consequences
- Recognition/signs and symptoms (psychological, behavioural, biological/ vital, social)/differentiation physiological mood
changes and maternal distress
- Assessment predisposing factors and emotional wellbeing
- Assessment negative birth experience
- Problem and emotion focussed questions based on sense of coherence
- Local healthcare map
- SBAR
- Interpretation EDS scores and cut-off points
- Interpretation VAS scores perceived burden or emotional stamina
- SSRI usage
- Use toolkit
- Reading material (EPDS [39,40]/Distress-thermometer [36]/Salutogenesis model [47,48]/Post partum Post Traumatic Stress
Syndrome [49]/NICE guideline Antenatal and Postnatal Health [50]/Guideline SSRI use [51])
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Application: Use of the stakeholders in program development
improved commitment between program developers and
implementers, and ensured that intervention components were
acceptable and workable for implementation in practice. Since
the eectiveness of the intervention must be demonstrated
before broad implementation could be considered, the WazzUp
Mama?! intervention was implemented in a pilot-study among 17
midwifery practices. e participating midwives received a nancial
reimbursement for time spent delivering the intervention and
accreditation for the professional quality register (i.e. continuing
education credits) aer they had attended the training on how to use
the intervention.
Step 6: Design a plan for evaluation
e nal step of the Intervention Mapping protocol is developing
an eect evaluation plan, looking at the evaluation process as an
opportunity to improve implementation. Development of the
measurement instruments can be based on the information gathered
in all previous steps of Intervention Mapping [13].
Application: e eect of the program was evaluated among
17 participating midwifery practices in using a non-randomized
pre-post intervention study design with a sequential control and
experimental group. Midwives were asked to recruit pregnant women
eligible for midwifery care at booking for both control (n = 215) and
experimental condition (n = 218). ese women were asked to ll
out a self-reported maternal distress instrument [38,41,52-57] before
their rst visit with the midwife and again at 36 weeks of gestation. e
control group received care-as-usual, while the experimental group
was exposed to the Wazzup Mama?! intervention. e dierence in
the prevalence of maternal distress between the participants in the
control group and experimental group diered signicantly. In the
control group maternal distress signicantly increased from rst to
third trimester (20.9% to 26.5%) of pregnancy, in the experimental
group it signicantly decreased (22.5% to 13.3%) aer receiving the
intervention, and thus WazzUp Mama?! was interpreted as successful
[58].
Discussion
In this paper we described the use of the Intervention Mapping
protocol to develop the Wazzup Mama?! intervention for pregnant
women eligible for midwife-led care. Intervention Mapping provided
a valuable protocol to guide program planners through the structured
development of the intervention. In addition, our extensive needs
assessment, performed to provide the building blocks for the
intervention, has added to the body of knowledge regarding maternal
distress [8].
To our knowledge this is the rst study that fully describes the
development of an antenatal intervention for maternal distress.
A strength in applying intervention mapping in this study was
that quantitative information from pregnant women [7,17] and
quantitative [15] and qualitative information from midwives [18]
were systematically collected and combined with expert validation
[17], and with behavioural change theories to develop an intervention
tailored to the needs of the target groups and implementers.
Bringing together both program developers and implementers of the
intervention from the start ensured that commitment remained strong
during the development of the intervention, and that intervention
components were acceptable for implementation in practice [13].
Including both midwives and other healthcare professionals involved
in the psychosocial wellbeing of women in the consortium was also
strength, since it provided insight into the clinical relevance of the
practical strategies we used.
e eect of our intervention is not the simple result of the sum of its
separate components. It is rather the result of an approach that integrates
several features to address maternal distress and considers women and
their environment as a complex adaptive system [59]. Women using the
intervention were recognised as having personal histories and diering
initial conditions. Because the intervention contained several interacting
components, it is possible that separate components variably contributed
to the overall eect of WazzUp Mama?!. e structure and content of the
two parts possibly enhanced each other and the various features of the
two program parts were likely to have an interchangeable intervention
eect. Individual women might respond or benet dierently to separate
intervention parts or components. Because of the tailoring and self-
management aspects of the intervention, women were able to choose
what suited them best but also to relate the information to their personal
life [25]. Combining computer tailoring with professional face-to-face
contact has shown to have positive results in pregnant women in earlier
studies [60].
A major limitation of applying the Intervention Mapping
protocol is the time it requires. Also in multi-facetted problems such
as maternal distress where multiple behavioural and environmental
factors are involved and that all must be translated into the program
objectives, can result in overwhelming matrices of change objectives
that are impossible to address completely. We have incorporated all
determinants that have emerged from our quantitative and qualitative
data. e positive eect of the current matrices of change objectives
is that these are likely to be complete. However, in future projects
evaluation of program objectives and determinants that are essential
for program development could lead to a more parsimonious
list and more eciency in steps 3-6. Process evaluation among
midwives regarding the quality of the training, delity and dose of the
components delivered, dose of the components received, usefulness
of intervention components (resources)and barriers for use is
required [61,62]. Pregnant women should be asked to evaluate the
components of the intervention and to indicate dosage received [62].
When we have more insight into the results of the process evaluations
of both women and midwives involved in the intervention, we can
rene the selection of relevant program objectives and determinants
and adapt the intervention for future use. Process evaluation also
enables correct interpretation of ndings from eect studies and can
be used to identify key facilitating and hindering factors for future
program implementation and dissemination [13,16].
In addition, women in our studies represented a healthy
population, where women were predominantly Dutch and fairly
auent. Midwives were practising in midwife-led care, which is not
common practice in other countries. ese characteristics may mean
that the women as well as midwives’ needs are dierent for women
and midwives in other countries or other settings. erefore, as
specied by intervention mapping, a maternal distress intervention
should start with a need assessment in the specic setting.
Conclusion
Intervention mapping can be a useful tool to apply to the
development of an intervention in the complex area of emotional
wellbeing during pregnancy. By involving stakeholders from the start of
the project, the intervention is not only tailored to the needs of pregnant
women, but also to the abilities and possibilities of the midwives as
implementers. By combining evidence from theory and practice an
intervention for handling maternal distress with the potential for broad
dissemination was developed. Our goal was to make the development
of our intervention more transparent in order to enable other program
planners to identify and retain crucial elements when translating the
intervention to other populations and settings. We strongly encourage
future program planners in the eld of midwifery to do so.
Funding
is study is part of the research project ‘Promoting Healthy
Pregnancy’, funded by Regional Attention and Action for Knowledge
(RAAK PRO, ref. 2-014). RAAK is managed by the Foundation
Innovation Alliance (SIA) with funding from the ministry of
Education, Culture and Science (OCW).
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