2. Literature on Peer Support in Perinatal Mental Health
2.1 Overview of the evidence base
Peer-reviewed literature examining the impact of peer support in the perinatal period is limited. The peer-reviewed evidence is mainly comprised of articles from England and North America. None of the peer reviewed literature returned in the search focused on Scotland.
The wider research evidence includes large scale quantitative studies of telephone based-peer support and generally smaller qualitative studies of face-to-face peer support. Third sector evaluations tend to focus on pilot projects or small numbers of clients. The research base in Scotland is comprised of third sector evaluations.
A significant proportion of the evaluation literature of peer support in the perinatal period found in the search comes from rural Pakistan and India (Sikander et al., 2015; Atif et al., 2017). However, this evidence was not included in the literature review because the social, economic and health context is not comparable to the UK.
The literature shows general positive effects, with some studies showing mixed outcomes. However, the particular mechanisms which effect the positive impact of peer support are not identified or tested robustly in the literature.
The evidence supports the effectiveness of peer support in reducing social isolation and improving self-esteem and parenting self-efficacy for new mothers. Many studies also demonstrate a reduction in depressive symptoms for mothers and an increase in social contact outside the home.
The literature makes only passing comment on the situation of women from marginalised groups. The distinct challenges for women from ethnic minority backgrounds, women with disabilities, women living in isolated geographical areas or those women whose religious or cultural beliefs may make it difficult for them to access support are not well represented. No studies were found that evaluated peer support for fathers or other caregivers. In addition, peer support for women who experience miscarriage or baby loss is not represented in the literature.
Overall, the literature review suggested that evaluation of perinatal peer support is at an early stage in Scotland. Third sector perinatal peer support services would benefit from integrating evaluation into their service to offer a robust evidence base for their work and to expand knowledge of what works and doesn't work in the sector.
The results of the literature search are presented thematically below, across six headings; (1) acceptability of peer support, (2) training and matching volunteers and clients, (3) social support and reducing social isolation, (4) improving self-esteem and self-efficacy, (5) reduction of depressive symptoms, (6) impact on peer supporters.
2.2 Acceptability of peer support
The acceptability of peer support to mothers is well evidenced across the literature base. Studies evaluating telephone-based and face-to-face peer support found a high level of satisfaction and positive feeling toward peer support among mothers. In a pilot randomised controlled trial of telephone-based peer support in Canada, Dennis (2003) found a high level of maternal satisfaction with and acceptance of the service. In a later study examining the perceptions of mothers who received telephone-based peer support as a preventative strategy for postpartum depression Dennis (2010) found that the majority of the mothers viewed their experience as positive. A more recent small scale quasi-experimental study also in Canada (n=64) found that telephone-based peer support is acceptable to mothers and effective for both early postpartum depression and maternal depression up to two years after delivery (Letourneau et al., 2015).
While most studies demonstrated that women accept and feel positive about peer support, there are indications that peer support may be especially helpful to women who feel stigmatised, are socially isolated or in high-stress circumstances. In their study conducted in England, Fogarty and Kingswell (2002) found that telephone- based and face-to-face peer support was most welcomed by women who were new to the area and especially valuable to women involved in or leaving, an abusive relationship.
Stigma was also a significant factor impacting on the acceptability of peer support services for women. Letourneau et al. (2007) conducted 52 semi-structured interviews with women in Canada who had experienced postnatal depression. Stigma surrounding postnatal depression, both self-stigma and feeling stigmatised by external experiences, was identified as the main barrier to seeking support. Women identified that a combination of one-to-one peer support in your home and the option of attending a peer support group would be the most effective way to support women to overcome the stigma surrounding postnatal mental illness and seek help. Participants also suggested that peer support could reduce stigma by increasing knowledge of the symptoms of postnatal depression for their families and friends. Peer support was particularly valuable for counteracting stigma, as the peer volunteers modelled openness and honestly about their experiences, demonstrating that poor perinatal mental health was nothing to be ashamed of.
Deprived socioeconomic circumstances may challenge women's engagement with peer support. Murphy et al. (2008) conducted a qualitative interview study with peer supporters and women receiving face-to-face, home-based support in Northern Ireland. While many women appreciated the support and sharing of experiences by peer supporters, relationships were difficult to initiate and maintain, which negatively affected the morale of peer supporters. The study was conducted in a highly deprived area, and it seems that the challenging circumstances of some women's lives led to them engaging inconsistently with the support or disengaging entirely. This result was echoed in a recent evaluation of the National Childbirth Trust's (NCT) Parents in Mind programme (MacLeish and Hann, 2019) Parents in Mind was trialled over three sites in England, and the most highly deprived location experienced low referral numbers and inconsistent engagement, especially for support groups.
Another indicator of acceptability appears to be that an equal power balance is key to successful peer support. In Canada, a study evaluating home-based peer support for mothers found no significant treatment effects after a 12-week support programme featuring maternal-infant interaction teaching by peer volunteers. The authors concluded that maternal–infant interaction teaching by peers is not well received by mothers with postnatal depression and that the service would be better delivered by professionals (Letourneau et al., 2011). It seems that while support and validation from a peer is beneficial, using peer volunteers to give advice or deliver training diminishes the benefits of the peer role.
2.3 Training and matching peer volunteers and clients
Adequate training for peer supporters is vital, whether employed as a peer worker or working as a volunteer. Several papers reference how the training process and careful matching of peers and clients contributes to the success and sustainability of peer support programmes. In their review of the perinatal peer support literature, Letourneau and Leger (2015) identified six studies, three conducted in Canada (Dennis, 2003; Dennis et al., 2009; Dennis, 2010), two in England (Fogarty and Kingswell, 2002; Barnes et al., 2009) and one on Ireland (Murphy et al., 2008). Overall, Letourneau and Leger found that adequate training of volunteers and matching of peer volunteers with mothers is important. They also emphasise ensuring that support is meeting the needs of mothers and families by seeking their input. Dennis (2010) also found that paying close attention to the matching of volunteers and mothers and training for volunteers would be likely to benefit the development of a supportive relationship.
The importance of training has also been highlighted by third sector reports. All of the volunteers taking part in NCT's Parents in Mind programme rated their 8 week training programme as good or excellent, however after starting to volunteer many peers expressed that they did not feel the training had prepared them sufficiently for the reality of the work (MacLeish and Hann, 2019). An evaluation of a Home Start project in North Glasgow providing perinatal peer support reported that after completing an 8 week training course and starting to work with clients, peer volunteers requested additional training on specialist areas, such working with refugees and asylum seekers (Heywood et al., 2016). Similarly, in their evaluation of the Family Action Perinatal Support Project, Barlow and Coe (2012) found that robust training was an essential part of establishing safe practice, and after the initial 6 week training volunteers also requested additional training on issues such as domestic violence. The Family Action model was adapted and expanded by Scottish charity Aberlour, in the development of their Perinatal Befriending Support Service.
Evidence from peer reviewed and third sector literature suggests that robust training which responds to the needs of peer volunteers is a key factor in the success and sustainability of peer support work. Appropriate and timely clinical supervision for peers is also essential to maintain safe and high quality support for mothers and babies. This is also reflected later in Section 3 on current models of peer support in Scotland.
2.4 Improving self-esteem and self-efficacy
Peer support has been shown to enhance self-esteem and self-efficacy for mothers across a range of studies. Several dimensions of this effect are demonstrated, increased self-esteem, enhanced parenting self-efficacy and positivity toward their parenting role. A pilot study with mothers who took part in a six week programme of peer support with volunteer supporters reported increased self-esteem and positivity towards their parenting role (Cust, 2016). The most recent qualitative study based in England, Mugweni et al. (2019), interviewed 14 women and gathered pre-post outcomes data from 123 women. Mothers reported that the peer-befriending service enhanced their sense of self-efficacy as parents. Several further studies conducted in England and one in Northern Ireland offer the closest site for comparison with Scotland, and suggest that peer-support programmes have demonstrated an improvement in parenting self-efficacy for mothers (McLeish and Redshaw, 2015; Mugweni et al., 2019).
In addition to enhancing self-esteem, self-efficacy and parental warmth, research suggests that peer support may offer additional benefits to women who are from an ethnic minority background, recent migrants and women experiencing multiple disadvantages. McLeish and Redshaw (2017) conducted a qualitative study, using semi-structured interviews with 47 women to describe the experience of organised peer support in the perinatal period. This study recruited participants from 10 different perinatal peer-support projects across England, finding overall that peer support helped the women to feel less isolated and more empowered as parents, increasing their sense of self-esteem and self-efficacy. The authors found that peer support can be especially positive and impactful for women who are recent migrants without any social support network, women who have a cultural or religious background where mental health problems are taboo, or those who are very isolated for other reasons, for example by having controlling and critical partners.
2.5 Social support and reducing social isolation
One of the strongest themes in the literature was the impact of peer support in providing social support and reducing social isolation. Lack of social support is a major risk factor for perinatal mental health problems, and several studies report that women link the onset of their poor perinatal mental health with the loss of social support. Mauthner (1995) used semi-structured interviews with mothers in England who experienced postnatal depression and had accessed peer support, finding that the extent and nature of the mothers' relationships with other mothers are closely linked to mothers' own feelings of psychological and emotional well-being. The study suggests that social withdrawal from peers was associated with the onset of postnatal depression. Interviewees also linked their journeys out of postnatal depression with the renewal of contact with other mothers. Mauthner suggest that befriending approaches and support groups may harness the impact of this effect in a valuable way.
In another study, Montgomery et al. (2012) gathered data to describe Canadian women's experience of a peer support group. Women expressed that 'Peers validated that mothering in illness "is very difficult"' and described attending peer support groups as a safe environment, providing recognition and support for each other's growth as capable mothers in challenging circumstances. The authors identify this process of seeking support and sharing suffering and wisdom with peers as part of the women's path to recovery from their postnatal depression. Qualitative data from interviews and focus groups conducted by Cheyne et al (2016) reports that a Scottish befriending service was effective in helping mothers to gain confidence, both as parents and to take part in activities outside of the home. Increased social contact is a significant step towards recovery for many women experiencing perinatal mental health problems.
It seems that the impact of social isolation could be even more powerful than socioeconomic deprivation. Raymond (2009) conducted semi-structured interviews with women in England from highly disadvantaged backgrounds. While many experienced poverty, cramped living conditions and chronic unemployment, emotional isolation resulting from a lack of social support was the most problematic issue for the women. The women expressed that social support and contact with other women in their situation would have been hugely helpful for them, with several participants offering to provide peer support to other pregnant women as a result of their experience of feeling unsupported.
One of the major advantages of peer support is the bridge that it offers to social activities outside the home. McLeish and Redshaw (2017) reviewed 10 different perinatal peer-support projects across England and found that women were less socially isolated after receiving peer support and more likely to participate in activities outside the home. In a recent English study Mugweni et al (2019) found that mothers reported that peer support helped them to attend activities outside the home, for example a peer-support group which mothers described as 'invaluable'.
Peer support groups can be especially supportive as many women report that those close to them don't understand their situation. In Canada, Letourneau (2007) reported that many women are discouraged from seeking support from family and friends, who can be keen to normalise or minimise their difficulties. In their meta-ethnography, Jones et al. (2014) identify five qualitative studies examining the role of peer support in acting as a protective factor against mental ill health in the perinatal period. Women experienced peer support as particularly helpful as people close to them often had limited understanding of postnatal depression, and so their ability to offer effective support was also limited in the perception of the mothers.
The fact that peers are people who are not part of your existing social network is also significant. Tammentie et al. (2004) interviewed Finnish mothers and fathers experiencing postnatal mental health difficulties about social support. Mothers reported that peer support groups were an important source of support, especially if they were organised by a third sector organisation and with mothers they did not know before pregnancy. This was distinct from peer support from friends, as discussing their situation with friends who were mothers led to comparison and inhibited mothers' ability to be open about their difficulties. One mother described the peer support group like this:
'You get to hear that everybody has the same problems, that we are not the only ones who have failed, mothers talk about their lives and it felt like they were talking about my life.'
Peer support reduces social isolation by providing direct social support, and by offering support with social activities outside the home. Social isolation is identified as the central difficulty for women even when they are experiencing other challenges, for example poverty and unemployment. Peer support is especially valued as peers are likely to validate and accept the experiences of the mother, not minimise them.
2.6 Reduction of depressive symptoms
Many studies use measures such as the Edinburgh Postnatal Depression Scale (EPDS) to record any measurable change in depressive symptoms after engagement with peer support. This offers a range of data demonstrating that peer support is linked to a reduction in depressive symptoms, including one large scale randomised controlled trial. A Canadian multisite randomised controlled trial (n=701) found that telephone based peer-support provided by trained volunteers soon after the birth was effective at preventing postnatal depression in women identified as high risk (Dennis et al., 2009). This study showed that women who had been supported had significantly lower scores on the EPDS than women in the control group who had not received support.
There is limited evidence of the reduction in depressive symptoms in Scottish research. An evaluation of the Aberlour Perinatal Befriending Service in the Forth Valley and East Lothian area was conducted with the University of Stirling (Cheyne et al., 2016). This was a mixed-method study using the Hospital Anxiety Depression Scale to measure depressive symptoms (n=14). The evaluation found that the outcome measures reflected a trend toward lower levels of anxiety and depression and increased warmth among the supported mothers, however the very low sample size means this data should be interpreted with caution.
Fogarty and Kingswell (2002) reviewed the effectiveness of a programme of telephone-based and face-to-face support in England. The service, 'Pals in Pregnancy' supported vulnerable women via trained, paid peer workers. A significant reduction in EPDS scores was shown in 71% of women who took part, and women expressed that they found the listening skills of the peer workers beneficial. A pilot study in England with 30 mothers supported by untrained volunteer peer support volunteers found a six week programme of support delivered a significant reduction in EPDS scores over a 6 month period (Cust, 2016). In contrast, an evaluation of the impact of peer volunteers in England conducted by Barnes (2009) showed no link between peer support and a reduction in EPDS scores over the first year of the child's life.
Internationally, Prevatt et al. (2018) examined the impact of a peer-led support group in the US, finding that the support of other mothers could help women adapt to their new role and reduce the impact of stigma. The pre-post outcome measures in this study showed a significant reduction in EPDS scores, although participants who had experienced birth complications or an unplanned Caesarean section showed less improvement than those who had not. In the only study identified looking at digital peer support, participants recruited from the US trialled the use of 7 Cups of Tea (7Cups), a digital platform that delivers self-help tools and 24/7 emotional support through trained volunteers (Baumel et al. 2018). 7Cups is an additional treatment for mothers diagnosed with postnatal depression and includes self-help tools and chats with trained volunteers who had experienced a perinatal mood disorder in their past. Participants experienced a significant decrease in scores on the EPDS. The authors suggest that access to a peer support service of this type may be beneficial in improving treatment outcomes for women with perinatal mental health problems and especially those who may find other forms of support inaccessible.
Overall evidence from studies in the UK and North America demonstrates a reduction in scores for women on the Edinburgh Postnatal Depression Scale when they engage with peer support in various forms, online (Baumel et al., 2018) telephone-based (Dennis, 2003) peer support groups (Prevatt et al., 2018) or one-to-one peer support (Fogarty and Kingswell, 2002). This is one of the clearest themes of the literature review.
2.7 Impact of peer support on peer supporters
The NCT's review of the Parents in Mind programme, trialled across 3 sites in England, offers a well-developed logic model, theorising the positive and negative outcomes anticipated for peer volunteers. The model suggests that positive outcomes for peer supporters include increased knowledge, skills and confidence, satisfaction in helping others and increased recognition of their own continuing mental health challenges. Negative outcomes included feeling stress and sadness, feeling unprepared for the role, not feeling able to meet the level of need of the mother, worrying if mothers do not 'get better' and being emotionally triggered by their role to be affected by their own difficult perinatal experiences (MacLeish and Hann, 2019).
The peer reviewed literature reflects these themes, although there is limited literature looking at the experience of peer supporters. Overall evidence suggests that the impact on peer supporters is generally positive. In a Canadian study, Letourneau and Leger (2015) returned mixed results on the efficacy of peer volunteers, but overall suggested that peer support can be rewarding for both those providing support and those receiving support. In Also looking at peer support, but in relation to breastfeeding, Ingram (2013) used an online survey, interviews and focus groups to explore mothers' and professionals' experiences in England. The study found that psycho-social benefits for mothers, peer supporters and health professionals were associated with the provision of the breastfeeding peer support service. Continuity of visits with the same peer supporter from the antenatal to postnatal period was also found to be beneficial.
The urge to help and support other women seems to be the primary motivator for peers. In a study looking at the impact on peer volunteers working on a perinatal mental health helpline in Australia, Biggs et al (2019) found that volunteers in general were very motivated to make a difference and felt a strong desire to help others experiencing emotional distress.
There is also evidence of attitudinal change among peer volunteers over the course of providing peer support. In their qualitative pilot study of a volunteer peer support programme for mothers in England, Carter et al. (2018) found that peer support workers rejected the use of formal counselling approaches in favour of using their own experience and empathy as the basis for their supportive relationship. They found a transformation in the perceptions of peer volunteers, who at the outset of the project expressed a desire to 'help fix' the problems of women they were working with, and by the end of the project had come to see their role as more aligned non-judgemental support, rather than advice.
In addition to these shifts in perspective, studies suggest that peer volunteering can be a pathway into paid work for some women, with paid peer work or therapeutic training being the most common pathways into employment (Barlow and Coe, 2012; MacLeish and Hann, 2019).