Midwife-led Cognitive Behavioral Intervention for Perinatal Depression. Multisite RCT

Effectiveness of Midwife-led Cognitive Behavioral Intervention for Perinatal Depression in Ethiopia: A Multisite Randomized Controlled Trial

Perinatal depression, or depression during pregnancy and within one year following childbirth, is the most burdensome maternal mental illness. Women in low-income countries like Ethiopia have suffered from the disease. PND carries several negative outcomes on women's mental health condition, their household functioning, workplace efficiency, and relationships with their children and families. It also has adverse outcomes on fetal and neonatal health, such as intrauterine fetal growth restriction, increased risk of underweight infants, and child cognitive and developmental delays.

Mothers experiencing PND in Ethiopia remain underserved because stakeholders' primary attention is directed toward other competing maternal concerns such as pregnancy-related hemorrhage or pregnancy-induced hypertension. As a result, depressed perinatal women continue to suffer without adequate recognition or intervention. Furthermore, women with PND in this country face numerous barriers to care; pharmacological treatment is limited due to affordability issues, a shortage of prescribing experts, and accessibility challenges. Thus, to challenge the treatment gap in maternal mental health care for PND, cognitive-behavioral interventions (CBI) may be an alternative that could be delivered by relatively accessible professionals such as midwives. Although midwives offer essential maternal healthcare services, the effectiveness of PND care using CBI stratagies delivered by them remains limited. This approach may help to ensure women with PND receive both maternal and mental healthcare holistically and sustainably.

This study aims to evaluate the effectiveness of midwife-led cognitive-behavioral intervention delivered to women with PND in reducing depression, increasing social support, lowering stress, and measuring progress in cognitive restructuring, behavioral activation, and perceived problem-solving compared to usual care.

The study will be conducted in three hospitals in the South Gondar region, Ethiopia. It will include pregnant women in the third trimester who are experiencing depression, able to hear and speak the local ( Amharic) language, and willing to be part of the study. Women with severe medical conditions that limit their ability to participate in the intervention will not be included.

Participants for the main RCT will be randomized into an intervention and control group in a 1:1 ratio. Participants enrolled in the intervention group will receive cognitive behavioral intervention delivered by trained midwives, and also receive usual maternal care services. The control group will receive usual standardized care. The intervention contains seven sessions that start at 32 weeks of pregnancy and continue after childbirth. The first five sessions will be provided during pregnancy and the remaining two sessions after childbirth. Both antepartum and postpartum sessions will be provided weekly in groups ( 8-10 participants per group), delivered in a face-to-face format, for 45 to 50 min.

The intervention strategies were formulated with the core principle of the cognitive behavioral model, and various strategies were used to contextualize it. The core content of each session was structured as a story-based example to capture and retain participants' attention and enhance clarity. Concepts were articulated using locally familiar and simple colloquial expressions. The behavioral activation techniques frequently practiced by Ethiopian women were incorporated to encourage engagement in routine activities. The intervention will utilize psychoeducation, group-based brainstorming, guided identification of negative thoughts, support to identify cognitive distortions, demonstrate technique to replace them with rational positive thoughts. For behavioral activation, activity scheduling and goal-setting techniques will be used to engage participants in pleasant activities. Additionally, problem-solving will be supported to improve social interaction and enhance parenting practices. Participants' take-home assignments and daily mood follow-up chart will also be used as part of the intervention strategies.

To evaluate the study effect, various outcome measurements will be conducted before the intervention, immediately after the intervention, and three months after the intervention.

Study Overview

• Status: Not yet recruiting
• Conditions: Social Support; Perinatal Depression; Perceived Stress
• Intervention / Treatment: Other: Midwife-led Cognitive Behaviroal Intervention

Detailed Description

The structured approach of cognitive behavioral intervention (CBI) is beneficial in reducing perinatal depression (PND). It empowers women with practical skills to manage stressors beyond the treatment period, foster resilience, and improve coping abilities. CBI increases assertiveness and strengthens relationships, which encourages women to seek support. Its behavioral activation component reduces social withdrawal through promoting engagement in supportive activities such as mother support groups and peer networks. Despite CBI yielding meaningful healthcare benefits and reducing PND, its applicability using non-mental healthcare professionals has not been tested in Ethiopia. Leveraging midwives for delivering CBI may be a strategy to fill the marked mental health care gap. Moreover, midwives are uniquely positioned to deliver CBI interventions for PND due to their accessibility across the maternal health care continuum and their trusted relationships with mothers.

The intervention has a pre-specified session duration and frequency, which may ensure consistency, fidelity, and replicability across providers and settings. It is also expected to enhance adaptability for delivery by non-mental health care professionals, for low-resource settings, where access to specialized mental health services is limited.

• Study Type: Interventional
• Enrollment (Estimated): 192
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Shimeles B. Zewude; Phone Number: +852-57795794; Email: shimeles-biru.zewude@connect.polyu.hk

Study Locations

• Ethiopia
  • South Gondar
    • Debre Tabor, South Gondar, Ethiopia
      • Addis Zemen Hospital
    • Debre Tabor, South Gondar, Ethiopia
      • Debre Tabor specialised hospital
    • Debre Tabor, South Gondar, Ethiopia
      • Wereta Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Women aged 18 or more years.
2. In the third trimester of pregnancy.
3. Speak and read the local language.
4. Women who screen positive for perinatal depression with an EPDS score ≥7.

Exclusion Criteria:

1. Have an EPDS score of ≥ 20.
2. Women with active suicidal ideation.
3. Participants with severe medical or obstetric conditions.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Midwife-led Cognitive Behavioral Intervention	Other: Midwife-led Cognitive Behaviroal Intervention; The intervention contains seven sessions. The first session equips participants with foundational knowledge to recognize the cognitive, emotional, and behavioral symptoms of PND. The second session provides practical guidance to help participants identify and record negative thoughts. The third session demonstrates the technique of replacing negative thoughts with realistic thoughts. Session four involves engagement in a pleasant activity utilizing goal-setting strategies. Session five focuses on challenging parenting problems. Session six demonstrates techniques for identifying and acquiring social support. The final seventh session focuses on relapse prevention and maintaining gains.
No Intervention: Usual care; Participants will receive standard usual care. This standard usual care includes perinatal education on personal health, adequate sleep, nutrition, self-care, and an obstetric complication readiness plan. Advice on where and how to get support in case of an adverse event or emergency.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in perinatal depression	Perinatal depression (PND) is the primary outcome of the study, which is measured using the Edinburgh Postnatal Depression Scale (EPDS). Participants will rate their experiences using a 10-item EPDS tool, with each item scored on a 4-point Likert scale between 0 and 3. The total score ranges from 0 to 30, with higher scores indicating more depressive symptoms.	At three time points; Baseline outcome assessment (T0), immediately postintervention (T1), and three months following the intervention.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in perceived social support	Perceived social support will be evaluated using the short form of the Social Support Questionnaire (SSQ). Respondents rate the six-item SSQ using a 6-point Likert scale from 0 (not at all) to 5 (always).	At three time points; Baseline outcome assessment (T0), immediately postintervention (T1), and three months following the intervention.
Change in Perceived Stress Level	The Perceived Stress measurement includes 10 items that evaluate participants' stress experiences over the past month. Each item is rated on a 5-point Likert scale ranging from 0 (never) to 4 (very often), and the total score ranges from 0 to 40, with higher scores indicating greater perceived stress.	At three time points; Baseline outcome assessment (T0), immediately postintervention (T1), and three months following the intervention.
Change in cognitive condition	The Automatic Thoughts Questionnaire-8 (ATQ-8) is a psychological tool used to measure change in cognitive functioning following Cognitive Behavioral Intervention (CBI). It contains 8 questions that check the frequency of negative thoughts that crossed participants' minds during the past week. The scale is a 5-point Likert scale from not at all (1) to 5 all the time (5), and as the score increases, the frequency of negative thought patterns increases.	At two time points: Baseline assessment (T0) and three months following the intervention.
Change in behavioral activation status	Behavioral Activation for depression scale-short form (BADS-SF) will be used to measure behavioral change in participant activities. The scale uses a 7-point Likert scale ranging from "0-not at all to 6 completely". A higher total score indicates greater behavioral activation.	At two time points: Baseline assessment (T0), and three month following the intervention.
Change in Perceived Problem-solving	The Negative Problem Orientation Questionnaire (NPOQ) is a 12-item instrument that assesses participants' cognitive set on their problem-solving abilities. The participant rates each item using a 5-point Likert scale. A higher score indicates doubt about the ability to cope and less cognitive set for challenging problems.	At two time points: Baseline assessment (T0), and three month following the intervention.

Collaborators and Investigators

• Sponsor: The Hong Kong Polytechnic University

Study record dates

Study Major Dates

• Study Start (Estimated): September 15, 2026
• Primary Completion (Estimated): April 17, 2027
• Study Completion (Estimated): May 17, 2027

Study Registration Dates

• First Submitted: August 29, 2026
• First Submitted That Met QC Criteria: August 29, 2026
• First Posted (Actual): September 2, 2026

Study Record Updates

• Last Update Posted (Actual): September 2, 2026
• Last Update Submitted That Met QC Criteria: August 29, 2026
• Last Verified: August 1, 2026

More Information

Terms related to this study

• Keywords: Ethiopia; Perinatal depression; Social support; stress level; Maternal mental health; Cognitive Behaviroal Intervention
• Other Study ID Numbers: HSEARS20260512003

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: To safeguard participants' confidentiality and protect privacy, I chose not to share participants' data.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No