The perinatal period, defined as pregnancy through the first year postpartum, often includes dealing with new or exacerbated mental health challenges which can impact both parent and infant health if not treated. Perinatal mental health conditions, such as depression and anxiety, are increasing at alarming rates and are now one of the most common complications of pregnancy [1,2,3,4,5]. The cost of untreated maternal mental health challenges is estimated at over $14 billion annually in the United States [6]. These conditions disproportionately impact populations experiencing other challenges related to community impacts on health, such as lack of insurance and lower socioeconomic and education status [7,8]. In addition, those who are younger (≤24 years of age) and non-White have increased risk and adverse outcomes [8,9,10].

Perinatal mental health conditions have been linked to adverse birth outcomes, including intrauterine growth restriction, preterm birth, low birth weight, and neonatal or infant death [9,11,12,13]. Such conditions can also lead to increased medical expenses, decreased breastfeeding initiation or cessation, and increased risk of child abuse and neglect [12,13,14]. Longer term infant outcomes include impacts to social, emotional, and cognitive development, including elevated reactivity to stress, sleep disturbances, attention-deficit hyperactivity disorder, conduct disorders, and cognitive deficits [15,16,17]. Ineffective parenting due to mental health challenges may result in further negative impacts to infant/child functioning [18].

Despite the growing need, substantial barriers exist to addressing perinatal mental health, including lack of infrastructure, policies, and workforce. To address these barriers, the Taskforce on Maternal Mental Health has recommended innovative approaches to integrate care across medical, community and social systems [5].

Universal screening and access to evidence-based treatment (e.g., cognitive behavioral therapy, medication) are well-identified strategies to reduce perinatal mental health conditions, such as depression and suicide [1,19,20]. While those with perinatal mental health concerns have increased use of both psychiatric and non-psychiatric services, access to services is a treatment barrier, especially for those of lower socioeconomic status [7,21]. Lack of knowledge, cultural complexities, and stigma are also recognized barriers to treatment [22].

Community-based interventions to address perinatal mental health conditions have shown some success. Integration of mental health interventions (e.g., staff training, participant screening, and referral) into perinatal home visitation programs, has reduced depression and anxiety symptoms [1,23]. Further, parenting interventions can reduce perinatal depression, possibly due to enhanced perceived ability to care for the infant [24,25]. Organized peer support has also shown some success in improving wellbeing in the perinatal period [26,27].

In terms of suicide in the perinatal period, few prevention strategies have been described beyond universal screening and access to treatment [20]. Both perinatal women who experienced suicidal thoughts and perinatal mental health professionals recommend developing interventions prioritizing components to (a) support distancing oneself from the appeal of suicide; and, (b) establish positive connections between the birthing person and therapist, baby, and parenthood [28]. Yet there is a paucity of research on interventions to reduce mothers’ suicidal experiences during the perinatal period, especially in resource-poor communities [28].

Baby Talk is a free prenatal education program and part of the statewide Kansas Perinatal Community Collaborative (KPCC) program [29]. It is funded through Title V Aid to Local grants and managed by the University of Kansas School of Medicine (KUSM) Center for Research for Infant Birth and Survival (CRIBS). Labor and delivery nurses teach six 2-hour sessions on topics, including healthy pregnancy, labor and birth, feeding and infant care, and postpartum health. The modes of instruction include didactics, videos, demonstrations, and hands-on activities. Participants who complete all six sessions receive infant safety items, such as a car seat or a portable crib. Classes are available both day and evening, virtual (statewide) and in-person (Sedgwick and Harvey Counties). Baby Talk aims to reduce infant mortality, improve maternal health, and improve birth outcomes. Program participants have shown significant increases in knowledge and intentions related to having a healthy pregnancy and following safe and healthy infant care practices [30]. Participants in KPCC programs, including Baby Talk, have lower preterm birth rates than Kansas overall [31]. The longest-running KPCCs have seen significant reductions in infant mortality [31].

While the Baby Talk curriculum has always addressed perinatal mental health topics, in late 2020 a maternal mental health screening was introduced. The Edinburgh Postpartum Depression Scale (EPDS) is a validated tool for assessing depression and anxiety during the perinatal period and includes an item on suicidal ideation [32]. All Baby Talk staff are trained and authorized to administer the EPDS. The EPDS is administered upon program enrollment (prenatal) and ~6 weeks postpartum; however, completion is optional. Rescreening can be done anytime a concern is expressed by the participant, their support persons or a staff member. Approximately 30% of Baby Talk participants have at least one positive EPDS [33].

For those with a positive screening, Baby Talk staff offer a brief intervention and resources, such as referral, if appropriate. However, while urban areas, such as Sedgwick County, have some perinatal mental health resources available, most counties are designated as both mental health and obstetrical deserts, with 96 of 105 counties designated as mental health shortage areas and 71 of 105 counties considered to have maternity care shortages [34].

In 2015, Wichita State University (WSU) developed the #WSUWeSupportU awareness campaign, which expanded in 2020 to the Suspenders4Hope^R program. Suspenders4Hope^R is a comprehensive, strategic approach to promoting mental health wellness, preventing suicide, substance use, and sexual violence. In 2023, the program began distribution of Hope Kits to individuals who screened positive for suicidal ideation at the WSU Student Wellness Center and the Sedgwick County community crisis center, Comcare [35,36,37]. Hope kits were inspired by the concept of distress tolerance kits, an established practice in Dialectical Behavioral Therapy (DBT) and Cognitive Behavioral Therapy for Suicide (CBT-S), where patients meet regularly with a trained therapist and learn skills to engage in mindfulness, cognitive restructuring, emotion regulation and distress tolerance to reduce suicide behaviors [37,38,39]. Over the course of several weeks, patients work with their therapist to create a personal kit with items to prompt use of the new skills in a crisis and increase hopefulness about the future. The Suspenders4Hope^R program recognized that not all people in crisis have access to mental health professionals and support. When there is access to care, there may be significant wait times before meaningful treatment can begin, and the service providers available may not be trained in evidenced-based treatments for suicide prevention like DBT and CBT-S. This is a rate-limiting factor in reducing suicide and self-harm as the effectiveness of DBT and CBT-S in reducing depression and suicidality is well established [40,41,42]. Therefore, the Hope Kit project was developed to address the gaps in access to care and to connect persons to needed support, skills, resources and services.

Recognizing the need for perinatal mental health resources and the strengths of the evidence-based interventions offered by the Suspenders4Hope^R program, CRIBS staff reached out to WSU to explore the opportunity to partner in the development of a Hope Kit specifically for those in the perinatal period. WSU staff were excited to pursue the opportunity, and a development team was convened. The development team consisted of the following members:

An advisory panel of perinatal mental health experts was convened to provide guidance and review materials for appropriateness and relevance, provide recommendations for improvement, and ensure the kit content prioritized evidence-based information and tools. The advisory panel included a licensed social worker with perinatal mental health certification who was also chair of the Kansas Chapter of Postpartum Support International; the Kansas Department of Health and Environment Behavioral Health Consultant; and a Reproductive Psychiatric Mental Health advance practice registered nurse who was also founder of community-based perinatal mental health program.

The specific purpose of the perinatal focused Kit was to develop a scalable, low-barrier, cost-effective way to provide mental health tools and information to the perinatal population, especially in low resource areas. As such the Growing Hope Kit content was curated to address the following goals and decrease symptoms related to depression, anxiety, substance use and suicidal ideation. Kit goals included:

Previous work by CRIBS identified strategies to reduce barriers to perinatal mental health care as perceived by perinatal persons, physicians and mental health professionals [43]. In addition, review of the literature regarding pertinent topics, such as perinatal mental health, pregnancy-related suicide and infant care provided evidence-based strategies and best practices that informed kit content. For example, qualitative research identified factors believed to trigger or maintain suicidal thoughts and behaviors for birthing persons, including isolation, loss of control, self-perception of being a “bad” parent or unable to meet baby’s needs, and gaps in expectations versus reality of parenthood [25,44,45,46]. Further, interventions to improve the mother/infant interaction improve outcomes for both mother and infant [47]. Strategic efforts were made to address these drivers with inclusion of resources related to parenting (e.g., group prenatal education; one-on-one support through home visiting), many of which also provide tangible supports, such as diapers. Efforts were also made to ensure the kit was adaptive, engaging, universally appealing, appropriate for both prenatal and postpartum periods, and used clear and simple language.

The development team reviewed items from the original Suspenders4Hope^R Kit and determined the Hope box, love letter, coping skills activity page, gun lock and medication lock would be appropriate when updated with perinatal themes (Table 1). In addition, multiple perinatal-themed coloring books were purchased and reviewed for content to identify the most appealing and universally appropriate version to included (e.g., did not reference “husband” as many Baby Talk program participants report being single).

Several items from the original kits were not included. The Suspenders4Hope^R Kit provided a t-shirt in each kit. However, the challenge of sizing during the perinatal period along with the substantial cost of maternity t-shirts, made this both logistically and financially prohibitive. The original kit also included a magnetic lapel pin. The United States Consumer Product Safety Commission has issued numerous warnings and recalls due to the dangers of injury or death in children due to ingesting small magnets [48]. To prevent potential adverse events, this item was not included.

To address other mental health and parenting skills and resources, several new items were developed for inclusion in the Growing Hope Kit:

These initial items were drafted and revised by the development team between February and May 2024.

A protocol approval was not needed by an ethics committee to conduct this project.

Following initial development, the items were sent to the expert panel for review and feedback. After review, all items were retained, but wording and resource links were updated (e.g., resource page, card deck). A book on perinatal mental health was also added to the kit based on expert panel recommendation. Once content was finalized, a WSU graphic designer assisted with branding and designed the new box, letter and card deck.

Once content was finalized, CRIBS prenatal education and home visiting staff reviewed the Kit regarding perceived usefulness and appropriateness for perinatal clients to ensure face validity of materials. Staff were overwhelmingly supportive of the Kit and content with only minor changes suggested.

With the Growing Hope Kit design finalized, next steps involved production, distribution and recipient feedback of the kit. Production began in July 2024, with anticipated distribution beginning in October 2024. For the pilot project, 250 kits were built at a cost of approximately $55 each, with lower costs per kit expected if more kits are created. Shipping was anticipated between $15 and $20 per kit.

Baby Talk participants who screen positive for mental health or substance use concerns, or who disclose a pre-existing mental health condition will receive standard care, but in addition will be offered a Growing Hope Kit. Kits will be distributed in-person (Sedgwick and Harvey Counties) or by mail (virtual participants). Approximately 6 weeks after distribution, an electronic survey will be sent to request participant feedback on the kit. Survey administration will be managed through Research Electronic Data Capture (REDCap) a secure, web-based data capture application hosted at the University of Kansas Medical Center [51,52]. Evaluation will focus on three primary areas: (1) overall look and impression of the kit; (2) use and function of items in the kits; and (3) self-report of mental health symptoms and behavior changes after receiving the kit. It is anticipated that feedback from the end user will result in further modifications to the kit.