Georgia and Great Plains Tribal Leaders Health Board

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Georgia and Great Plains Tribal Leaders Health Board Strategies
Supports for Parent Mental Health in Home Visiting: Mothers and Babies

Mothers and Babies (MB) is an evidence-based intervention to prevent onset of major depression and reduce depressive symptoms in pregnant and parenting people. Based on cognitive behavioral therapy and attachment theory, MB uses a psychoeducational approach to help parents learn to use coping strategies. These include methods for monitoring their moods and managing stress with a focus on pleasant activities, thoughts, and social supports. MB is delivered in-person or virtually, either one-on-one (for nine sessions of 20-25 minutes) or in groups (for six sessions of 90-120 minutes).

This profile provides an overview of MB and then examines how MB is implemented statewide in Georgia’s home visiting programs and in tribal communities in North and South Dakota served by Great Plains Tribal Leaders Health Board home visiting programs.

Service providers in 33 states have been trained on MB, with home visiting being one of the main settings in which implementation occurs. Home visiting models that have incorporated MB include Family Spirit, Healthy Families America (HFA), Nurse-Family Partnership (NFP), and Parents as Teachers (PAT). MB is developing materials to show how the intervention maps onto model-specific standards for HFA and PAT.

MB can be delivered based on results of maternal depression screening or universally as a stress management program. Often, home visiting programs begin offering targeted MB and then expand to universal delivery after a year of implementation. Home visiting programs vary in the way they deliver MB; some integrate MB content into regular home visiting sessions, others reserve the last 25 minutes of a session for MB, and some alternate between MB and home visiting sessions. MB counts as a completed referral for a positive maternal depression screen for the purposes of Maternal, Infant, and Early Childhood Home Visiting (MIECHV) benchmarks. While some mothers may still need referrals to additional mental health care beyond what MB can provide, it serves as an important support, especially in areas where there are barriers to accessing this care, including a shortage of clinicians who can address maternal depression.

MB offers a range of training pathways that differ for individual service providers, individual agencies or organizations, or statewide networks. Those interested in being trained complete an initial readiness survey, which is followed by a conversation between MB national office team members and program leads to help to gauge existing staff knowledge and comfort with perinatal and infant mental health, existing resources in the community and an understanding of organizational structure; as a result, supplemental technical assistance covering trauma-informed care or an introduction to infant mental health can be added as needed. Training participants complete a 75-minute self-led module that provides an overview of MB followed by two half days of live virtual training. An additional “train-the-trainer” session is available for those who are interested and is critical for sustaining MB since home visiting programs often have high rates of staff turnover. MB offers monthly consultation to all training participants for the first year to support implementation. MB also provides access to an online library of implementation resources, such as tips on how to introduce MB, which can help home visitors bring up sensitive topics related to mental health and depression with parents.

MB aims to be responsive to the needs of diverse families. Materials for implementing MB are available in various languages including English, Spanish, Haitian Creole, and Arabic. Home visiting programs are encouraged to adapt MB for the particular populations they serve, and MB offers guidance on allowable adaptations that maintain fidelity to the model.

MB has undertaken work to adapt its manuals and guides for work with indigenous communities, fathers, and LGBTQ families. The impetus for this work has come through feedback from families and providers about the need to adapt MB to be inclusive of all types of parents and families. MB conducts extensive outreach to stakeholders, including families and service providers, to contribute to these adaptations.

Over the course of a year, MB worked on an adaptation with maternal and child health providers representing the Great Plains Tribal Leaders’ Health Board (GPTLHB), which serves 18 tribal communities, and a Lakota cultural consultant. (See the section below on MB in GPTLHB home visiting for more information on this adaptation.)

While there is increasing recognition of the importance of addressing the mental health of fathers, including during the perinatal period, few interventions developed for perinatal fathers focus directly on addressing paternal mental health. To fill this gap, MB developed the Fathers and Babies intervention, an in-person or text message-based adaptation for fathers that can be delivered in conjunction with MB or as a stand-alone intervention. Following a pilot of Fathers and Babies conducted with 30 mother-father dyads, some of the fathers participated in refining and finalizing the adaptation (for more information see: Examining the Effectiveness of the Fathers and Babies Intervention: A Pilot Study and The Development and Pilot of a Technology-Based Intervention in the United States for Father’s Mental Health in the Perinatal Period). MB is currently developing trainings for Fathers and Babies.

Parents and Babies aims to support communities underserved by or served outside of home visiting programs, primarily LGBTQ families, including nonbinary and trans parents, well as families with experiences of adoption and assistive reproductive technologies. The Parent and Babies adaption is currently being developed with a team of content experts and LGBTQ families. This work has also involved identifying implementation partners and spaces where these families typically access care (e.g., doulas and Postpartum Support International, which offers support for queer and trans families).

Financing

The cost of MB consists of the training itself, as well as technical assistance and evaluation. Home visiting programs have used staff training and development funds from MIECHV, as well as federal American Rescue Plan Act funds. Smaller organizations often use philanthropic grants. Manuals are available to download at no cost to on the MB website.

Because home visitors can implement MB within their models without affecting caseloads or fidelity, MB does not add to home visiting program costs, other than for minor expenses (e.g., printing, and child care, refreshments, transportation for group participants). For Medicaid-eligible fee-for-service providers, MB can be billed under counseling codes.

Evaluation and Monitoring

MB works with programs to develop an evaluation plan and use evaluation findings to refine and improve MB implementation. At each site, service providers or supervisors trained on MB complete an annual implementation survey, administered by the MB team. Sites also collect client-level data on outcomes, including parent depression, anxiety, and stress, parenting behavior, and child social-emotional development (see examples of measures here), and share deidentified data with MB.

MB has been the subject of extensive research (see here for more information). Six randomized controlled trials have shown that MB reduces maternal depression, anxiety, and stress; increases maternal social supports and coping skills; and prevents onset of major depression. MB also improves child outcomes, including levels of stress hormones, and supports positive parenting.

A survey of home visitors implementing MB found that more than 90 percent reported significant increases in their ability to engage in discussions of sensitive family issues and depression, and to recognize depressive signs and symptoms. More than 60 percent reported that MB training significantly improved their skills and confidence in addressing mental health issues.

MB is planning to conduct ongoing evaluations of its adaptations for Indigenous communities, fathers, and LGBTQ families that will be tailored to meet the specific needs of these participant populations.

Great Plains Tribal Leaders Health Board

The Great Plains Tribal Leaders Health Board (GPTLHB) serves 18 tribes in four states (Iowa, Nebraska, North Dakota, and South Dakota). Through its Maternal and Child Health Department, GPTLHB offers home visiting using Family Spirit, an evidence-based, culturally tailored home visiting model for American Indian families, to a number of tribal communities in North and South Dakota. These include:

  • A Tribal-MIECHV grant serving Sisseton Wahpeton Oyate (SWO)
  • Home visiting that is part of an Indigenous LAUNCH grant serving the Rosebud Sioux Tribe
  • Home visiting within Healthy Start, a federally-funded initiative to reduce infant and maternal mortality serving the Cheyenne River City Tribe, Crow Creek Sioux Tribe, Rapid City, Oglala Lakota Nation, Standing Rock Sioux Tribe, Sisseton Wahpeton Oyate, and Turtle Mountain Band of Chippewa Indians;
  • In partnership with in Indigenous LAUNCH grant serving Sisseton Wahpeton Oyate (SWO).

Leaders from these home visiting programs attended a MB training in 2020 and all agreed that MB, and its cognitive behavioral therapy-oriented approach, would benefit the families they serve. They also recognized the need to adapt it for tribal communities and reached out to MB about developing a version for Lakota families. This collaboration resulted in the adaptation of the facilitator and parent manuals for Lakota language and culture, including visual depictions, other design elements, and cultural and spiritually grounded content incorporating the Lakota worldview. Guided by a tribal elder with years of experience in the mental health field, much of the group’s work focused on integrating Lakota values into MB and ensuring activities would be more relatable for native parents.

The report, Cultural Adaptation of the Mothers and Babies Intervention for Use in Tribal Communities, provides details about the adaptation and offers examples of how Lakota values are woven into the model’s content, for instance: “In the first MB session, as participants are introduced to stressors that can affect the mother–baby relationship, they are also introduced to the Lakota worldview of governance of self, family, and community referred to as Woop’e Sakowin (Seven Sacred Laws)—compassion, generosity, humility, fortitude, respect and honor, bravery, and wisdom.” An artist incorporated Lakota colors, all of which have specific meanings, into the MB materials, as well as depictions of people with a more Native appearance.

The Lakota version of MB was subsequently translated into Dakota for use with Dakota-speaking families through the efforts of the SWO ILAUNCH program. The Healthy Start community health worker serving the Turtle Mountain Band of Chippewa Indians currently adapts the Lakota version for use with families there.

MB works well as a supplement to Family Spirit since MB’s activities are more centered on the mother and delve deeper into tools for self-care and addressing anxiety and depressive symptoms. MB also helps to fill a gap in the broader need for curricula and interventions for Native families that focus on mental health, especially given the scarcity of mental health services in communities served by GPTLHB. The process of adapting MB into Lakota and Dakota produced a sense of ownership among home visitors and program leaders that strengthened their commitment to implementing and supporting MB.

MB has proven extremely popular with the home visitors who have been trained on it; they report that its tools are helpful and easy to use, and that they benefit from using MB in their own lives. They initially implemented it with women during the perinatal period, but quickly saw the value in using it with women who have children up to age five. Likewise, home visitors now offer it to all women, not just those with elevated depression screens, especially because stigma around discussing mental health means screening tools often fail to reliably identify those who would most benefit from MB.

Mothers have responded positively to MB; for example, home visitors report some have continued to use the mood journals that are part of the MB program after its completion. The mood journals also provide openings for home visitors to discuss and work with mothers on the challenges they are facing.

After initial weekly visits, FS moves to biweekly, then monthly, and finally bimonthly visits, allowing home visitors to deliver the nine-week MB program to families they serve without difficulty. Some home visitors offer MB starting at program enrollment while others introduce it after visits are biweekly (after the child is three months). For home visitors who include MB content in FS visits, they work with the family to decide whether to focus on MB or FS in a given session. The flexibility of MB allows home visitors to deliver specific sections of content to address a family’s particular needs during a visit and to revisit sections, which is particularly helpful for families who may only be meeting intermittently with a home visitor.

Workforce Development

Program managers with GPTLHB, including those with the Tribal MIECHV and both Indigenous LAUNCH programs, received MB train-the-trainer training and now conduct the initial training on MB with newly hired home visitors. Each home visitor has both weekly individual and program-specific (e.g., Healthy Start, Tribal MIECHV, Indigenous LAUNCH) reflective supervision sessions, where they can discuss cases, including the use of MB. One of the Indigenous LAUNCH grantees, Sisseton Wahpeton Oyate, has a mental health consultant who offers reflective consultation sessions with SWO Indigenous LAUNCH and GPTLHB Tribal MIECHV home visitors. All home visitors with GPTLHB meet together for group monthly training sessions, which can cover topics specific to MB, such as stressors (e.g., money problems, problems with breast feeding, health problems, lack of support), caregivers’ strengths, MB activities (e.g., keeping a mood scale journal, meditation, mindfulness and breathing exercises, and finding pleasant activities). MB program developers also offer quarterly consultation sessions with home visitors, where they report on their experiences with MB, ask questions, and spend time reflecting on cases.

Financing

The MB model developers provided funding for the MB training within GPTLHB, train-the-trainer training, and consultation sessions. The only additional costs to programs are for printing the facilitator and participant manuals, which MB model developers have also been able to cover at times.

Evaluation and Monitoring

Tribal MIECHV grantees are required to conduct an evaluation, which in this case is focused on parenting stress and aligns well with grantee’s use of MB. Data will be collected through surveys of home visitors and parents, and include the Parenting Stress Index-Short Form, as well as from parent focus groups. SWO ILAUNCH’s evaluator has developed a survey for participants who complete MB that asks about activities and practices covered by MB lessons (e.g., overcome obstacles to doing activities I enjoy, practice being calm through mindfulness activities). SWO ILAUNCH has shared the survey with the Tribal MIECHV program, which will also use it with parents who complete MB.

Georgia

The Georgia Home Visiting Program (GHVP) was established to strengthen Georgia’s capacity for addressing the overall health, safety and wellbeing of families and children through the implementation of Evidence-Based Home Visiting (EBHV) services and the enhanced coordination of services for at-risk families experiencing adversities. The program is supported by a state-level infrastructure that strengthens home visiting implementation and evaluation through the provision of technical assistance and trainings as well as the collection of data for performance monitoring and continuous quality improvement over time.

GHVP is managed by the Georgia Department of Public Health and provides home visiting services to eligible families who reside in at-risk communities. These families and represent priority populations in Georgia counties that are served by approximately 20 Local Implementing Agencies (LIAs). The home visiting models implemented are HFA, PAT and NFP.

The Georgia Department of Public Health contracts with the Center for Family Research at the University of Georgia to provide support to Georgia’s Home Visiting programs. The Technical Assistance and Quality Team (TAQ) provides technical assistance, training, data system maintenance, performance monitoring, continuous quality improvement and evaluation support.

In 2017, MB was first introduced to the Georgia Home Visiting Programs by a Healthy Families Georgia (HFG) program participating in the MIECHV Collaborative Improvement and Innovation Network (CoIIN) 1.0, which had focused on maternal depression as its continuous quality improvement goal. After seeing gains in maternal depression-related outcomes in the county where the program operates, the HFG network supported scaling of MB to its affiliates through additional trainings, including a two-day, in-person MB training for their 60-plus home visiting staff and supervisors. Further scaling took place in August 2020 for HFG and PAT programs through a three-day virtual training, which also included train-the-trainer trainings for members of the state-level TAQ team and representatives from local home visiting programs. Beginning in 2022, the TAQ team has provided MB trainings home visiting programs that had not participated in the previous trainings. At home visiting programs with staff who had participated in train-the-trainer trainings, new staff now receive their MB training from these in-house trainers.

Currently, all MIECHV funded Home Visiting programs have received training on MB. The majority of HV programs target their use of MB to families with an elevated maternal depression screen and offer it one-on-one during home visits, though some are exploring group delivery. Some programs are piloting universal MB because they see the value of offering MB to all families, though they are working to ensure that MB aligns with families’ goals and needs. Programs have found success with MB, particularly among families who were less inclined to accept referrals to external mental health services, in places with fewer mental health services available, and in Spanish-speaking communities with fewer available bilingual mental health service providers. One recently trained program serving refugee families anticipates finding MB helpful because of barriers to accessing mental health services, including language differences and and stigma related to discussing mental health, a stigma that is present across communities served by Georgia home visiting programs implementing MB.

Workforce Development

MB training for home visitors is currently offered through on-demand online modules, which participants can take at their convenience. These modules are supplemented by a one-hour live in-person or online training on how to implement MB in the context of Georgia Home Visiting Programs, which covers when and to whom MB should be offered, what MB looks like in practice, and required documentation. This training can be delivered by in-house trainers for home visiting programs with that capacity or by members of the TAQ team.

The TAQ team continues to explore systems-level supports for incorporating MB into programs at the local level. Following each training cycle, participants have been offered a six-month community of practice, which is currently led by the CQI State Lead. Participants meet monthly to discuss successes and challenges in implementing MB and share resources and experiences. The aim of these supports is to encourage home visitors to start using MB right away, even to test it with each other, so they can increase their comfort with using it and build it into their work as a matter of routine.

Additionally, home visiting programs in Georgia hold regular one-on-one and group reflective supervision sessions, where home visitors can discuss strategies for supporting their families, including the use of MB. Supporting home visitors using MB during this regular reflective supervision is important for incorporating it into existing practice.

Based on feedback from supervisors, the CQI State Lead is planning an annual meeting for program-level supervisors on supporting MB’s use by home visitors and is developing FAQs and other resource documents for them. The TAQ team also plans to solicit feedback from home visitors and programs on how they are adapting MB and the model’s materials to meet individual families’ needs, and what they are finding successful.

Financing

The federal Maternal, Infant, Early Childhood Home Visiting (MIECHV) program is the primary funding stream for home visiting; other funding streams for home visiting include Title V, Child Abuse and Neglect Prevention (CANP), and state dollars. The MB trainings were made possible by the Georgia Department of Public Health through MIECHV funding. This includes access to the MB training modules, as well as staff time for the TAQ team and at local programs to support implementation, such as through the Georgia-specific implementation training and the community of practice. Sites covered the minimal costs of printing facilitator and participant handbooks and worksheets.

Evaluation and Monitoring

An implementation evaluation conducted by Northwestern University covering August 2020-September 2021 included a survey of home visitors and supervisory staff. The survey found approximately two-thirds of respondents were very satisfied with MB and nearly two-thirds felt fairly or very strongly that being trained on MB improved their ability and skills to address mental health issues with clients. Additionally, there was a significant drop in depressive symptoms among MB recipients based on pre-post scores on the Edinburgh Postnatal Depression Scale.

Since the formal evaluation, the TAQ team continues to monitor a number of implementation metrics and outcomes, including number participants who begin to receive MB services.

Through the MIECHV Collaborative Improvement and Innovation Network (CoIIN) 2.0, participating home visiting programs are collecting data to examine the reduction of depressive symptoms among participants with elevated depression screening scores who received MB and were not already receiving other mental health services.

Using MIECHV funds, Georgia is beginning a coordinated state evaluation of its home visiting program with a focus on maternal health, one of four priority topic areas identified by the federal Health Resources and Services Administration (HRSA). Georgia is part of a peer network of MIECHV awardees from other states that also selected maternal health, and network members have decided to focus specifically on caregiver depression. Georgia expects to examine MB implementation in greater depth as part of this evaluation.

Special thanks to the following individuals for providing information for and reviewing this profile: Emma Gier, Jaime Hamil, Jessica Ogwumike, Darius Tandon, and Erin Ward at Northwestern University Mothers and Babies Program; Kate Teague and Paige Ferrell, University of Georgia, Center for Family Research; Nora Boesem; Terri Rattler, Great Plains Tribal-MIECHV Program Manager; April Eastman, Indigenous LAUNCH Sisseton Wahpeton Oyate, Project Director; Dawn Nixon, Licensed Psychologist, IECMH consultant.

Last updated June 2022