The perinatal period is challenging for parents, and the changes and demands encountered during this life transition can seriously impair parents’ well-being. The impact of these challenges is well-recognized in mothers with postpartum depression rates of approximately 20% in Australian women [1]. Most new mothers (50-80%) experience some distress [2]. A meta-analysis of fathers’ postpartum mental health found comparable rates of depression (10%) [3], with Australian figures reporting the rate at approximately 5% [4,5]. Initiatives by beyondblue and the Federal Government have increased perinatal depression screening and intervention rates in Australia. However, screening and preventive programs for perinatal depression have not been universally available [6], and have been almost non-existent for fathers, despite the potential suitability of the Edinburgh Postnatal Depression Scale (EPDS) for fathers [7]. Lack of availability of these father-specific programs is a reflection of both supply (eg, a focus on mothers, service capacity, and staff adherence) and demand issues (eg, reluctance to disclose symptoms and receive treatment) [8]. An accessible perinatal well-being intervention designed for both mothers and fathers is the target of this trial.

Postpartum distress has significant and wide-ranging consequences. In mothers, postpartum distress affects attachment [9], child development [10], and academic achievement [11]. Some effects can be long-lasting, including increased risks of later childhood behavioral problems [12] and subsequent episodes of parental depression [13]. More recently the negative effects of paternal postpartum distress have been reported, including its association with emotional difficulties in children [14], the impact on marital relationships and family well-being [15], and the detrimental effect on the mother’s relationship with her child [16].

In addition to significant costs to family well-being, perinatal distress has high economic costs. The annual health costs associated with perinatal depression and anxiety could be up to AUD $70 million in new mothers and AUD $16 million in new fathers, if their baby was delivered in 2012 [17]. The cost of psychological distress in otherwise healthy adults is substantial. For example, lost productivity cost Australian employers AUD $5.9 billion in 2009; productivity losses for each treatment seeker were AUD $19,810 for men and AUD $9183 for women [18]. The cost from one year’s lost productivity for untreated maternal depression is AUD $142 million [17].

Many mothers prefer psychosocial treatments during the postpartum period, especially while breastfeeding [19]. Rapid acting, easily communicated treatments for depression in other contexts involve behavioral activation [20], physical activity [21], problem solving [22], parenting skills and self-efficacy [23-25], social support networks [24,26], and meditation mindfulness [27]. Treatment with a mental health professional is not easily accessible for non-urban populations, creating a barrier for treatment [28].

There is growing evidence, however, that interventions may not always require substantial clinician involvement to reduce distress. A single face-to-face psychoeducational session with a maternal and child health nurse was found to reduce depression and anxiety in women without psychiatric histories [23]. Another study found no difference in clinical outcomes between a psychoeducational booklet and group cognitive behavior therapy (CBT) in primary care [29]. In the second study, however, 60% of eligible women turned down group CBT, highlighting that traditional interventions may not match the needs of new parents. Adherence to treatment appeared especially low when symptoms were mild, women had competing commitments, or motivation was limited. Women also cited time, childcare, and transportation as further barriers to engagement.

Online interventions may overcome these uptake barriers, as the Internet is a highly accessible and cost-effective vehicle for the delivery of flexible and sustainable support. In 2012-2013, 83% of Australian households had Internet access [30], and 89% had a mobile phone with Internet access [31], indicating that electronic interventions are available to most Australians. Internet-based interventions have well-established efficacy for alleviating depression and anxiety, and for promoting well-being [32]. Clinical gains approximate those from face-to-face treatment, especially when dealing with low-severity problems [33]. In addition, stigma is avoided and location inequities are minimized.

The Internet has already proven feasible for screening postpartum depression in mothers [34]. Furthermore, randomized controlled trials (RCTs) for two online postpartum depression treatment programs found decreases in postpartum depression at 12 weeks [35] and 17 weeks [36] respectively, as compared to conventional treatment. Online treatment for postpartum depression shows promise, and may address the substantial economic, community, and family impact of perinatal distress. Development of programs that promote the maintenance and enhancement of perinatal mental well-being should be a priority.

The perinatal period is a time of transition [37], offering a window of opportunity when timely introduction of tools and information could positively influence later outcomes [38]. For example, a study investigating the well-being of 5000 mothers found that positive maternal outcomes after birth are influenced by mental and physical well-being during the perinatal period [38]. Perinatal well-being is a complicated construct determined by an individual’s perception and evaluation of their life during the perinatal period [37]. If expectant and new parents were offered tools to support and enhance well-being throughout this process, both maternal [39] and paternal [40] outcomes could be improved . However, few universal strategies for preventing perinatal distress and enhancing well-being have been evaluated in rigorous, large-scale studies [37].

Online programs targeting prevention of postpartum depression are in their infancy. A fully-automated program developed for pregnant women presented psychological strategies across 44 short sessions [41]. Information in this program was presented on a schedule, and this lack of flexibility may be a deterrent for some mothers. An RCT testing the effectiveness of this program is currently underway [42]. A second online prevention program has been evaluated in a pilot trial, but the study found no differences in effectiveness between the online program and the information-only control condition [43]. A limitation of this study was the minimal program use by participants, suggesting that email or text message reminders could be used to increase retention and use of the program. Furthermore, the intervention was linear in design, meaning that if earlier program material was not of significant interest to participants, program use would discontinue.

Although some programs addressing the prevention of postpartum depression in women have succeeded in engaging fathers [23,44,45], fathers’ mental health and well-being has not been specifically targeted. Fathers are offered little support in the way of treatment or prevention of perinatal distress. Syntheses of studies investigating men’s experiences ante- and postnatally found that fathers felt overlooked in antenatal classes [46], and excluded and unsupported by maternity services in general [47]. Despite this limitation, fathers reported a desire to be actively involved in this life experience, and to be supportive of their partners [48], indicating that an opportunity to involve invested fathers is being missed. Based on qualitative interviews with new fathers, Kowlessar et al recommend that men are actively engaged, informed, and offered support [48], and that the presentation of psychoeducation material and well-being tips may help fathers feel more involved and valued during this life stage [40]. More research is required, and high quality RCTs of interventions that promote psychological well-being in both mothers and fathers are needed [49].

To date, no study has trialed a web-based intervention targeting perinatal well-being in both mothers and fathers, nor has a related cost-effectiveness analysis been conducted. This proposed study addresses these gaps, and constitutes one of few trials that focus on well-being and universal prevention, rather than the treatment of established depression. Due to this novelty, our results are likely to have wide application. Electronic programs have the potential to alleviate maternal and paternal distress, and help recent parents enjoy the enriching and exciting experience of early parenthood by increasing access to effective support at minimal cost. By addressing parents’ well-being and supporting childcare, participants may also assist in promoting positive parenting, offering potentially long-range benefits for this and future generations of Australian children.

Participant recruitment commenced March, 2015 and continued until October, 2015. Follow-up data collection has commenced and will be completed May, 2016 with results expected in July, 2016.

Depression and distress have substantial impacts on new parents and their babies, with potential to affect later adjustment, relationships, and child development [11-16]. The economic impacts of such depression are also large [17,18]. The perinatal period is an opportunity to engage expectant parents in well-being-based programs, which is particularly important given that better well-being during this phase is associated with positive postpartum outcomes [38]. Although mothers are often the focus of support and interventions during the perinatal phase, fathers also experience perinatal distress, but have received little research attention or support from services, despite a desire to be involved during the perinatal period [45]. Internet interventions offer a flexible, accessible, cost-effective solution for enhancing perinatal well-being in mothers and fathers.

The current research addresses several issues. This project has developed an innovative program with a unique combination of modules, based on several related programs designed by the authors. Baby Steps screens for distress and depression, provides childcare resources and interactive tools, and addresses emotional and physical well-being of both fathers and mothers. Key foci are self-selected childcare issues and maintaining pleasurable physical and social activity. Personal tailoring, after-hours availability, rural accessibility, and low cost per user allow the platform to be easily disseminated to large numbers of people across Australia. This study conducts the first perinatal trial to differentiate component effects from a combined intervention of this type, examining distress, functioning, and childcare confidence, and is the first to compare cost-effectiveness of such interventions. As such, this project helps to facilitate the translation of research into policy and practice at state and national levels. Baby Steps is one of few trials that focuses on well-being and prevention rather than established depression (thereby having wide applicability), and is also one of the few trials to focus on the well-being of new fathers.

This project has the potential to influence standard services to support parents, thereby increasing their effectiveness, with minimal increases in cost. Baby Steps offers a strategy to engage and support fathers, improving their own outcomes as well as their support of mothers, and potentially preventing losses in work time and productivity associated with depression. In concert with other strategies to address the causes of depression and anxiety, this project assists in promoting the long-term emotional and physical health and well-being of Australian children and their families.