key: cord-1028155-1ibc791z
authors: Dol, J.; Aston, M.; Grant, A.; McMillan, D.; Tomblin Murphy, G.; Campbell-Yeo, M.
title: Implementing Essential Coaching for Every Mother during COVID-19: A Pilot Pre-Post Intervention Study
date: 2021-01-15
journal: nan
DOI: 10.1101/2021.01.13.21249598
sha: 93c5d92345eac4c2511fbe725e16e63c2e6783c8
doc_id: 1028155
cord_uid: 1ibc791z

OBJECTIVES: The primary objective was to evaluate the preliminary impact of Essential Coaching for Every Mother on self-efficacy, social support, postpartum anxiety and postpartum depression. The second objective was to explore the acceptability of the Essential Coaching for Every Mother program provided during the COVID-19 pandemic. METHODS: A prospective pre-post study was conducted with first time mothers in Nova Scotia, Canada between July 15th and September 19th, 2020. Participants completed a self-report survey at enrolment (after birth) and six-weeks postpartum. Variety of standardized measures were used and qualitative feedback on the program was also collected. Paired t-tests were carried out to determine changes from baseline to follow-up on psychosocial outcomes and qualitative feedback was analysed through thematic analysis. RESULTS: A total of 88 women enrolled. Self-efficacy increased between baseline (B) and follow-up (F) (B:33.33; F:37.11, p=0.000) while anxiety (STAI) declined (B:38.49; F:34.79; p=0.004). No other significant changes were found. In terms of acceptability, 89% of participants felt that the number of messages were just right, 84.5% felt the messages contained all the information they needed relative to caring for a newborn and 98.8% indicated they would recommend this program to other new mothers. CONCLUSION: Essential Coaching for Every Mother may play a role increasing maternal self-efficacy and decreasing anxiety, although future work with a control group is important to delineate the true effects of the program. Overall, mothers were satisfied with the Essential Coaching for Every Mother program and would recommend it for other mothers, during COVID-19 and beyond.

In the postpartum period, women face challenges in the ability to access information and find adequate support (Chalmers et al., 2008) , which has only been magnified during the COVID-19 pandemic (Chivers et al., 2020) . In March 2020, all public health drop-in classes were closed indefinitely in Nova Scotia and public health visits turned virtual (Nova Scotia Health Authority, 2020) . This contrasted pre-pandemic support options of visits with family and friends or attending new parent groups (Aston et al., 2018; Johnson, 2015) and in-person public health nurse visits (Reproductive Care Program of Nova Scotia, 2002) . Not surprisingly, studies have found that has resulted in a significant increase in rates of postpartum depression and perinatal anxiety (Davenport et al., 2020; Lebel et al., 2020) . High levels of social and family support are associated with greater maternal self-efficacy in first time mothers (Esmaelzadeh Saeieh et al., 2017) , yet this support may be lack during the pandemic due to physical distancing recommendations, potentially leading to low maternal selfefficacy. Innovative solutions to bridge the postpartum care gap, such as mobile health (mHealth), are more important than ever.

One such innovation is Essential Coaching for Every Mother, a mobile health, text message program designed to send daily text messages to mothers during the immediate six-week postpartum period (Dol et al., 2020b) . Essential Coaching for Every Mother was designed prior to COVID-19 but had not yet been evaluated. With the outbreak of COVID-19 and the ability for the program to fill the sudden gap in postpartum education and support, a decision was made to modify the program to contain COVID-19 relevant messages and to be offered immediately with a pre-post . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 study design. Details on the modification are reported elsewhere (forthcoming) but briefly, nine messages were modified from the original program to include information related to COVID-19 (e.g., changes in availability of postnatal support due to COVID-19 restrictions), and five new messages were added to the program (e.g., breastfeeding safety), with a total of 56 messages in the program. Feedback on the modifications was obtained from three mothers and seven healthcare providers who participated in the original development and thus were knowledgeable of the program (Dol et al., 2020b) .

The primary objective of the current study was to evaluate the preliminary impact of Essential Coaching for Every Mother on maternal self-efficacy, social support, postpartum anxiety and postpartum depression. The second objective was to explore the acceptability of the Essential Coaching for Every Mother program provided during COVID-19.

At IWK Health, approximately 169 primiparous women give birth each month (Reproductive Care Program of Nova Scotia, 2020). As this was part of a feasibility study, no power calculations were conducted. Instead, the target was to recruit 15% of primiparous women who gave birth over a three-month period (n=75 from an estimate of 500 expected births). First time mothers were targeted to minimize the confounding factor of parity (Figueiredo & Conde, 2011; Gameiro et al., 2009) .

To participate, women must (1) have given birth to their first baby at IWK Health and live in Nova Scotia; (2) have daily access to a mobile phone with SMS capabilities; (3) be over 18 years of age; and (4) speak and read English. Women were excluded if (1) it was not their first baby; (2) they did not live in Nova Scotia and/or deliver at IWK health; and (3) if their baby was over 21 days old at time of recruitment.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 No exclusions were made for mothers of infants who required care in a neonatal intensive care unit or if their infant had any major abnormalities.

This was a prospective pre-post study to pilot the Essential Coaching for Every Mother program with first time mothers in Nova Scotia Canada between July 15th and September 19th, 2020. Self-report data was collected at enrolment and after the intervention (six-weeks postpartum). Ethics approval was obtained by IWK Health (REB #1024984).

The recruitment process was reported elsewhere (forthcoming). Briefly, women were recruited primarily via social media, news media, and study posters in the hospital and could indicate interest in participating between 37 weeks' gestation and delivery (considered antenatal recruitment) or could enrol after they gave birth up to three weeks postpartum (considered postpartum recruitment). Once a women enrolled and gave birth, she started receiving Essential Coaching for Every Mother messages based on her delivery date. Women could enrol immediately after birth and up to three weeks postpartum with messages designed to start the evening of the second day after birth.

Surveys were collected at two time points -enrolment (shortly after birth) and after the program was completed (six-weeks postpartum). Participants were reminded a maximum of six times via text (every other day) and once via email up to 14 days post enrolment or until surveys were completed. At that time, incomplete surveys were considered loss to follow-up. Women were able to message "STOP" to withdraw from the study at any time at which point they stopped receiving messages and were no longer asked to complete surveys.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10. 1101 /2021 Essential Coaching for Every Mother is a six-week postpartum text message program that was developed in consultation with postpartum mothers and healthcare providers with the goal of improving women's psychosocial outcomes in the immediate postpartum period (Dol et al., 2020b) . Essential Coaching for Every Mother (COVID-19 stream) contained 56 messages related to newborn care and maternal mental health, with nine messages modified to be consistent with postpartum care provided during COVID-19 and five COVID-19 specific messages added. Of the originally designed program, 44 messages were unchanged. Essential Coaching for Every Mother is designed to send twice daily messages during the first two weeks postpartum, and then one daily message for the following four weeks (Dol et al., 2020b) . In the COVID-19 stream, there were three days in the first two weeks in which a third message was sent. Women were also asked to self-select preference for breastfeeding or formula feeding messages which they were able to modify throughout the program if desired. The TextIt platform was used to program and schedule the messages and the Twillo gateway service was used to send and receive messages to participants (TextIt, 2017; Twilio, 2018) .

Background maternal demographics and newborn characteristics were collected at enrolment. At six-weeks, a follow-up survey collected data on whether mothers had any postnatal healthcare contacts for themselves or their infant, health concerns, and to gather information on feeding behaviour as well as to complete an evaluative component to seek input on their experience with the program. At both time points, participants completed standardized assessments of self-efficacy (primary outcome) as well as social support, postpartum anxiety, postpartum depression, and COVID-19 anxiety and stress (secondary outcomes). Participants were also asked to rate how . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101/2021.01.13.21249598 doi: medRxiv preprint beneficial they found the Essential Coaching for Every Mother program on the above psychosocial outcomes (e.g., Please indicate how beneficial you found Essential Coaching for Every Mother to you for reducing your feelings of anxiety on a 5-point scale from 1 (not beneficial at all) to 5 (completely beneficial)?)

Maternal self-efficacy was measured using the Karitane Parenting Confidence Scale (KPCS) which is a 15-item tool to assess perceived self-efficacy of mothers of newborns, birth to twelve months of age, with an acceptable internal consistent (Cronbach's alpha = 0.81) and test-retest reliability (r = 0.88) (Crncec et al., 2008) . A cut-off score of 39 or less (out of a possible 45) is considered to be a clinically low perceived parenting self-efficacy with scores below 31 considered to be in the moderate or severe range (Crncec et al., 2008) .

Social support was measured through the Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al., 1990) . This scale is a measure of how much support a parent feels they get from family, friends and significant others from which subscales from each can be calculated as well as a total score. The MSPSS has been determined to be valid and internally reliable with Cronbach's alpha ranging from 0.81 to 0.94 on individual subscales to 0.83 to 0.92 for the scale overall (Zimet et al., 1990) .

Postpartum anxiety was measured using the Postpartum Specific Anxiety Scale (PSAS) (Fallon et al., 2016) . The PSAS is a valid and reliable measure to assess anxiety during the first six-months postpartum, with individual factor reliability having a Cronbach's alpha from 0.80 to 0.91 with an overall alpha of 0.95 (Fallon et al., 2016) .

The State-Trait Anxiety Inventory (STAI) (Spielberger et al., 1983 ) was used to measure general anxiety. The STAI-State has 20 items for assessing state anxiety, with higher scores indicating greater anxiety. Internal consistency coefficients for the scale have ranged from .86 to .95 (Spielberger et al., 1983) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101/2021.01.13.21249598 doi: medRxiv preprint Postpartum depression was measured using the 10-item Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987) . This scale can be used to screen mothers at risk for developing postpartum depression, with a score above 14 (out of 30) indicating a likelihood of having or developing postpartum depression (Cox et al., 1987) .

Anxiety specific to COVID-19 was measured using the Coronavirus Anxiety Scale (CAS) (Lee, 2020) . This is a 5-item scale developed specifically to be a brief mental health screener to identify probable cases of dysfunctional anxiety associated with the COVID-19 crisis (Lee, 2020) . CAS discriminates well between persons with and without dysfunctional anxiety using an optimized cut-off score of greater or equal to 9 (90% sensitivity and 85% specificity) (Lee, 2020) . The Impact of Stressful Event Scale -Revised (IES-R) (Weiss, 2007) was used to measure the impact of COVID-19 related stress. This 22-item self-report scale assesses subjective distress caused by traumatic event, which for our purposes was the COVID-19 pandemic. The IES-R yields a total score (ranging from 0 to 12) and subscale scores can also be calculated for the Intrusion, Avoidance, and Hyperarousal subscales (ranging from 0-4) (Weiss, 2007) .

Data was analysed using Statistical Package for Social Sciences version 26.

Demographic characteristics are expressed in means and standard deviations and percentages, as applicable. A p-value of 0.05 was considered significant for all outcomes. For the first objective, paired t-test were used to determine changes from baseline to follow-up on key outcomes. As this was an exploratory study, consideration of covariates occurred (i.e., number of messages received, perinatal timing of enrolment, maternal age). For the second objective, thematic analysis was used to analyse qualitative responses, which was led by the first author (Braun & Clarke, 2006) .

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101/2021.01.13.21249598 doi: medRxiv preprint Participants A total of 88 participants enrolled in the study but not all participants completed each assessment at both time point. Women were on average 30.81 years of age at enrolment (standard deviation [SD] = 4.7) and 91.3% identified as heterosexual. Most identified as white (87.5%) and were married (67.5%) or common-law (26.3%). Over half (51.8%) had a household income over $100,000CAN and 9.9% had a household income less than $49,999CAN. Almost all women had singleton births (98.8%) with one woman who gave birth to twins. Women were on average 39.3 weeks pregnant when they gave birth (SD =1.5 weeks, range = 33.5-42 weeks). In terms of mode of birth, 67.5% had a vaginal birth, 27.5% had unplanned caesarean sections, and 5.0% had a planned caesarean section. For 87.5% of participants, this was a planned pregnancy. Thirty percent had a history of diagnosed anxiety or depression.

In terms of receiving the Essential Coaching for Every Mother program, of the 88 participants enrolled, 42 (47.7%) received the full 56 messages. For women who enrolled late, they received a mean of 45.36 messages (SD = 9.9 messages, range = 27 -55 messages received). Seventy-eight participants (88.6%) opted in for breastfeeding messages and the remainder for formula feeding messages, with two participants changing from breastfeeding to formula while in the program. The average time between completion of the baseline survey and follow-up survey was 36.8 days or 5.25 weeks (SD = 6.28 days, range = 22-53 days).

Changes in psychosocial outcomes are shown in Table 1 . While there were some significant correlations, when examining the scatterplots, no clear relationship or trend of the covariates could be determined, and thus no covariates were taken into account in the analysis. Overall, self-efficacy improved between baseline and follow-up, with an . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101/2021.01.13.21249598 doi: medRxiv preprint improvement from the moderate clinical range (i.e., a score 31 to 35 out of 45) to the mild clinical range (i.e., 36 to 39 out of 45). Anxiety measured using the STAI-State showed a significant decline from baseline to follow-up. No significant changes over time were found across the other outcome measures.

In terms of acceptability, 89.0% of participants felt that the number of messages were just right while the rest felt there were too few (7.3%) or too many (3.7%) messages. Most participants (84.5%) felt the messages contained all the information they needed related to caring for a newborn and 98.8% indicated they would recommend the program to other new mothers. Table 2 shows how helpful participants found Essential Coaching for Every Mother in relation to the psychosocial outcomes measured on a scale from 1 (not at all) to 5 (completely).

Areas where participants felt they would like more information were primarily related to breastfeeding and newborn sleep. Participants generally felt the timing of messages was relevant to their newborn's development. One mother said: "…there were a few days that I was wondering about something and then the text messages for that day would end up being related to what I was thinking about." Another mother commented: "The messages I received were so relevant to the stage we were in! Sometimes I felt as though someone was listening to my conversations. Very, very helpful." A few women did comment that the messages arrived after they had already experienced that concern, but the majority felt the timing was appropriate.

Women felt that the messages were helpful, particularly in light of the reduced face-to-face healthcare provider support available during COVID-19 pandemic restrictions. One participant said: "With a lack of in person support these texts were great little daily messages". Participants also felt that the messages would be helpful is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101/2021.01.13.21249598 doi: medRxiv preprint even beyond COVID-19: "I feel as though this could be helpful always, even without a pandemic." In particular, participants felt re-assured in the information they were getting: "It made me feel more confident about the information I was obtaining rather than what I would google." However, some participants felt that due to the low COVID-19 prevalence in Nova Scotia at the time of the program implementation, they had low COVID-19 anxiety and stress already, thus the COVID-19 messages were not that helpful and actually increased their anxiety. One participant explained: "Mainly because I didn't have any concerns about COVID-19, I found those messages to be the least helpful, but I think they were still important." Another women said: "The messages were all helpful, but I noticed the ones specific to COVID increased my anxiety as it sparked things I didn't want to think about or had not thought about and made COVID feel a little more real and scary even though I already know how real and scary it is!" Participants felt supported by the program -like they had access to a daily digital nurse: "It was nice just to be having constant communication. Our families both live outside the Atlantic bubble, so we haven't had the initial support that we had always envisioned. Having the texts felt like we were being cared for and gave advice that we imagined our parents would give." Women indicated that the messages made them feel less alone, particularly in relation to the loss of family support and peer support parenting groups.

Another aspect of the program that participants appreciated was the normalization of what to expect with their newborn. One participant commented: "Messages of the witching hour normalized our witching hour and I felt less concerned that something was wrong and more confident that this was normal." Another participant explained: "There were several occasions when we were experiencing something, and then the text would indicate this was a normal time to experience that . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101/2021.01.13.21249598 doi: medRxiv preprint thing. It made me feel like we were hitting milestones (or challenges) as we should.

There also was a feeling of togetherness."

Overall, what participants felt what they liked most was the consistency of the daily messages and the personalization with their child's name. One mother said: "I liked the consistency of the texts and looked forward to receiving them". Participants felt that the information validated what they already knew and/or what they were already doing. The information was consistent with messaging they were receiving from other healthcare sources. Participants appreciated that the information came directly to them, that they did not have to seek it out and that they could trust the information being provided.

Areas for improvement included enhancing the ability to reply and/or engage with the messages or a support person with whom they could ask additional questions or to seek further classification. A few women commented that being able to tailor or opt in for additional messages would have been helpful: "… tailoring it to responses of mothers if they have certain issues [that] they would like more support with [such as] breastfeeding or colic." Many women suggested the Essential Coaching for Every Mother continue beyond the first six-weeks postpartum: "Would love for it to go on longer. Even if the texts came less often but continued until 6 months. At 6 weeks I feel I've figured some out but she's still not sleeping great and is gassy, so I still have lots of questions and know we have lots ahead of us to figure out with months 4-5 based on other mothers". Women also suggested that the program be available for their partner, as one participant said: "I ended up sending him a screen shot of the messages most days".

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 The primary objective was to evaluate the preliminary impact of Essential Coaching for Every Mother on maternal self-efficacy, social support, postpartum anxiety and postpartum depression. This study found that maternal self-efficacy increased, and postpartum anxiety measured using the STAI-State decreased between baseline and the 6-week follow-up after receiving the program messages. However, there were no significant changes on feelings of social support, postpartum anxiety measured using the PSAS, postpartum depression, or COVID-19 anxiety and stress. The second objective was to explore the acceptability of the Essential Coaching for Every Mother program provided during COVID-19. Overall, participants were satisfied with the program, with almost all participants willing to recommend the program to other mothers. While there was room for improvement, there were particular aspects of the program that women appreciated, including the daily messages with information they knew they could trust, the general appropriateness of the timing of the messages in relation to their newborn's age, and the support and normalization of the postpartum experience the messages provided.

Although it is encouraging that self-efficacy increased between baseline and sixweeks postpartum, it is difficult to delineate the impact of Essential Coaching for Every Mother above and beyond the increase in self-efficacy that is expected to take place as women become more comfortable in their parenting role. A meta-analysis on postpartum parenting interventions found that self-efficacy significantly increased when measured immediately after the intervention and at a short-term follow-up between four weeks and six months (Liyana Amin et al., 2018) . However, a systematic review on the use of mHealth interventions in the perinatal period found an unclear impact on selfefficacy due to variation in measurement tools and intervention focus (Dol et al., 2020a) . Self-efficacy is an essential component of a woman's transition to motherhood . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101/2021.01.13.21249598 doi: medRxiv preprint (Albanese et al., 2019) , and thus is an important area to focus on for parenting interventions.

Interestingly, a decrease in anxiety measured using the STAI-State was found yet there was no significant difference when measured using the postpartum-specific anxiety measure. Two measures of anxiety were used in this feasibility study as the measures evaluate anxiety differently. Specifically, the STAI-State asks more general questions around anxiety such as feeling calm or secure within the past seven days (Wenzel, 2017) , whereas the postpartum-specific measure is very specific to the postpartum period, asking questions around worry about baby's weight or bonding (Fallon et al., 2016) . Thus, these measurement tools may be getting at different aspects of anxiety in the postpartum period, with the STAI-State exploring a broader aspect of anxiety while the PSAS exploring anxiety in specific relation to the postpartum experience. In a study exploring the ability to identify mothers at risk of postpartum anxiety using the STAI, Dennis and colleagues (2013) found that having a high score on the STAI within a week postpartum was highly predictive of a high score at four (84.5%) and eight weeks postpartum (83.6%). The challenge is that there is no consensus to date on how to best measure postpartum anxiety (Meades & Ayers, 2011) .

A systematic review on anxiety measurement tools used in the perinatal period found the most common measurement tools were the General Health Questionnaire, the STAI, and the Hospital Anxiety and Depression Scales with significant heterogeneity of measurement tools across studies (Meades & Ayers, 2011) . On the other hand, Dennis and colleagues (2017) found that most studies used the STAI to assess postpartum anxiety in their systematic review on postpartum anxiety prevalence. One challenge is that measurement tools used to measure postpartum anxiety were not specifically designed for this purpose (Meades & Ayers, 2011) . One such measure designed to cover . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 this gap can be argued to be the PSAS, released in 2016 (Fallon et al., 2016) . While the STAI-State can be argued to evaluate situation-specific anxiety, there is insufficient evidence to suggest that it is a superior measure to the PSAS as a postpartum specific measure. Further work is needed to understand and identify the best approach to measuring postpartum anxiety.

Given the emerging evidence around increased postpartum depression and perinatal anxiety in women during the COVID-19 pandemic (Davenport et al., 2020; Lebel et al., 2020) , it is important to consider the impact and opportunity of virtually delivered interventions, such as a text message postpartum program during this period.

In terms of acceptability of the Essential Coaching for Every Mother program, almost all women felt the program was acceptable in terms of timing and content and was recommendable to other women. Women felt supported in receiving the personalized messages and even desired the program to continue beyond the six-weeks of the intervention period. Interestingly, while the messages were modified to provide some content related to COVID-19, due to the low, near zero prevalence of the virus in Nova Scotia while the program was implemented, this appeared to have limited impact. Thus, further iterations of the program should be modified to reflect primarily changes in care, rather than repetition of recommendations around physical distancing and safety. This finding may have been different if implemented when or where epidemiology of the virus was higher. Nevertheless, the Essential Coaching for Every Mother program was well-received and should progress to evaluation in a randomized controlled trial to determine true effectiveness on psychosocial outcomes.

This study was a feasibility study to determine the practicability of solely recruiting remotely for a text message program during COVID-19. While it is important to explore . CC-BY-NC-ND 4.0 International license It is made available under a perpetuity.

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The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10.1101/2021.01.13.21249598 doi: medRxiv preprint the potential impact of the program on participants, it is difficult to tease apart the impact of the program compared to the normal psychosocial adjustment that occurs during the postpartum period. Thus, the findings from this feasibility study are being used to inform the design of a randomized control trial to experimentally evaluate the effect of Essential Coaching for Every Mother.

While not necessarily a limitation, but a point of discussion, is the fact that during the implementation of this study in the summer of 2020, Nova Scotia had a particularly low, near zero prevalence of new COVID-19 infections. However, there was still COVID-19 related impacts, including small family bubbles, not being able to travel freely beyond the Atlantic borders, having to wear masks and social distance, and is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted January 15, 2021. ; https://doi.org/10. 1101 /2021 to determine whether the messages were read in full when received, limiting our ability to determine the true implementation uptake of the program.

A final limitation is that not all participants completed the survey in full at both time points, thus there were differences in the sample size across analysis of each outcome variable. However, data from participants who completed both assessments at each time point was included, even if they did not complete each measure in the survey.

The survey may have been too time consuming, especially for new mothers, suggesting it is important to reduce the number of assessment tools used in future iterations to enhance completion rates.

In conclusion, preliminary findings suggest that Essential Coaching for Every Mother may play a role increasing maternal self-efficacy and decreasing generalized anxiety, although future work with a control group is needed to delineate the true effect of the program beyond changes that occur in the postpartum period generally. Overall, mothers were satisfied with the Essential Coaching for Every Mother program and would recommend this to other mothers, during the COVID-19 pandemic and beyond.

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