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Abstract

Background:

In the United States, only 15% of women with postpartum behavioral health (BH) conditions receive timely treatment. Peer support, an evidence-based strategy deploying nonclinical individuals with lived experience to provide support, may improve postpartum BH service delivery and can serve as a critical linkage for individuals who lose care access through prenatal structures. Yet, implementation barriers have hindered integration and scaling of postpartum peer support. We conducted a scoping review to synthesize implementation strategies for postpartum peer support interventions.

Methods:

Eleven interventions were identified through comprehensive searches of four databases. The study analysis identified contextual factors and implementation outcomes according to the Practical, Robust Implementation and Sustainability Model framework.

Results:

Successful programs incorporated flexible delivery formats, consistent supervision, and structured peer training to support fidelity while accommodating participant needs. Feasibility and acceptability were high among both participants and peer supporters; however, reach remained limited by exclusion of non-English-speaking individuals and those without technology access. Implementation was further influenced by local public health infrastructure, availability of clinical supervision, and societal norms. Sustainability challenges, including cost and integration within existing health systems, were common.

Conclusions:

While peer support interventions may improve postpartum depressive symptoms, their reach to vulnerable populations and sustainability are limited. Further work is needed to strengthen the implementation of peer support interventions in limited-resource communities and non-English-speaking populations. Tailored strategies include adaptation of intervention components to local contexts, enhancing supervision of peer supporters, and identification of sustainable models for integration within existing systems.

Keywords

postpartum period behavioral health peer support depression postpartum depression

Introduction

Behavioral health (BH) conditions are the leading cause of maternal mortality in the United States,^1,2 but national initiatives to resolve the U.S. maternal morbidity and mortality crisis often fail to address behavioral health care.³ One in five peripartum individuals, defined as those in the period shortly before, during, and immediately after giving birth, experience a BH condition, with perinatal mood and anxiety disorders (PMADs) being the most common.^4–6 In particular, the postpartum period is a season of increased vulnerability due to physiological symptom exacerbation and loss of ongoing prenatal care structures. Beyond the initial postpartum period, PMADs have been associated with long-term health risks, such as increased cardiovascular disease.^1,6,7 Furthermore, PMADs can have generational consequences; children of mothers with untreated PMADs are at higher risk for developmental and behavioral disorders.⁸ These findings highlight the critical need for timely intervention, emphasizing that addressing maternal mental health is essential not only for the mother’s well-being but also for the health of the entire family unit.⁶

Despite these consequences, only 10%–15% of affected individuals receive timely, evidence-based treatment (e.g., counseling and pharmacotherapy), and even fewer achieve full symptom remission.^1,6,9 Evidence-based guidelines from the American College of Obstetricians and Gynecologists, the American Heart Association, and the U.S. Preventive Services Task Force recommend routine postpartum screening, counseling, integrated care, and pharmacotherapy when indicated.^6,10 However, low rates of BH screening and management, particularly in the postpartum period, persist due to systemic gaps in the United States, including fragmented postpartum care, lack of standardized screening and management protocols, insufficient BH integration, and constrained health care capacity, which are factors needed to implement evidence-based guidelines into clinical practice.^1,11,12 Limited health care access and maternity care deserts, defined as counties with no hospitals or birth centers offering obstetric care (obstetricians, midwives, or nurse-midwives), reduce intervention reach.^13,14 Beyond systemic barriers, individual postpartum barriers to BH care, including childcare, transportation access, language barriers, fragmented insurance coverage, and fear of child protective service involvement, further prohibit close postpartum follow-up for many individuals with BH conditions.^11,12,15 Notably, those experiencing conditions that make BH care more challenging to access, such as poverty, housing and food insecurity, complex medical conditions, lack of insurance coverage, limited parental leave, and intimate partner violence, have an increased vulnerability to BH conditions,^11,12 further emphasizing the need for care models that integrate evidence-based BH interventions, improve accessibility, and address structural determinants of health.

Peer support, defined as support provided by a family member, friend, or another patient who is either receiving treatment for a similar condition or has a relationship with the primary patient, can address community- and individual-level barriers to postpartum BH care.^16,17 Peers can offer emotional and practical support, share personal experiences, participate in self-help and mutual aid activities, and collaborate with other community members or health care providers to meet patient needs, including prevention and treatment.¹⁶ Peer support programs help connect individuals with lived experience of BH conditions to those currently navigating similar challenges.¹⁸ They have emerged as part of the broader recovery movement in BH¹⁸ and function as a complementary care strategy by filling gaps in traditional health systems through outreach to underserved populations, addressing stigma, facilitating engagement for those with limited access to services, and providing culturally relevant guidance.^19–22 Evidence has shown peer support interventions can reduce symptoms of postpartum BH conditions, particularly among high-risk, early postpartum women, while providing social connection, emotional support, and empowerment to recipients and peer providers.^23,24 The ability of peer supporters to fill these gaps is closely linked to their lived experience, which allows them to connect authentically with patients and navigate challenges that formal health systems may not fully address.^16,25

Peer support interventions have demonstrated positive clinical outcomes, including reductions in the incidence and severity of PMAD.^23,26 These interventions have shown promise in particularly benefitting populations facing health care access barriers, bridging the gap between postpartum BH care and those who need it most.^12,26 With the increased symptom burden and waning support of the postpartum period, peer support serves as a promising linkage to BH services during postpartum. However, despite promising outcomes, gaps remain in optimal delivery and implementation related to heterogeneity in program design, limited training and resources, and barriers in integrating peer support within existing health care infrastructures.^26–28 This review aims to identify and analyze the key facilitators and barriers that shape the delivery and effectiveness of peer support interventions targeting postpartum BH conditions. By examining how these interventions are implemented in real-world settings, the review seeks to clarify the factors that enable successful uptake, scalability, and sustainability, as well as the individual, organizational, and contextual barriers that constrain their impact in postpartum care.

Materials and Methods

This scoping review seeks to (1) describe the types and components of peer support interventions implemented during the postpartum period; (2) summarize available evidence on their implementation outcomes, barriers, and facilitators; and (3) identify gaps in the literature to inform future research and practice. The scope was limited to postpartum populations in high-income, English-speaking countries to account for differences in health care infrastructure, access, and cultural context to synthesize peer support implementation barriers and facilitators applicable to U.S. health care settings. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guided the reporting of this review.²⁹

Search strategy

Four electronic databases, PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health, and APA PsycInfo, were searched using controlled vocabulary terms (e.g., Medical Subject Headings) and relevant keywords related to postpartum mental health (e.g., “postpartum depression,” “perinatal anxiety,” “maternal mental health”) and peer support (e.g., “peer mentoring,” “support groups,” “lay health worker”). Searches began in 2023 and were refined, including a search of the final strategies through January 2024. Searches included articles published in database from 2013 through January 2024 and were restricted to English-language publications. Search strategies were refined in consultation with a medical librarian, and the final search strings are available in the Supplementary Appendix. A bridge search was conducted from May 11, 2023 to October 2, 2025, to capture recent literature across the same four databases.

The Sample, Phenomenon of Interest, Design, Evaluation, and Research type framework informed eligibility criteria (Table 1).³⁰ Exclusion criteria included studies without primary evaluation data, interventions not involving peer support, and populations outside the postpartum period. Studies were included regardless of control or comparison group presence. Papers describing only methods were eligible if they clearly detailed the intervention implementation. Reference lists of included articles and relevant systematic reviews were searched to identify additional eligible studies.

Table 1.

SPIDER Framework

Sample	Phenomenon of interest	Design	Evaluation	Research
Postpartum women and persons from well-resourced English-speaking countries between the ages of 18 and 45.	Role of peer support in addressing postpartum mental health conditions.	Clinical programmatic/intervention papers, clinical trials, quality improvement methods, case studies	Satisfaction with care, mental health disorder symptom burden, service delivery/receipt, reduction in broader chronic disease burden	Qualitative, quantitative, mixed methods

SPIDER, Sample, Phenomenon of Interest, Design, Evaluation, and Research.

Study selection

Search results were imported into Covidence³¹; duplicates were removed automatically prior to screening. Independent screening was conducted at both the title/abstract and full-text stages by two reviewers. Reasons for exclusion at full text were recorded, and study selection was documented in a flow diagram (Fig. 2).

Data extraction

Studies were abstracted by one reviewer, followed by a secondary review by a separate study member to ensure accuracy and completeness. Extracted items included author and year of publication, study setting, sample demographics, guiding theory or framework, detailed description of the intervention, BH outcomes, implementation outcomes, equity considerations, implementation facilitators and barriers, and study limitations.

Linking multiple publications to a single study

When multiple publications reported findings from the same underlying study, we linked these articles and treated them as a single study unit for the purposes of data extraction and synthesis. Publications were considered to originate from the same study if they shared key characteristics, including study design, sample population, setting, intervention components, and study timeframe. In such cases, data were consolidated across articles to capture all relevant outcomes and methodological details while minimizing the risk of double-counting participants. Discrepancies across publications were resolved through team discussion.

Data analysis

Extracted data were synthesized descriptively and summarized in Table 2. Implementation evaluation was guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework (Fig. 1). The PRISM framework has been widely applied across health care settings, including primary care, BH integration, and maternal health, to identify multilevel barriers and facilitators to implementation.⁴⁹ Its emphasis on the dynamic interaction between context and intervention makes it well suited for evaluating real-world implementation. Compared with other implementation frameworks, PRISM captures both system-level influences and patient-centered perspectives, which aligns with our focus on understanding the delivery and sustainability of BH interventions in complex postpartum care settings. Its inclusion of contextual determinants makes it particularly useful for identifying barriers and facilitators within the postpartum setting.⁴⁹ PRISM has been successfully used to guide implementation of community health interventions,⁵⁰ making the findings of this review translatable to inform implementation of peer support in a variety of postpartum settings. PRISM builds upon the well-established Reach, Effectiveness, Implementation, and Maintenance (RE-AIM) framework, which has been a mainstay of implementation evaluation for the last 25 years, and integrates the implementation outcomes of reach, effectiveness, adoption, implementation, and maintenance.⁵¹ The PRISM framework adds contextual factors to understand how both internal and external features may impact the implementation of an intervention, which allows for integration of structural drivers of health inequities.⁵² The PRISM framework includes four domains: (1) perspectives on the intervention; (2) characteristics of the implementers, recipients of the intervention, and setting; (3) external environment; and (4) implementation and sustainability infrastructure.⁵² Collectively, these domains highlight how contextual factors shape implementation and outcomes.

Table 2.

Included Studies

Author, year of publication	Design and purpose	Sample and setting	Intervention description	RE-AIM outcome measures	Contextual factors
Amani, 2022³²; Amani, 2023³³	Randomized Controlled Trial (RCT) among mothers at risk for postpartum depression (PPD) with EPDS ≥10 To examine the impact of a 9-week peer-delivered group cognitive behavioral therapy (CBT) intervention on symptoms of PPD and anxiety as well as mother–infant relationship.	N: 73 Mean age: 32 (experimental group) Black (%): Not Reported (NR) Other race/ethnicity (%): NR Community: Ontario, Canada	Weekly group intervention delivered in 2-hour sessions over 9 weeks covering CBT skills, unstructured discussion, cognitive restructuring, and behavioral techniques. Administered in person at local community center.	Reach: Acknowledged there was little ethnic diversity in sample. Effectiveness: Depression symptom severity decreased significantly compared with control as measured by EPDS and was more likely to meet criteria for depression reaching remission. Improvements were also noted in infant emotional regulation measured via frontal alpha asymmetry and high-frequency heart rate variability. No significant differences by group in general anxiety scores as measured by Generalized Anxiety Disorder 7-item scale (GAD-7), social support, or mother–infant bonding. No significant differences by group in general anxiety scores as measured by GAD-7, social support, or mother–infant bonding. Implementation: Peer supporters received 2 days of in-classroom instruction, participated in a 9-week observership of CBT delivered by experienced therapists, and delivered interventions in pairs. Therapist listened to session recordings and provided direct supervision. Maintenance: High loss to follow-up rates.	Recipient: Participants experienced a high level of positive collaboration with peer facilitator and positive peer facilitator input. Implementation and sustainability infrastructure: Group therapy was chosen to be more cost-effective. Environment: COVID-19 pandemic occurred during trial, preventing recruitment of target sample; universal health care in Canada thought to potentially impact outcomes.
Babiy, 2024³⁴Drage, 2025³⁵	RCT among mothers ≥18 years old within the first year postpartum with EPDS ≥10; to examine the effect of 1-day online peer-delivered CBT-based workshop on PPD symptoms 12 weeks after enrollment.	N: 405 Mean age: 32.2 Black (%): NR Other race/ethnicity (%): 65% White Community: Ontario, Canada	One-day-long CBT-based interactive workshop delivered online by trained peers; covered didactic teaching, discussion, and role-playing to promote cognitive restructuring. Finished with goal setting and action planning. Participants received an electronic copy of the written workshop manual prior.	Reach: Difficulty reaching many potentially eligible participants despite parents self-referring. Effectiveness: Participants had a decrease in average EPDS scores 12 weeks after intervention from 15.95 to 11.37; significantly more intervention participants had a ≥4-point improvement in EPDS scores compared with control (53% vs. 36%). Intervention participants had greater improvements in anxiety symptoms, parenting stress, infant-focused anxiety, and infant bonding scores compared with control group. There were no significant improvements in general social support or partner relationship quality. Adoption: 37% of participants did not receive allocated intervention. Participants reported choosing to participate because the workshop was free (51.1%), brief (45.4%), and delivered by peers (39.4%). Implementation: Peer supporters received 2 days of in-person learning with psychiatrist and observed recording of workshop delivered by psychiatrist; supporters worked in pairs. Workshops were delivered online in a single 6-hour session with trained peers with lived experiences of recovering from PPD, using a structured CBT manual and supervised practice. Intervention was shown to be cost-effective compared with others. Maintenance: 32% not reached for follow-up questionnaires.	Intervention: Peer supporters had delivered CBT intervention before as recruiting new supporters was limited by the COVID-19 pandemic. Delivered to groups of 30 participants at a time. Noted that improvement rates were similar to that of workshops delivered by experts. Participants reported feeling validated by peer supporters but sometimes struggled to relate if supporters had different experiences than their own. Recipients: Participants who were married were more likely to remain in the study. Noted lack of diversity in sample. Over half of surveyed respondents would have preferred two half-day sessions. Participants were largely White, partnered, and in Ontario. Peer delivery aligned with participant preferences for support from individuals with lived experiences and contributed to feelings of validation. Implementation and sustainability infrastructure: Similar quality-adjusted life years between groups; intervention groups had lower health care costs than control groups. External environment: universal health care thought to make usual treatment arm more robust
Chyzzy, 2019³⁶	RCT among pregnant adolescents at risk for PPD To evaluate the feasibility and acceptability mobile phone-based peer support for pregnant adolescents.	N: 40 Mean age: 21 Black (%): 56 Other race/ethnicity (%): NR Community: Toronto, Canada	Received peer support from trained peer mentor by phone calls or text message from the last trimester of pregnancy through 12 weeks postpartum.	Effectiveness: Lower mean depression scores at 12 weeks postpartum; no differences in anxiety or social support. Implementation: Peer supports received a 12-hour training program. Contact frequency was determined by participant. Average of 6.4 contacts per participant, 93% of contact was via text message. Maintenance: Given a research phone for intervention that was returned at end of intervention.	Intervention: Participants reported enjoying anonymity and nonprofessional nature of program; positive correlation between number of contacts and participant satisfaction. 100% of participants were satisfied with the experience. External environment: 47% reported poor phone connection quality hindered connecting with peer support as frequently as they would like.
Dennis, 2009³⁷; Dennis, 2014³⁸; Dukhovny, 2013³⁹	RCT among postpartum women with EPDS > 0 To prevent onset of PPD within 12 weeks after birth	N: 701 Mean age: NR Black (%): NR Other race/ethnicity (%): NR Community/home (telephone outreach); Ontario, Canada	Telephone-based peer support program for women in the first 22 weeks postpartum matched with volunteer peer support by location and ethnicity if preferred by participant. Volunteer peers called participants within 48–72 hours of program entry; were asked to have at least 4 telephone contacts, but frequency and additional calls decided by the participant/volunteer.	Reach: 28% of potential participants declined enrollment due to lack of interest. Effectiveness: Decreased number of women with PPD at 12 weeks postpartum. Adoption: 94% of participants had documentation of the intervention initiation. Implementation: Had full-time paid coordinator; peer supports contacted participants within 48–72 hours of enrollment. Previously did a pilot trial to assess feasibility and refine implementation; matched participants with supports matched by location and ethnicity and completed a 4-hour training session and then excluded those who did not pass skills screen. Leaving voicemails if not able to contact them was perceived as important to let participants know they had source of support. Average of nine contacts over 12 weeks, primarily telephone calls (≥1 contact within 48–72 hours of randomization). Participants reported negative effects of peer support, which were addressed in revised training sessions. Maintenance: Struggled with volunteer peer turnover; 29% of peer matches continued calls past the 12-week intervention period. For ethical concerns, participants with depression at 12 weeks were referred for treatment, which limited understanding of longitudinal outcomes from intervention. Peer supporters requested refresher training for longitudinal involvement. 12.6% of participants lost to follow-up at 12 weeks.	Intervention: High participant satisfaction. The diagnostic interview for depression had to be shortened because it was conducted while mothers were caring for their infants, which may have affected depression diagnosis rates. Recipients: Peers had a history of PPD and required monitoring of mood during intervention as well. Excluded those on antidepressant or antipsychotic medications. English-speaking-only sample. Implementation and sustainability infrastructure: Resulted in a mean increase cost of $1117 per individual, costing $10,009 per case of PPD averted. External environment: Routine care in Ontario includes phone call from public health nurse 24–48 hours after discharge, which was used to introduce intervention as well as to conduct follow up with participants with clinical depression diagnosed through intervention.
Duffecy, 2019⁴⁰	Randomized two-arm trial among pregnant women with depressive symptoms (PHQ-8 scores of 5–14) To develop and test a CBT-based online program with peer support to prevent PPD in pregnant women experiencing mild to moderate depressive symptoms.	N: 24 Mean age: 30.5 Black (%): 8 Other race/ethnicity (%): 72% White, 8% Asian, 8% Multiracial, 4% Latina Hospital and universities: Illinois, United States	CBT internet website with an 8-week intervention consisting of 10- to 15-minute didactic lessons and tools, including direct applications of included CBT strategies. Website included newsfeed, discussion topics, and accountability features to encourage participation.	Reach: 57% of potential participants did not complete screener/baseline questionnaire. Effectiveness: Depressive symptoms decreased overtime for both groups. Implementation: Average of 13.7 lessons completed; while 59% of participants used at least one of the peer support features (most commonly commenting on discussion posts), overall use of peer support features was fair low.	Intervention: Build with participant feedback via design groups, provided requested pregnancy information from patient stakeholders as well as mood management information. Participants were satisfied with website usability. Recipients: English speaking only, had access to internet. Implementation and sustainability infrastructure: website had already been created and tested for depression treatment but was tailored to pregnancy in this trial.
Law, 2021⁴¹	Single-group nonrandomized feasibility trial among expectant first-time mothers To provide social support from mummy buddies to new mothers, with the goal of managing their transition to motherhood.	N: 45 Mean age: 31 Black (%): NR Other (%): 73% White, 13% Asian, 14% Other race/ethnicity Community: Perth, Australia	Mummy Buddy Program included pairing an experienced mother with first-time mothers and education via in-person workshops, information sessions, development of personalized support plans, ongoing peer support until 6 months postpartum, and check-in phone call by 6 weeks postpartum by community-based parenting support organization.	Reach: Many interested mothers were noncontactable (30/77); ability to attend training workshop limited involvement. Effectiveness: No significant differences in EPDS scores or perceived stress across timepoints. Implementation: Design based off of patient experiences and recommendations, all components in person, partnered with a well-known community-based parenting support organization. Peer volunteers completed a 3-hour training session; frequency and type of peer support were decided by participants; however, less interaction seemed to cause difficulty forming bond.	Intervention: Peer supporters reported they were well trained and able to support mothers, but struggled with addressing stressors after the baby was born. High acceptability to participants of workshops, low utilization of written handbooks. Recipient: Inclusion criteria were limited to those with EPDS < 13, in a committed relationship, and with no physical or mental health issues. The main reason for the lack of follow-up call was participant was unreachable.
Lutenbacher, 2018⁴²	RCT among Hispanic pregnant women (≤26 weeks gestation) To improve maternal and infant health outcomes by providing home visitation support from trained peer mentors, focusing on enhancing breastfeeding self-efficacy, promoting safe infant care practices, reducing maternal depressive symptoms and parenting stress, and increasing social and emotional support for mothers.	N: 178 Mean age: 30 Black (%): NR Other race/ethnicity (%): 100% Hispanic Community: Tennessee, United States	Maternal Infant Health Outreach Worker (MIHOW) program provided home visitation support from trained peer mentors, focusing on enhancing breastfeeding self-efficacy, promoting safe infant care practices, reducing maternal depressive symptoms and parenting stress, and increasing social and emotional support for mothers. Monthly home visits lasting about 1 hour were completed as well as periodic group gatherings for the first 6 months postpartum.	Effectiveness: Depression symptom severity as measured by EPDS improved at 6 months postpartum compared with control. Also noted improvement compared with control group in Parenting Stress Index-Short Form, Home Observation for Measurement of the Environment—Infant-Toddler, and parenting practices as measured by PRAM Standard Measures. Implementation: 40 hours of training, built into existing MIHOW program with established standards and accreditation. Maintenance: Due to budget, duration limited to 6 months of age rather than typical MIHOW duration to the child’s third birthday. 100% retention rate through 6 months postpartum.	Implementation and sustainability infrastructure: Data analysts as well as peer supporters are also bilingual Hispanic women from the community. Funding limited sustainability.
Merza, 2023⁴³	RCT among mothers with PPD (EPDS ≥ 10) To determine if a synchronous online 9-week group intervention delivered by mothers who have recovered from PPD could effectively improve PPD symptom burden.	N: 183 Mean age: 32 (patients), 41 (peer volunteers) Black (%): NR Other (%): 79% White Community: Ontario, Canada	Participants completed a 9-week synchronous, online peer-delivered CBT intervention delivered by mothers who have recovered from PPD (i.e., peers) via an online video conferencing platform. Participants completed a 2-hour session per week; the first hour was used to practice core CBT skills, followed by 1 hour of unstructured discussion.	Effectiveness: Significant improvement in PPD symptom burden among intervention group vs. control; improved anxiety symptom burden, social support, and infant negative emotionality at 12 weeks postintervention. Implementation: Underwent 3-day training program delivered by psychiatrist and subsequently observed. Psychotherapist provided weekly supervision. 77% attended 6 or more of the 9 sessions; participants reported a high degree of positive collaboration with facilitators. Maintenance: 26% in experimental group lost to follow up.	Recipients: Limited diversity in sample, English speaking. Peer supporters were screened for ongoing depression symptoms and excluded if positive. Implementation and sustainability infrastructure: Unclear how effective the intervention would be without the support of a psychotherapist (provided weekly supervision). External environment: Universal coverage promoted PPD treatment access for all participants. Completed online due to the COVID-19 pandemic, which may have affected participants’ baseline social support.
Shah, 2025⁴⁴	Qualitative analysis of RCT among postpartum mothers at risk for PPD (ranging from >24 gestational weeks to 6 months PP); to understand the experiences of women with postnatal care and the impact of smartphone application.	N: 30 Mean age: 30 Black (%): NR Other race/ethnicity (%): 60% Malay, 23% Chinese Community: Singapore	SMART (Supporting at-risk Mothers Across the perinatal period) phone application for pregnant and postpartum women allows for peer support via instant messaging and educational resources.	Effectiveness: participants reported feeling emotional validation and connection with peer supporters. Enjoyed having educational resources. Mothers cited the peer chat and forum features as sources as validation and practical advice. Control group reported continued social isolation and reliance on inconsistent sources of support. The “mom-to-mom” understanding and emotional safety offered through SMART was seen as a meaningful form of psychosocial support. Implementation: SMART intervention included in-app peer support chat, forum space, and multimedia educational sources. Peer support was given asynchronously and anonymously to reduce stigma and encourage help-seeking. Was considered most helpful when culturally relevant and delivered by experts. Adoption: Participants reported preference for digital resources.	Recipients: Single mothers in particular reported struggling with social isolation. Included only English-speaking mothers. Participants were at-risk mothers facing low income, single parenting, mental health histories, past trauma, or babies with medical complications. They expressed wanting support that was specific to their vulnerability. Seeking support depended on cultural norms, generational tensions, and family expectations. External environment: Participants reported traditional views of their own parents caused stress, particularly related to mental health.
Shorey, 2019⁴⁵; Shorey, 2019⁴⁶	RCT among mothers at risk for PPD To reduce PPD, anxiety, and loneliness and increase perceived social support at 3 months postpartum	N: 138 Mean age: 32 Black (%): NR Other race/ethnicity (%): NR Hospital: Singapore	Technology-based peer support during first 4 weeks postpartum after hospital discharge with at least weekly contact for 4 weeks via phone calls, emails, or WhatsApp (participant’s choice)	Effectiveness: Improvement in depression symptoms as measured by EPDS at both 1 and 3 months postpartum; improvement in loneliness (UCLA Loneliness Scale) and perceived social support (PSSP). Adoption: Qualitative interviews of peer supporters found they felt prepared and easy to administer. Implementation: Half-day of training for peer supporters with psychiatrist and instructed on appropriate referrals to health care professionals.	Intervention: Participants reported preference to match with volunteers of similar age and ethnicity. Interviews of participants found they preferred text messaging and had difficulty matching up schedules for phone calls. Recipients: had access to technology, all English speaking Environment: confinement period typical in Singapore (87% of participants had a confinement period).
Shorey, 2021⁴⁷; Shorey, 2023⁴⁷; Shorey, 2024⁴⁸	RCT for married parents during pregnancy and first 6 months postpartum; to study application’s impact on maternal PPD symptoms.	N: 400 Mean age: 30 for mothers, 32 for fathers Black (%): NR Other race/ethnicity (%): 36% Chinese, 39% Malay Community: Singapore	Supportive parenting app includes knowledge-based content, informational videos, discussion forums, and chat groups with peer volunteers. Peer supporters and participants could interact through app or through other messaging platforms.	Effectiveness: No difference in depressive symptoms, intervention group had slightly lower anxiety scores until 6 months postpartum. Poorer parent-infant bonding in intervention group vs. control. Implementation: Peer volunteers were mothers with a history of recovered PPD, trained by a psychiatrist in a 3-hour web-based training session. Most peer supporters reached out weekly. Some peer supporters found it difficult to answer infant-care questions and navigate the app’s technology, which could have limited consistency and depth of support. Maintenance: 31% attrition by the 12th month. Peer supporters reported a need for updates on newborn care, as many of them had adult children and were not able to answer participants’ questions regarding childcare, as well as felt uncomfortable using the phone application due to limited technological familiarity.	Intervention: Developed using an iterative user-centered process with three cycles with input from all three major ethnic groups in Singapore. Knowledge base content most often accessed. Recipients: 47% were university graduates, a high-income sample. Showed different trends in symptoms between men and women. Peer supporters noted less responses from male participants. Implementation and sustainability infrastructure: regular push notifications used to encourage interaction. External environment: Singapore has more than 99% wireless broadband penetration and 92% mobile penetration. Was implemented during the beginning of COVID-19, which limited some of the implementation and may have affected results.

FIG. 1.

Practical, Robust Implementation and Sustainability Model (PRISM). PRISM showing the relationships between contextual factors, intervention design, implementation processes, and outcomes.

In this review, reach captured the number and demographic characteristics of participants (i.e., age, race/ethnicity, and language), which could influence participation or engagement with the interventions. Contextual features about recipients included internal and external factors that may affect engagement and outcomes, such as social support, cultural norms, access to technology, or structural barriers. Distinguishing between these elements allowed us to consider the individual and external factors shaping participation.

Results

A total of 741 records were screened for the scoping review, with 18 manuscripts (2.4%) describing a total of 11 separate interventions meeting inclusion criteria for synthesis (Fig. 2). An additional study, by Dennis et al.,³⁷ was not captured in the initial search due to a publication date prior to 2013; however, it was included in the data analysis as it described an intervention that was included within the captured manuscripts. The included interventions included nine randomized controlled trials, a single-group nonrandomized trial, and a randomized two-arm trial (Table 2). Studies were conducted in the United States, Singapore, Canada, and Australia and included sample sizes ranging from 24 to 701 participants. Interventions were delivered via phone or text, online or web-based CBT, home visits, group sessions, and peer-pairing programs. Peers provided a range of support, including emotional validation, CBT instruction, skill-building, parenting guidance, advocacy, and service navigation, with content and intensity varying across programs.

FIG. 2.

PRISMA Flowchart. PRISMA flowchart showing the identification, screening, eligibility assessment, and inclusion of studies (n = 11). PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension.

Outcome measures

Reach

Five interventions measured reach^{32,34,35,38,40,41}; multiple studies noted recruitment challenges^40,41 driven by difficulty contacting potential participants, participants’ inability to attend in-person study activities, and lack of interest. Studies also reported limited diversity in their sample.^32,43,45

Effectiveness

All 11 interventions discussed effectiveness, most commonly measured by depressive symptoms [Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire–8 (8-item depression scale-PHQ-8)]. Peer support interventions generally improved depressive symptoms and, in some studies, improved loneliness, parenting stress, and infant emotional regulation (Table 2). Five studies reported statistically significant reductions in PPD^{32,38,42,43,45}; most studies measured depressive symptoms at 12 weeks postpartum, with one study showing improvement in postpartum depression symptom severity at 6 months postpartum.⁴² The peer support interventions had variable effect on stress and anxiety symptoms,^36,41–43 and one intervention reported decreased feelings of loneliness.⁴⁵ Four interventions that reported on infant outcomes reported positive improvements with peer support interventions, including infant emotional regulation^32,43 and infant home environment.⁴² However, one study reported poorer infant bonding in the intervention group compared with control.⁴⁷

Adoption

Four interventions detailed adoption.^38,45 These studies reported variable adoption, with 37%³⁴ to 94% of participants initiating the intervention³⁸ and peer supporters reporting they felt prepared and found the interventions easy to administer.⁴⁵ Lower adoption was noted with group interventions,³⁴ and participants reported it was easier to adopt digital interventions.⁴⁴

Implementation

All 11 interventions detailed their implementation. Interventions were delivered via phone,^36,38 text (mobile or WhatsApp),^36,45 online platforms (i.e., websites or smartphone applications),⁴⁰ synchronous online groups,⁴³ and in-person group or home visits.^32,41,42 Training for peer supporters was most often provided by clinical professionals who often offered ongoing supervision^32,43,45; however, some studies implemented peer training into existing community programs.⁴² Training requirements for peer supporters were variable from 3 hours^41,45 to over 9 weeks³²; training requirements tended to be lower for those providing unstructured support, whereas interventions involving peers providing cognitive behavioral therapy-based interventions required more extensive training and occasionally observerships.³² Peer support roles varied by study: some were volunteer-based, while others were paid positions. Interventions were delivered one-on-one or in groups. Fidelity was supported through strategies implemented by the researchers including supervision from clinicians, session recordings, review of negative effects of peer support, and structured manuals. Unstructured phone support interventions often did not specify frequency of contact and were individualized to the needs of individual participants; however, less interaction seemed to cause difficulty forming a bond with their peer supporter.⁴¹ Some interventions were designed or refined by pilot trial feedback from participants.^38,41 Specific feedback provided by participants included matching participants with supporters matched by location and ethnicity,³⁸ leaving voicemails if participant not reached to show they have a source of support³⁸ and partnering with a well-known community organization to improve acceptability.⁴¹ Implementation was typically facilitated by training peer supporters and integrating interventions into existing programs when possible.

Maintenance

Maintenance was described in seven interventions^{32,36,38,42,43,47} and was a challenge for all interventions. Long-term sustainability was often limited by insufficient funding, volunteer turnover, and intervention constraints. For example, Dennis noted peer supporter turnover and ethical requirement to refer those with depression for clinical treatment as limitations to understanding the intervention’s long-term effects.³⁸ One study had to decrease the planned intervention from 3 years to 6 months due to budget limitations,⁴² while another gave phones to participants for the intervention that were returned at the end of the intervention, limiting ongoing peer support contact.³⁶ Retention rates were variable,^42,43 but one study reported that 29% of peer matches continued contact beyond the intervention period.³⁸

Contextual features

Intervention

Seven interventions discussed intervention features that impacted implementation.^{36,38,40,41,45} Participants reported enjoying the informal nature of peer support³⁶ and a preference for peer supporters of similar age and ethnicity as well as text messaging support due to difficulty scheduling phone calls.⁴⁵ Participant design groups for the intervention described in Duffecy et al. requested general pregnancy information be provided alongside mood management information.⁴⁰ Peer supporters reported feeling well trained but struggled to address postpartum stressors⁴¹ and having to shorten interventions to allow participants to care for their infant.³⁸ Of note, one intervention found that CBT intervention delivered by peer supporters had improvement rates in depression scores similar to an intervention delivered by clinicians.^34,35

Recipients

Seven interventions described contextual features about their recipients.^{32,34,38,40,41,43–45,47} Nondiverse participant samples were often driven by exclusion of non-English speakers^40,43,45 and reliance on participants having access to technology for virtual interventions.^36,40,43 Notably, some studies were limited to only those with negative depression scores,^40,41 while others were conducted among those who met the diagnostic criteria of PPD.³⁸ Two interventions involved peer supporters who had a history of PPD, which required the research team to monitor their mood symptoms as well to ensure no worsening of their depressive symptoms related to the intervention.^38,43 Acceptability of interventions tended to be high for both participants^38,43 and peer supporters.⁴⁵

External environment

Eight interventions described external environment features that impacted their implementation.^{32,36,38,43,45} Four interventions discussed that they were completed in countries with universal health coverage,^{32,34,35,38,43} which affected their participants’ ability to access behavioral health care if needed and may have strengthened the control arm’s access to care. Health care and societal norms were also noted to be key features in implementation; for example, one intervention used the routine public health nurse phone calls provided to all Canadian postpartum women to introduce the intervention as well as provide follow-up for those diagnosed with depression through the intervention.³⁸ Another intervention was tailored to the external environment in Singapore, where most postpartum women traditionally have a postpartum confinement period during which the intervention took place.⁴⁵ The COVID-19 pandemic affected three interventions and led to decreased recruitment and transition to online formats.^32,34,43 One study found that poor phone connection quality affected peer support interactions for almost half of their participants.³⁶

Implementation and sustainability infrastructure

Implementation and sustainability infrastructure captured the strategies used to support intervention delivery and fidelity. This included implementation strategies such as supervision, structured manuals, session recordings, and monitoring for adverse effects, all of which were used across studies to promote consistency. Seven interventions discussed their implementation and sustainability infrastructure.^{32,38,40,42,43} One intervention focused on providing peer support for Hispanic women employed both data analysts and peer supporters, who were all bilingual Hispanic women from the community to support intervention implementation. While one intervention utilized a psychotherapist to provide weekly supervision for group peer support sessions, they acknowledged that this could be cost-prohibitive long term and the effectiveness of the intervention without their support is unclear.⁴³ Two interventions discussed the role of sustainability in their study design; one study chose to utilize group therapy to make their intervention more cost-effective,³² while another online intervention tailored an existing website previously tested for depression towards pregnancy.⁴⁰ One intervention completed an economic analysis and found the intervention resulted in a mean cost of $1117 per individual, reporting that the intervention cost $10,009 per case of PPD averted.³⁸

Discussion

In this review, we characterize the implementation features (Fig. 3) and outcomes of peer support interventions for postpartum BH. Our review is consistent with previous systematic reviews that peer support interventions are largely effective complementary interventions for prevention and management of postpartum BH conditions while evidence for broader clinical outcomes has been mixed.⁵³ Our review also suggests that these interventions may have benefits for infant emotional regulation, potentially through multiple pathways; improved maternal BH may enhance sensitivity and responsiveness, while some programs also incorporated parenting support, suggesting more direct behavioral effects.^1,28 Future work should explore whether infant benefits arise from reduced maternal symptoms, parenting changes, or the unique contributions of peer support.⁵⁴ This review builds upon prior literature by specifying the defining implementation features of peer support interventions, which were successfully delivered through multiple formats, demonstrating flexibility of implementation to specific populations and care settings. Despite this, limited reach and challenges with long-term maintenance continue to restrict both the scalability and overall impact of these interventions. Implementing these programs brings important considerations for the mental health and well-being of peer supporters,³⁸ along with ethical questions about using peer support as an adjunct to standard care, including risks of exploitation through inadequate compensation or support, role ambiguity, and the potential for peers to be treated as substitutes rather than complements to professional services.^21,22 Overall, these findings show the potential of peer support and the real-world challenges that must be addressed to improve postpartum BH.

FIG. 3.

Implementation features of postpartum peer support. Implementation features of postpartum peer support interventions mapped to the PRISM.

Several recurrent challenges for the interventions included in this scoping review can inform future peer support interventions. While peer support shows promising effectiveness, evidence remains limited regarding their generalizability and long-term sustainability. Recruitment and retention are persistent challenges, often limiting program reach and representativeness. Many programs relied on self-referral or word of mouth, which can underrepresent populations most at risk for postpartum BH conditions including racial and ethnic minority women, low-income mothers, adolescents, rural populations, and non-English speakers.^1,7 Differences in participant selection reflected not only methodological choices but also underlying systemic structures. Clinically based studies primarily reached women already engaged in formal postpartum care, whereas community-embedded programs captured more socially vulnerable families who access support outside clinical systems. Digital recruitment relied on internet access and smartphone use, reinforcing technology-driven systems that may exclude women with limited digital literacy or resources. Future work should focus on strategies to enhance equity in access, improve recruitment methods, and ensure peer support programs are adequately resourced and supported. Collaboration between community organizations to support recruitment and provide infrastructure, with health care organizations to provide necessary oversight and adjunct medical care for both participants and peer supporters, is critical to responsible, sustainable peer support interventions. While peer turnover was not widely reported across the included studies, several interventions emphasized that structured training, clear role expectations, and ongoing supervision strengthened peer confidence and fidelity. Programs embedded within supportive community or health care organizations also facilitated retention and effectiveness, highlighting the importance of adequate organizational and management support.

An additional consideration is that many community-based organizations may be implementing effective, culturally responsive postpartum transition care strategies that are not reflected in the published literature. These programs often address barriers faced by vulnerable populations through tailored outreach, peer support, and integration of BH and social services. Strengthening collaboration between researchers and community-based organizations could help bridge the gap between evidence and practice, ensuring that the full range of effective postpartum care models is recognized and disseminated. Many of the interventions used platforms that were not clinically embedded (e.g., electronic health records), making integration with clinical services as well as evaluation of clinical outcomes more difficult. Further embedment of peer support into academic-community partnerships will promote both clinical team activation and understanding of their impact on patient outcomes.

Peer support for postpartum BH is unique compared with other conditions in several ways. Postpartum peer support often occurs during a sensitive and time-limited period and frequently addresses not only mental health symptoms but also parenting skills, infant care, social support, and family adjustment.^54,55 Consistent with other reviews of peer support, our findings indicate that these interventions can improve depressive symptoms, social support, and coping skills.^21,22 However, similar to prior literature, benefits are not uniform across participants, and implementation challenges—including training, supervision, and sustainability—are common.¹ These parallels and distinctions highlight the need to tailor peer support interventions to the specific developmental, clinical, and social context of the perinatal period, while learning from established best practices in broader peer support programs.

There are limitations to our study. The exclusion criteria for our study may have limited studies with effective interventions. For example, evaluating only manuscripts written in English and interventions in high-income countries may have limited our assessment of evidence-based interventions in non-English-speaking individuals. In addition, heterogeneity in intervention design, study setting, outcome measures, and follow-up time points limited direct comparisons across studies. Given that the goal of the study was to understand implementation features of peer support intervention, we did not complete risk of bias analysis of the interventions included. Although the included studies were conducted in high-income countries, significant income differences within these settings likely influenced who was able to participate, particularly when access relied on technology, consistent health care engagement, or community-based resources. International studies were included in our study, which enhances generalizability but introduces challenges for interpretation given the wide variation in health care systems, cultural contexts, and postpartum care structures across countries. However, interpretation must be approached cautiously due to substantial differences in health care systems, cultural contexts, and postpartum care structures across countries. Several interventions were facilitated by universal or highly resourced national health systems, contexts in which comprehensive postpartum services are routinely covered and accessible. These structural advantages may limit the direct applicability of such findings to U.S. settings, where fragmented coverage and variable access could affect implementation and impact.

Conclusions

While postpartum BH needs remain undertreated, this scoping review indicates that peer support interventions can be an effective and adaptable strategy to address postpartum BH, with potential benefits for infant well-being. These interventions demonstrate flexibility in design and delivery, making them applicable across various care settings and populations. However, limited reach, sustainability challenges, and ethical considerations related to the well-being of peer supporters continue to limit widespread implementation. Closing these gaps will require integration into existing systems, stronger support structures for peer providers, and strong approaches to scaling that maintain program fidelity.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under cooperative agreement (UR650351), Maternal Health Research Collaborative for Minority Serving Institutions. The information, content, and/or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U.S. government.

Supplemental Material

Abbreviations

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Evaluating Contextual Factors and Implementation of Peer Support Interventions to Address Postpartum Mental Health: A Scoping Review

Abstract

Background:

Methods:

Results:

Conclusions:

Keywords

Introduction

Materials and Methods

Search strategy

Study selection

Data extraction

Linking multiple publications to a single study

Data analysis

Results

Outcome measures

Reach

Effectiveness

Adoption

Implementation

Maintenance

Contextual features

Intervention

Recipients

External environment

Implementation and sustainability infrastructure

Discussion

Conclusions

Footnotes

Author Disclosure Statement

Funding Information

Supplemental Material

Supplemental Material

Abbreviations

References