Enhanced Prenatal Care Models and Postpartum Depression: The EMBRACE Randomized Clinical Trial

Racial, ethnic, and income disparities in perinatal depression prevalence and treatment are partially driven by social determinants of health. Effective treatments addressing these determinants are needed.

To determine whether enhanced group prenatal care (eGPC) outperforms enhanced individual prenatal care (eIPC) for reducing perinatal depressive symptoms.

This randomized clinical trial was conduced in 10 Medicaid-serving clinics in California's San Joaquin Valley, enrolling English- or Spanish-speaking Medicaid-eligible pregnant individuals at less than 25 weeks' gestation, from November 2019 to January 2024, with 2 follow-up surveys through 12 weeks postpartum. Analyses were conducted as intention-to-treat. Data were analyzed from December 2024 to December 2025.

Participants were randomized to eIPC or eGPC. eIPC enhancements included assessments tailored to individual psychosocial, clinical, oral health, and substance use needs. eGPC enhancements included childcare, perinatal mental health screening and referral, transportation stipends, free groceries, and information on community resources.

The primary outcome was depression, operationalized as change in Patient Health Questionnaire-9 scores from baseline to 3 months postpartum. Outcomes were assessed by masked assessors.

Of 1663 individuals assessed, 678 were enrolled and randomized; 4 withdrew consent, yielding an analyzed sample of 674 participants (mean [SD] age, 27.0 [5.8] years), including 50 African American or Black participants (7.4%); 37 biracial, multiracial, or multiethnic participants (5.5%); 485 Latine participants (72.0%); 77 White participants (11.4%); and 24 participants who identified as another race or ethnicity (3.6%). After randomization, there were 294 participants in the eGPC group and 380 participants in the eIPC group. No difference in reductions in depressive symptom severity from baseline to 3 months postpartum by randomization group was observed (Cohen d for between-group change, 0.1; 95% CI, -0.1 to 0.3; P = .45), adjusting for baseline depressive symptom severity, self-reported history of a mental health condition, language, and calendar time at enrollment. Instead, participants in both groups experienced small to moderate reductions in depression symptoms from baseline to 3 months postpartum (eGPC: mean [SD] difference, -2.2 [5.3]; Cohen d = -0.4; 95% CI, -0.6 to -0.3; P < .001; eIPC: mean [SD] difference, -1.6 [4.5]; Cohen d = -0.5; 95% CI, -0.6 to -0.4; P < .001).

In this randomized clinical trial of pregnant, low-income, primarily Latine individuals, statistically significant improvements were observed in depressive symptom severity from baseline to postpartum, regardless of prenatal care type. There was no evidence of a difference between enhanced prenatal care types for improving depressive symptoms.

ClinicalTrials.gov Identifier: NCT04154423.