Evaluating health visitor assessments of mother–infant interactions: A mixed methods study

Abstract

Background

Given the significance of reliably detecting cases where mother–infant relationships are not developing successfully, it is important that initial assessment processes are as sensitive and specific as possible.

Objectives

This study sought to examine the processes by which health visitors identify problems in mother–infant relationships in the post-natal period.

Design

Mixed methods.

Settings

Two universities and two primary care trusts.

Participant

In Phase One 17 first-time mothers and their 6- to 16-week-old infants were recruited. In Phase Two, a sample of 12 health visitors participated.

Methods

The study incorporated two data collection phases. In Phase One, each mother's interaction with her baby was video-recorded for 20 min in an observation laboratory. The video-recordings were coded and resultant data were analysed to derive a number of quantitative measures of interaction quality, including mothers’ responsiveness and sensitivity to their infants as rated by the Global Ratings Scales (GRS) of Mother–Infant Interaction. In Phase Two, 12 health visitors rated and assessed 9 clips of the video-recorded mother–infant interactions. The rationales for their ratings were then explored through in-depth interviews. Health visitor ratings of the video clips were compared to the GRS ratings. The relationship between the main focus of each health visitor rating, as reported in the interview, and the consistency of ratings with the GRS ratings were then investigated.

Results

Correlations between individual health visitors’ ratings and the GRS ratings ranged from .17 to .83 and were statistically significant in only four cases. There was a weak relationship with health visitors’ years of experience (r_s = .47, NS). When explaining their judgements, health visitors tended to comment on the mother's behaviours or the relationship between the mother and baby and often ignored the behaviour of the baby. There was a highly significant relationship between the consistency of health visitor/GRS ratings and the number of references to the baby in the health visitors’ explanations (r_s = .75, p = .005).

Conclusion

This study contributes to the understanding of how health visitors make assessments of mother–infant interactions. The frequent lack of attention and reference to the baby's behaviour suggests an area for further training.

Introduction

The establishment and maintenance of a healthy, warm and reciprocal relationship between a mother and her newborn infant is a crucial component in early child development (Bowlby, 1969, Gerhardt, 2004). For a majority of mothers, this is an expected outcome of the first weeks following the birth and, to a greater or lesser degree, most mothers achieve a satisfactory emotional bond with their infants that provides a sound basis for the future development of their relationships. However, a substantial number of mothers do encounter difficulties in establishing this basic emotional connection with their infant during the post-partum period and beyond, for a variety of different reasons. For example, for some it may be experiences in their own childhood which make it difficult for them to relate to their infant; for others it may be that the infant's temperament poses a challenge that they find hard to meet (Sutter-Dallay et al., 2003), while others may experience postpartum depression (Murray and Cooper, 1996, Morrell and Murray, 2003, Murray et al., 2003). Such difficulties are commonly exacerbated by limited support being available from a partner or wider social network, or other disadvantaging factors.

A large body of research has now established that appropriate early interventions to improve mother–infant relationships can be effective (Berlin et al., 2005, Svanberg, 2009, Robinson, 2010). This is true not only for the short term, in supporting mothers in overcoming the difficulties that they face in bonding with their infants, but also in avoiding the major longer term social and economic costs of children's attachment disorders. A secure attachment between mother and infant is now recognised as a key component in protecting against the effects of other risk factors and leading to positive mental health and good social relationships into adulthood (Oates, 2007).

There is also a growing body of evidence that links the failure to address the needs of children with negative outcomes in terms of their later social and emotional development and their ability to form positive social relationships (Mcdonald, 2001). Evidence from neurobiological studies is increasingly showing that brain development is associated with the quality of the emotional support and social environment in which an infant is nurtured (Schonkoff and Phillips, 2000, Hosking and Walsh, 2005, Moulson et al., 2009a, Moulson et al., 2009b, Nelson et al., 2009). In particular, studies have provided evidence of the deleterious effects on brain function of maltreatment and increases in stress hormones in childhood (Glaser, 2000, Teicher, 2002, Bremner et al., 2003, Hosking and Walsh, 2005). In a report for the World Health Organisation, Irwin et al. (2007: 7) have stressed the importance of “the nurturant qualities of the environments where children grow up, live and learn” for early child development.

In the United Kingdom (UK), the Healthy Child Programme (HCP), led by health visitors, is the core health service for promoting, protecting and improving the health and wellbeing of infants and children (DH, 2009). Health visitors (UK public health nurses) provide a crucial interface with mothers in the period following the delivery of a new infant. These professionals have contact with all new mothers from this time and are uniquely placed to detect incipient problems in the development of the mother–infant relationship (NICE, 2006) and to mobilise appropriate support and intervention at a time when it can be of most benefit (DH, 2011). In a clinical encounter health visitors are likely to be making a number of different types of judgements (Appleton and Cowley, 2008a, Appleton and Cowley, 2008b), while drawing on professional knowledge and tools such as the Edinburgh Postnatal Depression Scale (Cox et al., 1987, Morrell et al., 2009) to make an assessment of the extent and nature of a client's difficulties, and to decide on the most appropriate form of further support to offer. At the same time they will be considering safeguarding and other issues as well (Appleton, 2011).

Thus, the decisions made at this point are of key importance to the successful resolution of mother–infant difficulties through the provision of appropriate services. The importance of such early intervention work with children and families has also been outlined in a number of recent high profile reviews including Graham Allen's (2011) work on early intervention, Frank Field's (2010) report on childhood poverty and life chances and Eileen Munro's (2011) review of child protection. Furthermore, given the UK Government's commitment to expand the Health Visiting service by an additional 4200 health visitors by 2015 (DH, 2011), it is essential that health visitors’ initial assessment processes are as sensitive and specific as possible. An assessment that correctly identifies problems in the relationship between mother and infant at an early stage will enable mothers to be referred to the appropriate support that is best matched to their needs.

While standardised tools for assessing mother–infant interactions do exist in research contexts, for example, the CARE-Index (Crittenden, 2005), the PIRAT (The Parent–Infant Relational Assessment Tool) (Broughton, 2010) and NCAST PCI (parent–child interaction) Scales (Mischenko et al., 2004), they require specialist training and are not widely used in health visiting. As an example of the translation of such approaches into practice, Milford and Oates (2009) have developed a protocol to guide health visitors in the early identification of maternal mental health problems and infant attachment difficulties which is part of a care pathway programme.

There is limited published research evidence of how health visitors make assessments of mother–infant interactions, and these studies rely largely on health visitors’ reports of their practice. In a focus group study with 24 health visitors, Wilson et al. (2008) reported health visitors drawing on multiple sources of information in assessing parent–child relationships, as Appleton and Cowley, 2003, Appleton and Cowley, 2008a and McAtamney (2011) have also reported, including behavioural observations, use of risk factors, knowledge of local norms and intuitive reactions. These researchers found that the health visitor sample had received little formal training on analysing social relationships between parents and children (Wilson et al., 2008). In a later pilot study Wilson et al. (2010) explored how well health visitors agreed in their observations of 4 video-recorded mother–child interactions, where the children were one year of age. They found less agreement amongst the health visitors when “high frequencies of negative behaviours were seen alongside positive behaviours” (Wilson et al., 2010: 20); and while health visitors were more likely to identify problems after a half hour training session, they were asked to rate the same videos post-training, so there may well have been practice effects.

It was this dearth of research evidence about how health visitors assess early post-natal mother–infant interaction that led us to conduct this study. We wanted to address this gap in the research literature through a mixed-methods approach, and this paper reports on a study which examined the ways in which health visitors assess mother–infant interactions in the post-natal period, and the consistency of judgements between different health visitors.