Department of Psychology, University of Reading, UK
Parent Centre, Rosebank, Cape Town, South Africa
Department of Psychology, University of Cape Town, South Africa
Department of Psychiatry, Groote Schuur Hospital, University of Cape Town, South Africa
Department of Psychology, University of Stellenbosch, South Africa
Department of Psychology, University of Reading, UK
Correspondence: Professor Peter Cooper, Winnicott Research Unit, Department of Psychology, University of Reading, Whiteknights, Reading RG6 6AL, UK. E-mail: p.j.cooper{at}reading.ac.uk
Declaration of interest The study was supported by the World Health Organization and the Wellcome Trust.
1 Data on breast-feeding missing for two of the comparison group.
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ABSTRACT |
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Aims To train community workers to deliver an intervention to mothers and infants in Khayelitsha, and to compare mothers and infants receiving this intervention with a sample receiving no such intervention.
Method Four Khayelitsha women were trained in a motherinfant intervention, which they delivered to 32 women recruited in late pregnancy. At 6 months post-partum, maternal mood, the motherinfant relationship and infant growth were assessed. The findings were compared with a matched group of 32 mothers and infants.
Results There was no reliable impact of the intervention on maternal mood. However, compared with the comparison sample, the quality of motherinfant engagement was significantly more positive for those who had received the intervention.
Conclusions The pilot study produced preliminary evidence of a benefit of a community-based motherinfant intervention delivered by trained, but otherwise unqualified, community workers, sufficient to warrant a formal controlled evaluation of this treatment.
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INTRODUCTION |
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METHOD |
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Sample recruitment
Over the course of a 6-month period in 1998, a sample of 40 pregnant women
in a defined area of Khayelitsha (Makhaya) were approached and invited to
receive an intervention in the context of a study of its efficacy. All agreed.
Eight of the women either moved away within 2 months of the delivery or sent
their infants to relatives in distant parts of the country within the same
period.
Nature and delivery of the intervention
The intervention delivered was based on an adaptation of the Health Visitor
Preventive Intervention Programme (further details available from the author
upon request). This was adapted specifically for the Khayelitsha project by
incorporating the key principles of the World Health Organization
(1995) document Improving
the Psychosocial Development of Children, and by extending the
intervention until 6 months post-partum. The aim of the intervention was to
provide the mother with emotional support and to encourage her in sensitive
responsive interactions with her infant. A major aspect of the intervention
was the use of particular items from the Neonatal Behavioural Assessment
Schedule (NBAS; Brazelton & Nugent,
1995) to sensitise the mother to her infant's individual
capacities and sensitivites. In addition, based on the findings of this
assessment, specific advice was formulated concerning aspects of infant
management (e.g. sleep regimen, crying, feeding).
The intervention was delivered by four community workers, who had been selected by a subset of the authors in consultation with the local community council. These women had no specialist qualifications and, indeed, had limited schooling. They received training in basic counselling skills as well as in the specific motherinfant intervention. They delivered this intervention to the women in their homes in sessions lasting approximately an hour. The intervention involved women being visited twice antenatally, twice weekly for 4 weeks postnatally, weekly for 8 weeks, fortnightly for a month, and then monthly for 2 months. Written records were kept of each intervention session and these were reviewed weekly as part of a group supervision process (under the supervision of M.L.). In addition, each community worker taperecorded all the sessions involved in their last two cases and a random selection of the sessions was transcribed and subjected to a content analysis.
Assessments
The women were assessed at 6 months post-partum following the intervention.
A set of questions were drawn up to assess the mother's view of the help she
had received from the community worker. (This was an adaptation of a
questionnaire used in a study of health visitor intervention conducted in
Reading in the UK. The questionnaire is available from the author upon
request.) These questions were put to the mother in a standardised form by an
independent assessor. Another independent assessor carried out three
assessments. First, maternal mood was assessed, using a translated version of
the major depression section from the Structured Clinical Interview for DSM-IV
diagnoses (SCID; First et al,
1996). The depression section of the SCID interview was translated
into Xhosa, back-translated into English and then translated back into Xhosa.
Second, basic anthropometric measures were taken of the infant. Finally, at
the end of the intervention video recordings were made of the mothers and
infants within the research base during two situations: free play and the
mother feeding the baby. Each of these lasted 5-10 minutes. Following a
viewing of a subset of these video recordings, a rating system was devised.
The play interactions were coded on three variables: one concerned maternal
sensitivity, one the overall quality of the interaction and one the infants'
overall engagement in the interaction. The feeding interactions were also
rated on three dimensions, all concerning the quality of the mothers'
interactive behaviour: interactive engagement, affective expression and
overall sensitivity. Each of these was rated on an eight-point scale. Two
codes rated 19 of the interactions independently to assess reliability.
Satisfactory reliability was achieved for three of the scales: maternal
sensitivity during play (tau=0.62, P < 0.001), affective
expression during feeding (tau=0.90, P < 0.001) and sensitivity
during feeding (tau=0.74, P < 0.001).
The outcome at 6 months of the mothers and infants who had received the intervention was compared with a sample, selected by group-matching mothers and infants (i.e. on two of the following three variables: maternal age, parity and marital status) drawn from an epidemiological sample recruited and assessed in an adjacent area of Khayelitsha at the same time the interventions were being delivered (Cooper et al, 1999).
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RESULTS |
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Demographic characteristics
The demographic characteristics of the 32 women who received the full
intervention, together with the 32 comparison mothers, are contained in
Table 1. The groups differed in
terms of age and educational attainment. The women in the intervention group
were older (2=8.90, d.f.=2, P=0.01) and better
educated (
2=6.74, d.f.=1, P=0.01) than the comparison
group. The groups were comparable for the other demographic characteristics
shown.
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Virtually all the women in both groups initiated breast-feeding (i.e. 94% (30/32) of the intervention group and 97% (29/30)1 of the comparison group), of whom around two-thirds were still breast-feeding by 6 months (i.e. 66% (21/32) and 70% (21/30), respectively).
Mothers' perception of the intervention
A questionnaire was used to assess whether the mothers found the
intervention to be of help and the degree to which the mothers perceived the
intervention to have enhanced their sensitivity to their infants' needs and
capacities. Given a four-point choice of strongly agree,
moderately agree, slightly agree and
disagree, 90% (29/32) of the mothers strongly or moderately
agreed with the statement that the community worker had really
understood how I felt, and 94% (30/32) strongly or moderately agreed
with the statement that the community worker made me feel
supported, with the statement that I felt she was on my
side and with the statement that I felt that I could trust her
and talk openly about myself to her. Statements about the help given
with caring for the infant were similarly positively endorsed. For example,
90% (29/32) of the mothers strongly or moderately agreed with the statement
that the community worker helped me to solve problems I was having with
my baby. Several statements concerned with enhanced maternal
sensitivity to the infant were also positively endorsed. Thus, all the mothers
strongly or moderately agreed with the statement that the community workers
had made me appreciate the things that my child can do, and 90%
(29/32) agreed with the statement that she helped me understand my
child's needs and the statement that she showed me how to
respond to what my child was doing. Endorsement of negative statements
was extremely rare.
Maternal mood
The rate of DSM-IV major depression
(American Psychiatric Association,
1994) at 6 months post-partum was 19% (6/32) in the index group
compared with 28% (9/32) in the comparison group. After controlling for age
and level of education, using a MantelHaenszel test
(Armitage & Berry, 1996),
this difference was found not to be significant
(2MH=2.00, d.f.=1, P=0.16).
Motherinfant engagement
The three reliable interaction variables were transformed into binary
variables (i.e. none or little v. at least to a moderate degree). As
can be seen from Fig. 1, there
was evidence for a benefit of the intervention. Thus, after controlling for
age and education, relative to the comparison group, in the play and feeding
situations the index mothers showed greater sensitivity
(2MH=5.19, d.f.=1, P=0.02, and
2MH=5.95, d.f.=1, P=0.1, respectively),
and in the feeding situation there was an indication that they expressed more
positive affect (
2MH=3.11, d.f.=1,
P=0.08).
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Infant growth
Differences were observed between the two groups at 6 months in terms of
infant physical development (Fig.
2). These differences were tested using the MannWhitney
U test. The infants in the intervention group were significantly
heavier (P=0.01) and their weights were less variable than those of
the comparison group infants, i.e. median=85th centile (IQR=34) and 66th
centile (IQR=46) respectively. Height also differed significantly between the
two groups (P=0.02), with infants in the intervention group being
taller than those in the comparison group: median=75th centile (interquartile
range, IQR=42) and 58th centile (IQR=61) respectively. No significant
difference was found between the two groups for weightlength ratio (the
median BMI was 18.2 (IQR=4) for the intervention group and 17.7 (IQR=2.5) for
the control group) or for head circumference
(Fig. 2).
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In order to determine whether any association between group membership and
growth remained after controlling for the possible effects of breast-feeding
persistence and maternal age, CochranMantelHaenszel tests were
performed. Weight and height were both reduced to three class ordinal
variables below the 25th centile, 25-75th centile and above the 75th
centile. For infant weight, taking account of both breast-feeding persistence
and age, an indication of an intervention effect remained
(2MH=5.3, d.f.=2, P=0.07). For all age
groups (i.e. <28, 28-33, >33 years), among those whose mothers were
still breast-feeding at 6 months, a higher proportion of infants in the
intervention group than the comparison group were found to have a weight above
the 75th centile. For infants who were no longer being breast-fed, higher
proportions above the 75th centile for weight were also seen in the
intervention group than in the comparison group for the higher and the lower
age groups. Of the six infants below the 25th centile, five were from the
comparison group and only one from the index group. When infant height was
considered, the effect of the intervention remained significant when account
was taken of both breast-feeding persistence and age
(
2MH=6.5, d.f.=2, P=0.04); both for those
still breast-feeding at 6 months and those who had ceased breast-feeding, for
the higher and lower age groups, higher proportions of infants in the
intervention group than the comparison group were found to have a weight above
the 75th centile. Of the nine infants below the 25th centile on height, seven
were from the comparison group and only two from the index group.
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DISCUSSION |
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Post-partum depression in a South African peri-urban settlement
A high rate of post-partum depression has been reported in a South African
peri-urban settlement (Cooper et
al, 1999). It was also found that, as in Western samples
(Murray & Cooper, 1997), there was a strong association between maternal depression and disturbances in
the motherinfant relationship. This is a serious cause for concern. Not
only is children's developmental progress likely to be compromised by the
extreme levels of social and economic adversity which obtain in this South
African context (and in similar situations around the developing world), but
it is likely to be further jeopardised by the impact of such forces on the
quality of care infants receive from their mothers. It is, therefore, of
paramount importance that interventions are developed and evaluated to support
mothers and families living in indigent peri-urban contexts in caring for
young infants.
A study by Wendland-Carro et al (1999) of a small, disadvantaged Brazilian sample found positive benefits from a brief intervention intended to enhance the quality of the early motherinfant relationship. The intervention was designed to motivate mothers to be involved with their infants and to promote affectionate handling of the infant. It consisted of just one session during which a video was shown of infant capacities (based on an administration of the NBAS; Nugent & Brazelton, 1989), followed by a discussion with the mother emphasising the infant's potential to interact and the importance of affectionate and sensitive handling. This session was supplemented by written material. When motherinfant interactions were assessed 1 month later, in comparison with a group of mothers who did not receive this intervention, the index motherinfant dyads were found to have significantly more synchronised interactions, involving mutual gaze, vocalisations and smiles, and index mothers were more responsive to infant cries.
The findings of Wendland-Carro et al (1999) are surprising and encouraging. Early family intervention programmes in the past have usually been intensive, long-term treatments (e.g. Olds & Kitzman, 1993; Heinicke et al, 1999), lasting for at least 2 years. If brief programmes directed at the quality of motherinfant engagement can effect significant change in the motherchild relationship, then it is important to develop and evaluate such treatments, especially in high-risk populations.
The nature of the intervention
The pilot study described here was an evaluation of just such an
intervention. A treatment developed for delivery by trained health visitors in
Britain (further details available from the author upon request) was adapted
for delivery by trained, but otherwise unqualified, community workers in the
South African context. The training of the community workers in delivery of
the treatment was preceded by several focus group meetings concerned with
child-care beliefs and practices, and the community workers themselves were
given considerable latitude to shape the intervention. Cultural norms
surrounding the concept of infancy and child-care practices were taken into
account in delivering the intervention. Although there were consequently
differences in the implementation of the intervention in the African context
as opposed to the original British setting, the central tenets of the
intervention, which concern maximising the potential for sensitive
motherinfant engagement, appear to be equally acceptable and
appropriate for the two cultures.
Use of unqualified community workers
Questions have been raised about the appropriateness of using unqualified
workers in home-based family interventions. Indeed Olds & Kitzman
(1993) reported that of six
intervention programmes that were effective in enhancing child cognitive
development, five employed professional or highly trained staff. If the
disappointing findings reported from developed-world studies using unqualified
workers were to be replicated in the developing world, this would have grave
implications. The skilled human resources are simply not available in such
circumstances to provide a home-based service to more than a tiny proportion,
if any, of the population (Freeman &
Pillay, 1997). Yet, as our South African epidemiological study
revealed, in the context of the adversity which is endemic in these peri-urban
circumstances, disturbances in the early motherinfant relationship are
common. If a service is to be provided to meet the need, then it must
necessarily be a service that can be provided by the community itself.
Mothers' perceptions of the intervention
An encouraging finding of the study was that the intervention was extremely
well received by the mothers. Not only was it the common experience of the
mothers to feel well supported by the community workers, but they also felt
helped in the understanding and management of their baby. In no case was the
intervention regarded by the mother or the wider family as an unwanted
intrusion. This stands in contrast to home-based interventions in developed
countries, where high-risk populations not uncommonly perceive the
ministrations of a clinical or social agency as an intrusion
(Egeland & Erickson,
1990).
Impact of the intervention on the motherinfant
relationship
This study did not involve random assignment of participants to an
intervention and a properly constituted control condition. Indeed, it is
simply a comparison between two groups, one of which received an intervention.
Therefore, the findings can only be regarded as preliminary and must be
interpreted with caution. It is nevertheless encouraging that, based on the
small sample of women and infants who received the index intervention, an
advantage over the group who had not received it did emerge. In particular,
the mothers of those who had received the intervention were rated as being
more sensitive and more affectionate to their infants.
Two further findings require comment. First, although there was no reliable
antidepressant effect of the index intervention, there was a suggestion that,
assuming no pre-treatment difference obtained between the two groups studied,
should the current findings be replicated in a larger controlled trial, an
antidepressant effect might emerge. (If the 6-month post-partum rates in the
current study are robust, with 80% power and set at 0.05, two groups
of 180 would produce a significant difference in the rate of depression.)
However, the absence of a clear impact of treatment on maternal mood is,
perhaps, unsurprising. The social factors found to be associated with maternal
mood disorder in these highly adverse circumstances
(Cooper et al, 1999)
relate to the inordinate difficulties of having a child in these circumstances
and the absence of family support. It is, perhaps, over-optimistic to expect
that a home visit once a week, however sympathetic and supportive, would be
sufficient to counter such powerful social forces. The second finding
requiring comment concerns the anthropometric data. Although it was the case
that there was some evidence of a significant advantage for the intervention
in terms of infant weight and height, this needs to be interpreted with
caution. While the intervention appeared to protect against very low infant
weight, it was also associated with rather high weights. It is possible that
the additional attention the mothers who received the intervention were giving
their infants could, despite advice to the contrary, have led to excessive
feeding. Longer-term follow-up of a properly controlled sample would reveal
whether there is a genuine benefit of the intervention to infant physical
development.
The findings of the study are promising. They suggest that it might well be possible to improve the quality of the early motherinfant relationship in indigent peri-urban contexts using unqualified community workers to deliver an intervention. They also indicate that, despite the difficulties inherent in working in the peri-urban environment, it is possible to conduct rigorous research. In view of these considerations, a controlled clinical trial of this intervention is now being carried out in Khayelitsha.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication November 23, 2000. Revision received June 15, 2001. Accepted for publication July 20, 2001.
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