Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial

Abstract

Objective To assess the efficacy of an intervention designed to improve the mother-infant relationship and security of infant attachment in a South African peri-urban settlement with marked adverse socioeconomic circumstances. Design Randomised controlled trial. Setting Khayelitsha, a peri-urban settlement in South Africa. Participants 449 pregnant women. Interventions The intervention was delivered from late pregnancy and for six months postpartum. Women were visited in their homes by previously untrained lay community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother. Women in the control group received no therapeutic input from the research team. Main outcome measures Primary outcomes: quality of mother-infant interactions at six and 12 months postpartum; infant attachment security at 18 months. Secondary outcome: maternal depression at six and 12 months. Results The intervention was associated with significant benefit to the mother-infant relationship. At both six and 12 months, compared with control mothers, mothers in the intervention group were significantly more sensitive (6 months: mean difference=0.77 (SD 0.37), t=2.10, P<0.05, d=0.24; 12 months: mean difference=0.42 (0.18), t=−2.04 , P<0.05, d=0.26) and less intrusive (6 months: mean difference=0.68 (0.36), t=2.28, P<0.05, d=0.26; 12 months: mean difference=−1.76 (0.86), t=2.28 , P<0.05, d=0.24) in their interactions with their infants. The intervention was also associated with a higher rate of secure infant attachments at 18 months (116/156 (74%) v 102/162 (63%); Wald=4.74, odds ratio=1.70, P<0.05). Although the prevalence of maternal depressive disorder was not significantly reduced, the intervention had a benefit in terms of maternal depressed mood at six months (z=2.05, P=0.04) on the Edinburgh postnatal depression scale). Conclusions The intervention, delivered by local lay women, had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development. If these effects persist, and if they are replicated, this intervention holds considerable promise for use in the developing world. Trial registration Current Controlled Trials ISRCTN25664149.

Interventions for common perinatal mental disorders in women in low- and middle-income countries: a systematic review and meta-analysis

“…1). [22][23][24][25][26][27][28][29][30][31][32][33][34][35] China contributed three trials; India, Pakistan and South Africa contributed two trials each, and Chile, Jamaica, Mexico and Uganda contributed one each. Twelve studies were controlled and randomized either at the individual or the cluster level and one study 28 used a historical matched control from another epidemiological study.…”

“…However, the researchers hypothesized that individual parenting education provided by a supportive home visitor or within the context of a mother's group might also improve maternal depression and improve infant health and development. In South Africa, Cooper et al 26,28 demonstrated what neonates could do using a neonatal assessment scale. In a study conducted by Baker-Henningham et al 22 in Jamaica and in the adapted Learning Through Play (LTP) programmes implemented in Pakistan 24 and northern Uganda, 35 mothers were shown ageappropriate play activities and how to craft toys out of affordable, accessible materials to stimulate infant cognitive development.…”

“…Ho et al 33 and Lara et al 31 provided information about the symptoms and causes of postpartum depression in an information booklet and supplemented this with either supportive discussion with a primary care nurse to encourage early help-seeking behaviour, 33 or participation in a series of group discussions facilitated by professionals. 31 Five studies 22,24,26,28,35 did not address maternal mental health directly. However, the researchers hypothesized that individual parenting education provided by a supportive home visitor or within the context of a mother's group might also improve maternal depression and improve infant health and development.…”

“…In these studies, the social determinants of perinatal depression in women were either reported as relevant by participants or explicitly recognized on a theoretical level. [24][25][26][27][28]35 Such determinants include, for example, living in poor and overcrowded housing, suffering social exclusion as a result of illiteracy and unemployment, being a victim of the gender stereotypes that restrict women's social participation or underpin hostility towards women, and experiencing social instability and neighbourhood violence. 22 No study addressed these determinants directly.…”

“…23,29,31,33 In all other studies they were implemented by local trained community health workers under professional supervision. In seven interventions involving individual home visits, 22,[24][25][26][27][28]35 the therapeutic relationship between the health worker and the study participant was regarded as an important determinant of improvements in mental health. In this relationship, trust was of utmost importance.…”