Inside the black box of a successful parent-infant intervention in a South African informal settlement : mothers' and counsellors’ accounts of the process

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 t=−2.04 , P mean difference=0.68 (0.36), t=2.28, P 12 months: mean difference=−1.76 (0.86), t=2.28 , P 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 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. INTRODUCTION Extensive research over the past three decades has shown that when infants experience reliable care that is sensitive to their developmental needs over the first year or so of life, they are likely to develop a secure attachment to their principal carer, usually their mother, and that this security of attachment endures through to adulthood. In turn, security in the infant’s key attachment relationship is associated with better outcomes in several domains of development, in both the short term and the longer term. In early andmiddle childhood, the benefits of a secure attachment are prin- cipally shown in good peer relationships and socio- emotional adjustment ; in adulthood, associations are consistently foundwith lower rates ofmental health problems. Notably, emerging evidence also indicates benefits of secure attachments for physical health, including lowered rates of failure to thrive in infancy and early childhood, fewer chronic and recurrent health problems, and better health and lifestyle prac- tices in adulthood (for example, in relation to smoking, drug use, and sexual behaviour), and these benefits are reliably associated with lower health costs. The capacity of parents to provide the kind of care that promotes security of attachment in infancy and good developmental outcome in childhood can be severely compromised in adverse conditions such as poverty, particularly when mothers have depression. This is of particular concern in School of Psychology, University of Reading, Reading RG6 6AL Health Systems Research Unit, Medical Research Council, and University of Cape Town, 7505 Tygerberg, South Africa Department of Psychology, Stellenbosch University, Matieland 7602, South Africa Parent Centre and Stellenbosch University, Matieland Department of Psychiatry and Mental Health, Groote Schuur Hospital, Cape Town, South Africa Department of Psychiatry, University of Oxford, Oxford OX3 7JX Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford University, Oxford OX3 9DU Correspondence to: P J Cooper p.j.cooper@rdg.ac. uk Cite this as: BMJ 2009;338:b974 doi:10.1136/bmj.b974 BMJ | ONLINE FIRST | bmj.com page 1 of 8 on 18 May 2009 bmj.com Downloaded from