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Maternal mental health and attachment difficulties: promotional interviewing.

Milford and Oates (1) have produced a valuable protocol to guide health visitors in early postnatal identification and support of women at risk of mental health problems and whose infants are at increased risk of attachment difficulties. The need for early identification has been highlighted by policy, (2-4) and we would suggest some modifications to the pathway, complementary and consistent with the revised Healthy Child programme (HCP): (4)

* Effects of problems such as anxiety, depression, substance misuse and intimate partner violence in the antenatal period (5) mean we should no longer think in terms of identifying postnatal depression, but of promoting psychosocial health and identifying need across the perinatal period. The HCP assumes a health visitor will assess need universally during pregnancy to identify 'moderate' and 'high' levels of need and put support in place. Protocols and care pathways should begin during the antenatal period, with at least one promotional interview repeated after birth by the same health visitor

* Promotional interviewing is an evidence-based partnership method to support and screen women. The HCP recommends that health visitors be able to meet and conduct an antenatal promotional interview with all mothers at around 28 weeks. This offers an opportunity for parents-to-be to explore feelings, attitudes and expectations about the birth of their child, leading to better informed decisions. It also enables health visitors to begin to build a trusting relationship and to identify possible problems that may interfere with the ability to parent

* The promotional interview can be modified to include the use of Whooley questions, and other standardised tools of the type referred to by Milford and Oates, and two-day training in its use is now available. (6) The evidence strongly supports the case for the use of such standardised tools, but only as part of a partnership model of working with families

* Where there is 'moderate' concern during pregnancy, listening visits should be offered before the birth. During listening visits, health visitors should aim to support parents to explore and reflect on what their baby might be like. Aspects of the promotional interview can also be incorporated into the postnatal complementary care packages outlined by Milford and Oates. Women for whom there is 'high' concern should have appropriate care pathways put in place, including referral to specialist services

* The HCP recommends a second promotional interview by the same health visitor at around six to eight weeks. Listening visits are effective in improving maternal depression, but may not improve mother-infant interaction. (7) Their progressive provision by health visitors to support women with moderate need should include a focus on mother-infant interaction, and perhaps modelling, identifying strengths in the mother's interactions with her baby, anticipatory guidance, and encouraging play and taking the baby's lead. The HCP highlights other ways to support mother-infant interaction, such as infant massage. (8)

Training and contact for all health visitors to conduct a promotional interview at around 30 weeks is being piloted in Warwick and Leamington children's centres. This visit will allow the conduct of a promotional interview and include the use other of other tools such as the Social Baby DVD. It will be followed by a further visit by the same health visitor at six to eight weeks.

(1) Milford R, Oates J. Universal screening and early intervention for maternal mental health and attachment difficulties. Community Practitioner, 2009; 82(8): 30-3.

(2) Department of Health. National Service Framework for children, young people and maternity services. London: HMSO, 2004.

(3) National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health: clinical management and service guidance. London: National Institute for Health and Clinical Excellence, 2007.

(4) Department of Health. The Child Health Promotion Programme: pregnancy and the first five years of life. London: HMSO, 2008.

(5) Bergner S, Monk C, Werner E. Dyadic intervention during pregnancy? Treating pregnant women and possibly reaching the future baby. Infant Mental Health Journal, 2008; 29(5): 399-419.

(6) Warwick Infant and Family Wellbeing Unit. Training. Available at: (accessed 11 September 2009).

(7) Poobalan AS, Aucott LS, Ross L, Smith WCS, Helms PJ, Williams JHG. Effects of treating postnatal depression on mother-infant interaction and child development: systematic review. British Journal of Psychiatry, 2007; 191: 378-86.

(8) Underdown A, Barlow J, Stewart-Brown S. Infant massage: findings of a systematic review. Journal of Reproductive and Infant Psychology, 2009; (in press).

Jane Barlow, Angela Underdown Director and deputy director, Warwick Infant and Family Wellbeing Unit

Jane Williams, Theresa Bishop Head of children, young people and family services and professional lead for health visiting, Warwickshire Community Health

Kirstie McKenzie-McHarg Chartered clinical psychologist in perinatal psychology, Warwick Hospital
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Title Annotation:LETTERS
Author:Barlow, Jane; Underdown, Angela; Williams, Jane; Bishop, Theresa; McKenzie-McHarg, Kirstie
Publication:Community Practitioner
Article Type:Letter to the editor
Geographic Code:4EUUK
Date:Oct 1, 2009
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