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ocial adversity and poor maternal mental the effectiveness of antenatal interventions on the
health during pregnancy can have long-term reduction of maternal distress was inconclusive.
adverse effects on childrens health, social, One exception is the Family Nurse Partnership
educational and economic outcomes (OConnor (FNP) intervention. FNP specifically targets
et al, 2002; Olivier et al, 2015). Women with social vulnerable and/or disadvantaged young women
difficulties are more likely to suffer from stress, who are having their first baby. The long-term
depression and/or anxiety during pregnancy, impact of FNP in the UK is currently being
which may disrupt maternal sensitivity to the evaluated, although short-term results suggest
infants cues (Pearson et al, 2011). Poor mother an improvement in maternal sensitivity (Barnes
child interaction and poor maternal mental health et al, 2011). However, FNP is an intensive and,
strongly predict child maltreatment (Pawlby et therefore, expensive intervention, provided to a
al, 2011). Children who experience neglectful or limited sub-group of pregnant women. It may not
abusive, rather than nurturing, relationships in be transferable or feasible to offer this intervention
Dr Jane White 1 their early years are more likely to be disadvantaged to other women.
Dr Lucy Thompson 2 throughout their life (Mntymaa et al, 2004). This paper reports an exploratory trial of Mellow
Dr Christine Puckering 3 Language skills are more likely to be limited Bumps (MB). The impact on the mental health
Harriet Waugh 4 (Sylvestre and Mrette, 2010), with a potential of pregnant women with substantial additional
Dr Marion Henderson 5 negative impact on long-term outcomes such as health and social care needs of participation in a
Dr Angus MacBeth 6 educational attainment, mental health and levels MB group and that of a comparison intervention
Professor Philip Wilson 7 of employment (Law et al, 2009). (Chill-out in Pregnancy) was compared with
Improved antenatal support and more effective care-as-usual.
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For job titles and engagement with women facing social adversity has
affiliations see end been recognised as a priority if health inequalities Mellow Bumps
of article are to be reduced (Marmot, 2010). Maternal and MB is a group-based parenting intervention
contextual factors, such as substance misuse, designed to support pregnant women with
additional health and social care needs. MB was The programme is delivered non-didactically to
developed by Scotland-based charity Mellow maximise participant engagement and rapport.
Parenting (www.mellowparenting.org) as one Each session, which lasts 2 hours, incorporates one
of a range of early intervention programmes subject related to maternal wellbeing and one with
that promote positive relationships in families an infant focus. Maternal topics include healthy
(Breustedt and Puckering, 2013). MB aims to eating, exercise, having fun as well as exploring
encourage nurturing, engagement and attunement barriers to good parenting and beneficial sources
between mother and baby by decreasing maternal of support. Infant subjects include information
antenatal stress levels and increasing expectant about competencies, infant brain development
mothers understanding of the neonates and the significance of very early interaction for
capacity for social interaction. It is underpinned shaping development. There is an emphasis on
by attachment and self-regulatory theories. practical activities, viewing videos and discussion,
Qualitative evaluations have described positive rather than written materials. At the end of each
outcomes (Breustedt and Puckering, 2013; Birtwell week there is a guided relaxation session (Figure1).
et al, 2015).
MB is offered between 2030 weeks gestation, Chill-out in Pregnancy
to capture the period when the risk of miscarriage Chill-out in Pregnancy (CHiP) is a group-based
is low and fetal movement is felt, but before antenatal support programme underpinned by
major preoccupation with giving birth. Six self-regulatory theory. Like MB, it is designed
sessions are offered weekly pre-birth and there to be offered between 2030 weeks gestation.
is a reunion session around 3 months post-birth. The format of CHiP is similar to MB, with the
Six weekly
2-hour
sessions
> social connectivity
Strategies Awareness > knowledge of
Baby topic to reduce of baby attachment and
stress infant development
Activity for < stress
mother-to-be
Figure1:MellowBumps(BreustedtandPuckering,2013)
Six weekly
2-hour
sessions
Figure2:Chill-outinPregnancy
Clyde (NHS GGC). Both NHS health authorities Analyses were conducted using SPSS version 19
are in the west of Scotland. About 40% of the for Windows. Descriptive statistics were used to
population of Inverclyde CHCP live in one of describe the baseline scores of each study group,
the 15% most-deprived geographical areas of and Pearsons chi-square tests or independent
samples t-tests were used to determine whether statistically significant differences in the baseline
groups differed on these scores. Differences measures between the allocation groups (P0.05).
between post-intervention scores, accounting
for the effect of pre-intervention scores, were Change over time
measured using analysis of covariance (ANCOVA). The changes in EPDS and AWS scores by group
At each data-collection point, participants allocation between baseline and the two follow-up
were also asked to provide saliva samples, by data-collection points are illustrated in Figure 5.
drooling or spitting into provided receptacles, There seemed to be a trend towards improvement
for cortisol assays. Samples were to be collected in all outcome measures in all groups over time.
on three occasions (on waking, 45 minutes later Participants in the intervention groups appeared
and last thing at night) each day, repeated on to show improvements in the EPDS and some of
2 consecutive days. the AWS subscale scores that were not replicated
At 812 weeks post-birth, participants were in the CAU group. Nevertheless, no statistically
invited to take part in a semi-structured interview significant differences (P0.05) between the
to talk about their experiences and to be filmed groups were found.
while they cared for their baby. Interviews were
audio-recorded and transcribed verbatim. The
Referred n=50
videos were examined using the Mellow Parenting
Observation System (Puckering et al, 2014). Declined n=11
Failed contact n=4
Results Recruited n=35
Mellow Bumps n=12
Sample
Chill-out in Pregnancy n=9
Thirty-five women were recruited to the
Care-as-usual n=14
project. Of 31 participants who completed the Withdrew n=2
questionnaires at baseline, 21 (68%) completed Failed contact n=2
the information at all three time points. Of the Baseline data n=31
remainder, two participants completed baseline Mellow Bumps n=10
and post-intervention questionnaires and two Chill-out in Pregnancy n=9
completed baseline and 812 weeks post-birth Care-as-usual n=12 Withdrew n=2
measures (Figure3). No contact on advice of
health professional n=1
Post-intervention data n=23
Demographics Failed contact n=5
Mellow Bumps n=7
Table 2 shows a summary of the demographic Chill-out in Pregnancy n=6
characteristics of the sample. The majority of Care-as-usual n=10
participants had mental health issues (52%, n=16)
or there were child protection concerns (23%,
Contact attempted including failed contacts at post-intervention n=28
n=7). Five (16%) had children who were in local
authority care. Many, however, had complex issues.
For example, one had previous child protection Withdrew n=2
Failed contact No contact on advice
concerns as well as a history of substance misuse n=2 of health professional
and involvement with the criminal justice system. n=1
There were no statistically significant differences
between the groups at baseline (P0.05).
Questionnaires
Figure4 illustrates the proportion of women who
812 week post-birth data n =23
had scores in the probable problem range of
each outcome measure at baseline. A total of
Questionnaire Interview Video
14 participants (45.2%) had a score on the EPDS
that indicated there was likely depression. A Mellow Bumps n=9 n=8 n=8
similar number (n=13, 41.9%) had AWS depression Chill-out in Pregnancy n=5 n=5 n=4
scores that were in the same category. Two women
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100%
6
90%
80% 14 15
70% 20
12
22
60%
50% 3
40% 7
30%
14 13
20% 9
9 9
10%
0% 2
EPDS AWS AWS AWS Outward AWS Inward
Depression Anxiety Directed Directed
Irritability Irritability
AWSAdult Wellbeing Scale (Snaith et al, 1978); EPDSEdinburgh Postnatal Depression Scale (Cox et al, 1987)
Figure4:Baselinemeasureoflikelyproblems
it was like were all pretty much in the I panic a lot [I noticed that] when
same boat. (PID 113, MB) hes being sick, pooing and peeing and
scratching his face all at the same
The CHiPs [sic] group was fantastic time, I was just singing away to him,
[I felt] that I wasnt the only person that changing his bum I was like why am I
was going through this It makes you not panicking? and I realised half way
feel normal, instead of the outcast. (PID through, I was breathing [the way I was
123, CHiP) taught]! (PID 123, CHiP)
Even though some of the participants were Perhaps as a reflection of their enjoyment of the
experienced parents, they seemed to develop groups, several participants said that they thought
coping strategies as well as an understanding of the programmes were not long enough.
early infant development from the activities.
I didnt think it [MB] was long enough
I do it differently from what I what I did cause I remember saying to [another
with the rest of them We were watching group member], that was just like pure
the DVD and it was abouttalking to your crap, I was actually enjoying that and
childabout the brain cells I spend more [she] was like, I was just getting into it
time talking to him [this baby] I always and it finished. (PID 107, MB)
imagine, when Im talking to him, these
small extra brain cells. (PID 107, MB) Discussion
This study is the first attempt, to our knowledge,
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The relaxation sessions were particularly to assess the efficacy of a primarily antenatal
popular. Several participants spoke about using intervention with this traditionally hard-to-reach
the techniques that they had learned after the population. Even though the size of the sample
group had finished: means that the results should be interpreted
AWS inward-directed
8
irritability score
irritability score
4
6
4
2
2
0 0
Baseline Post- 812 weeks Baseline Post- 812 weeks
intervention post-birth intervention post-birth
Time point Time point
Figure 5: Edinburgh Postnatal Depression Scale and Adult Wellbeing Scale scores by group allocation
atbaseline,post-interventionand812weekspost-birth
with caution, this study suggests that these group interventions in the longer term. The small sample
programmes may have helped women facing numbers and relative short-term follow-up in
social adversity and their infants. Feedback from our study meant it was not possible to detect
those who took part in the groups was positive, any differences between the two interventions.
suggesting that the format of the programmes was The potential additional benefit of MBs focus
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Limitations
The findings of this project should be considered Key points
in the light of the following limitations. Firstly, l Social adversity and poor maternal mental health during pregnancy
the study was limited to participants living in may have long-term adverse effects on the infants health, social and
two areas in west Scotland. It is possible that the educational outcomes
working practices of community midwives may l There is limited evidence of the effectiveness of antenatal psychosocial
have differed from other settings. Secondly, all parenting support programmes
the participants were actively engaged with health l This study reports on a trial of antenatal group-based interventions
services when they were recruited to the study. designed to improve maternal mental health and sensitivity to the
It was not possible to identify individuals who infant in women with additional health and social care needs
were reluctant to engage with midwives. Also, we l The authors found that both Mellow Bumps and Chill-out in Pregnancy
cannot exclude the possibility that the participants were well-received by women in this study
approached were those thought by midwives to be l Providing group-based parenting support in an acceptable format to
most likely to take part in the group programmes. pregnant women with additional health and social care needs may have
Lastly, it is possible that participants answered a positive impact on their mental wellbeing, though further research
the questionnaires in a way that they felt would is required
be received positively by either the researchers or
health and social service professionals.
Sloan,JoanneMcGarry,KarenSmith,HalinaMcIntyre,NHS
Conclusion GGC;RosemaryMackenzie,HarrietWaughandtheMellow
Parentingteam;DrManjuHaridas,LeonaCunningham,
Intervening in the antenatal period may improve
ElsaEkevall,KimJones,CaoimheClarke,CatherineNixon,
outcomes for pregnant women with additional ShonaShinwell,DrClareAllely;theScottishCollaboration
health and social care needs and their infants, forPublicHealthResearchandPolicy;theMRC/CSOSocial
and be more cost-effective than intervening later andPublicHealthSciencesUnit,UniversityofGlasgow;the
(Dennis and Hodnett, 2007). The results of this ScottishMentalHealthResearchNetwork
study suggest that psycho-educational antenatal
interventions may benefit pregnant women with
significant psychosocial needs. Further research is Barlow J, Davis H, McIntosh E, Jarrett P, Mockford C,
needed in this area. Stewart-Brown S (2007) Role of home visiting in
improving parenting and health in families at risk of
abuse and neglect: results of a multicentre randomised
Author affiliations:1InvestigatorScientist,MRC/CSO controlled trial and economic evaluation. ArchDis
SocialandPublicHealthSciencesUnit,Universityof Child 92(3): 22933. doi: 10.1136/adc.2006.095117
Glasgow;2SeniorResearchFellow,UniversityofAberdeen; Barnes J, Ball M, Meadows P, Howden B, Jackson
3
MellowParenting,Glasgow;4EarlyInterventionResearch A, Henderson J, Niven L (2011) TheFamily-
Officer,SocialPolicy,WestLothianCouncil;5Senior NursePartnershipprogrammeinEngland:wave1
InvestigatorScientist,MRC/CSOSocialandPublicHealth implementationintoddlerhoodandacomparison
SciencesUnit,UniversityofGlasgow;6LecturerinClinical betweenwaves1and2aofimplementationinpregnancy
Psychology,UniversityofEdinburgh;7ProfessorofPrimary andinfancy. Department of Health, London
CareandRuralHealth,CentreforRuralHealth,University Birtwell B, Hammond L, Puckering C (2015) Me and my
ofAberdeen bump: an interpretative phenomenological analysis
of the experiences of pregnancy for vulnerable
Conflict of interest:Theauthorshaverelationshipswith women. ClinChildPsycholPsychiatry 20(2): 21838.
theMellowParenting(MP)organisation,butMPdidnot doi: 10.1177/1359104513506427
providefundingforthisproject.MPprovided,without Breustedt S, Puckering C (2013) A qualitative evaluation of
chargetotheproject,thetrainingforthegroupfacilitators womens experiences of the Mellow Bumps antenatal
andsomeofthegroupresources. intervention. BritishJournalofMidwifery 21(3): 187194;
187. doi: 10.12968/bjom.2013.21.3.187
Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal
Funding:ThisstudywasfundedbytheScottish depression. Development of the 10-item Edinburgh
CollaborationforPublicHealthResearchandPolicy(grant Postnatal Depression Scale. BrJPsychiatry 150: 7826
SCPH/13;1January201231March2013;74775). Dennis CL, Hodnett E (2007) Psychosocial and
psychological interventions for treating postpartum
depression. CochraneDatabaseSystRev 4: CD006116
Acknowledgements:Theauthorswouldliketothank: Fontein-Kuipers YJ, Nieuwenhuijze MJ, Ausems M, Bud
thewomenwhohaveagreedtotakepart;ElaineMoore,
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