In 2006 in north Somerset we launched the Postnatal pathway for maternal mental health and early attachment.

Ref: Milford R. Community practitioner Aug 2006

Hospital Anxiety Scale (HAD)

This is divided into two aspects depression and anxiety.

Depression

A score of 7 or lower is low concern

A score of 8-9 is moderate concern

A score of 10 or more is high concern

Anxiety

A score of 7 or lower is low concern

A score of 8-9 is moderate concern

A score of 10 or more is high concern

Mothers Object Relations Scales (MORS) Warmth and Invasion scores Warmth scale A score of 11 and lower is high concern A score of 15 - 10 is moderate concern A score of 16 and above is low concern Invasion scale A score of 17 and above is of high concern A score of 12 -16 is of moderate concern A score of 11 and below is of low concern

No concern Moderate concern High concern

Routine Health Visiting service

Up to 6 listening visits (review)

GP & Mental Health specialists

(NICE Guidance)

Refer to Mental Health Specialist for consultation

Additional appropriate services offered from a menu

of complementary care packages including

BABY MASSAGE FOR ALL

* GP

(NICE Guidelines)

Counselling IAPT

Referral to Adult Mental Health Team

Wait, watch and wonder/ Theraplay

based

Attachment group

No further action

We no longer use the HAD and now use

PQ9

GAD 7

We have commenced a pilot for the complimentary antenealt care pathway which aims to pick up women with mental health concerns at the first booking clinic

A secure attachment relationship between mother and infant is recognised as a protective factor and a key component in increasing the likelihood of children developing positive mental health in adulthood (Oates et al., 2007).

Recent research suggests 23% of non-clinical mothers have insecure-dismissive attachment, 19% insecure-preoccupied attachment and 58% secure attachment (Bakermans-Kranenburg and Van IJzendoorn, 2009).

By considering a possible links between maternal attachment style and the

dyadic relationship with the infant, this study looked at the effectiveness of infant massage in promoting improved mother-infant attachment and dyadic attunement.

cure attachment relationship between mother and infant is recognised as a protective factor and key component in children developing positive mental health in adulthood (Oates et al., 2007).

Recent research suggests 23% of non-clinical mothers have insecure-dismissive attachment, 19% insecure-preoccupied attachment and 58% secure attachment (Bakermans-Kranenburg and Van IJzendoorn, 2009).

Acknowledging these links between maternal attachment style and the dyadic relationship with the infant, this study looked at the effectiveness of infant massage in promoting improved mother-infant attachment and dyadic attunement.

NICE guidance for planning and commissioning children’s services suggests that health visitors and midwives should consider evidence-based interventions, such as baby massage, as part of provision for the social and emotional well-being of new mothers and the under 5’s.

Robust evidence of the effectiveness of baby massage courses would give confidence to decision makers about funding these resources within perinatal services.

Cut in local offer- lack of research used as a reason.

A Systematic review was conducted using 4 databases, including publications from January 1980 to May 2016.

The criteria included massage or touch, when used as an intervention on more than one occasion.

Two reviewers screened the extracted data for eligibility and quality, using standardised forms.

STUDY M ethod Part icipants Intervent ion Outcome M easures Data Collect ion Process Data ItemsAuthor's Judgment of

Bias/Limitat ionsSummary of M easures

232

Fujiki

279

Hart

392

Lee

520

O’Higgins

49

Beyer

115

Clarke

685

Watanabe

662

Underdown

523

Onozawa

264

Gurol

Very small sample size. High

drop out rate. Dif fering lengths

of sessions. Short period of

intervent ion.

data was analysed by non

parametric methods due to

sample size and M ann-Whitney

U-test (two tailed) or Fisher's

prbability test as appropriate

Quasi-

experimental

design.

Randomised

Controled

117 (3 excluded)

Breastfeeding singleton

M others of healthy babies

living in a specif ic city and

with a minimum of

highschool level of

educat ion.

Baby massage taught

at 5-7 days by IAIM

instructor, CD given

and technique checked

at 15 and 38 days). 15

minute massage given

daily for 48 days

Implementat ion of

M other-Infant Ident if ier

Poll.

M aternal Attachment

Inventory

Test between 24-48 hours after

birth in hospital and on the last day

of the study at home.

M aternal Affect ionate

Attachment

M AI conducted in dif ferent

environments. All mothers well

educated.

Analysis used SPSS. Percent iles

and means. Chi-square test. One-

way analysis of varience. Paired

sample t-test

Randomised

Controled

25 (9 dropped out)

M others scoring >13 on

the EPDS at 4 weeks

postpartum, with healthy

babies. 12 took part in a

massage group and 13

took part in a support

group

5 weekly sessions (1

hour for massage

group and 1 hour for

support group).

Edingburgh Postnatal

Depression Scale,

Video's coded using

Global Rat ings for

mother-infant

Interact ions at 2

months by Fiori-

Cowley and M urray

First and Last Sessions mother's

given EPDS and videoed playing

with their child for 5 mins.

Depression status. M aternal

contribut ion to interact ion.

Infant contribut ion to

interact ion. Quality of

interact ion.

No author comment but we could

consider limitat ions regarding

number, shortness of the interval

between outcome measures (no

follow up). Unknown care to

control group.

T-test

Crit ical Realist

research design

(mixed method -

quantat ive and

qualatat ive)

39 mothers at tending a

six week infant massage

programme in a group (six

did not complete). 72%

were white-Brit ish and

28% were other ethnic

minorit ies.

A f ive week massage

course (group) led by

the Internat ional

Associat ion of Infant

M assage (IAIM )

Working model of the

child interview (WM CI),

the Edinbrugh Post-

Natal Depression scale

(EPDS) and the care

index.

Interviews (unknown environment).

Videos. Pre and post intervent ion

Parental response classif ied

into one of three broad

attachment classif icat ions:

balanced, disengaged and

distorted. EPDS scores for

levels of depression and Care

Index (CI)measuring three

aspects of maternal behaviour

(sensit ivity, covert and overt

host ility and

unresponsiveness). Four

aspects of infant behaviour

(cooperat iveness, compulsive

compliance, dif f icultness and

passivity).

Diverse range of infant pract ices

observed between parents and

infants. They had a high

proporiton of white Brit ish

which may impact on the

contextual generalisat ion.

Possible bias in recruitment e.g

1/4 of part icipants had degrees,

meaning they may have been

more motivated to attend having

heard of the offer of high quality

infant massage programmes.

High level of low risk women

meaning that no signif icant

change was likely.

Quantat ive data was entered

direct ly into SPSS as well as

demographic details, WM CI

classif icat ions and EPDS and CI

scores. Appropriate stat ist ical

t -test were performed to

compare the means for

quantat ive data collected

before and after the

programme. Qualatat ive data

was also entered into NVIVO

whcih is a qualatat ive data

analaysis computer-software

packaged and analysed

thematically.

Intervent ion

research - Non-

equivalent

Control

First t ime mums, three

months post natal who

attended infant massage

classes. Full term infants.

20

10-15 minutes massage

per day over four

weeks. Control group

received normal care.

The Prof ile of M ood

States and the

Postpartum Bonding

Quest ionnaire. Pre and

post intervent ion.

Unknown

Tension-anxiety, depression,

anger-host ility, vigour, fat igue

and confusion.

Very small sample size. No

control group. Not randomised

in design. All part icipants were

married, proffessional and had

exist ing social support

networks. There were no high

levels of risk for stress or

relat ionship dif f iculty.

Recruitment via poster.

Visual comparison of Pre and

Post stress scores.

Post

Intervent ion

Evaluat ion

94 (52 dropped out)

Parents who had

completed IAIM baby

massage courses. 60 (140

dropped out) Parents who

had not taken part in the

massage courses

Unspecified 5

week programme

of baby massage.

Control group did

not attend this

programme.

Programme Evaluat ion

Quest ionairre, Infant

Social Interact ion

Quest ionairre, Focus

group Interviews.

Post interact ion quest ionairre by

mail, requiring mailing back and

Focus Group Interview.

Items about the baby, Parent 's

Competancy Scale, Items about

the parents, breastfeeding,

reading, chatt ing. Impact of

Social Interact ion and

Parent ing.

Post intervent ion data only.

M ost of the data was from the

focus group and just used one

trainer. Short length of t ime so

unknown longer term effects.

Sensit ivity of tools was limited.

Non intervent ion group was not

well matched to intervent ion

group so comparisons are

limited.

Qualitat ive data entered into

SPSS and analysed using

standard non parametric non

stat ist ical tests. Tapes were

transcribed and analysed using

Open Coding and Thematic

Analysis.

Single Pretest-

Posttest Design

4 (3 dropped out)

M others of healthy 1-3

months old infants

responding to a poster

advert .

One off t raining

session in non specif ic

massage and parental

sensit ivity. Applied 5 x

weekly for 15-30 mins

per day. Journal

complet ion. Contacted

at midpoint to discuss

progress and concerns.

Parent ing Stress Index -

Short Form

Pre and post quest ionairres.

Narrat ive analysis was done on the

journals.

Total Stress Score. Parent 's

rat ings of Infant 's temperament,

parental competancy,

at tachment, social support and

role habit disturbance.

Sensit ivity to infant cues and

other themes (eg. Time of day).

Not fully randomised in design.

Limited collect ion of

physiological parameters. All

babies lived with their families.

t -test and chi-square test

Prospect ive

Block -

Controled

Randomised

design

62 M others scoring 13+

on the EPDS at 4 weeks

post partum. Control

Group - 34 (56 dropped

out) scoring less than 9 on

the EPDS at 4 weeks post

partum. Both groups were

split equally between 2

intervent ions. M other's

attending 4 or more

sessions were included.

6 Sessions of either

IAIM Infant M assage

or a support group

Edinburgh Post Natal

Depression Scale,

Spielberg State Anxiety

Inventory, Infant

Characterist ics

Quest ionairre, Video

interact ions using the

Global Rat ings for

M other-Infant

interact ions. Social

economic quest ions.

9 to 12 weeks Quest ionairres and

Videos in Clinic. Repeated at 19

weeks in clinic. Social ecomomic

prof ile quest ions asked at the

beginning.

Depression and Anxiety State

M aternal Sensit ivity in

Interact ion, Infant Performance

in Interact ion, Overall

Interact ion, Fussiness/Dif f iculty

Scale.

The group were well educated

with no socio economic stress.

Part icipants were predominant ly

white and married. No treatment

for depression group was not

included for ethical reasons.

Init ial fall in EPDS scores may be

attributed to ant icipated

support (Appleby, et al. 1997).

ANOVA with post hoc

Bonferroni Tests.

Non-equivalent

Control Group

Pretest-

Posttest Design

129 (13 dropped out)

M others of Full term,

healthy 2-6 month old

babies, recruited at

M assage programme or

Well Baby Clinic. 26

M others agreed to the

massage programme and

103 took part as the

control group.

Non specif ic Baby

M assage course and

writ ten checklist .

Applied 4 x weekly at

home for 4 weeks.

M other's Percept ion of

Infant 's Temperament

Scale (modif ied),

Weight, Height, M other-

Infant Interact ion

(M IPIS Walker and

Thompson 1982)

Quest ionairre - not specif ied how

given. Video recordings of M other-

Infant interact ion in the health

centre, Weight -Cas electronic

scales, Height - collected in

triplicate and averaged. Social

demographics and feeding

information - quest ions were also

collected at t ime of select ion.

M other's Percept ion of Infant 's

Temperament (def ined as the

individual's emotional react ivity

and behavioural style in

interact ing with the

environment), M other-Infant

Interact ions, Height, Weight.

Wilcoxon rank sum test,

Student t-test. The level of

signif icance was set at 0.05.

Cort isol Levels determined by

enzyme-linked immnuosorbent

assay.

Non-equivalent

Control Group

Pretest-

Posttest Design

94 (52 didn't respond)

Parents usually present ing

with a perceived problem

(eg. Crying). 60 (140

didn't respond) Parents

with no perceived

problems. No select ion -

voluntary part icipat ion.

IAIM 5 week course. 15

courses in a variety of

sett ings. 12 parents at

each course.

Infant Social Interact ion

Quest ionairre,

Edingburgh Postnatal

Depression Scale,

Programme evaluat ion

Quest ionairre. Focus

group interviews

Quest ionairres mailed to

part icipants before and after

intervent ion. Interviews conducted

at focus group.

Parent ing sense of competancy,

Self Esteem, Breast Feeding,

Reading to child, Chatt ing,

General health of parent and

child, Depression status. Health

act ion zone funding

Not fully randomised in design.

Study focuses on one trainer.

Short period of intervent ion

requiring part icipants to mail

back quest ionairres. Long term

benef its can only be conjecture.

Indicit ive of future research

Percentages. Signif icance not

specif ied. Detailed results from

the report are reported

elsewhere in a further study.

Clarke, C et al. Social

Interact ion in Parent ing study:

Project Report , Newcast le

upon Tyne: university of

Northumbria @ Newcast le

2000.

STUDY DESIGN

Randomised

controlled

39 (18 dropped out) full

term, singleton M others @

6 weeks postnatal with no

complicat ions

Field's M ethod of

Baby M assage (did

not at tend a course).

Applied 10 mins per

day unt il 3 months

Cort isol in saliva,

Prof ile of M ood States

Cort isol taken between 10am and 3

pm at the start and end of the study

(in hospital and at home),

Quest ionairres were completed at

home before and after intervent ion.

All mothers were mailed the

quest ionairres.

Tension, Depression, Anger,

Vigour, Fat igue,

Confusion,Concentrat ion of

Cort isol Levels determined by

enzyme-linked immnuosorbent

assay

Short period of intervent ion,

requiring part icipants to mail

back responses, The second

Cort isol samples were delayed

unt il 6 weeks after the

intervent ion ended and taken in

dif ferent environments. Indicat ive

of further research.

Of 732 papers identified, 72 were included for consideration of the full paper.

10 papers met the criteria for inclusion in the systematic review.

Synthesis of the papers showed some evidence that baby massage has a positive effect on the dyadic relationship.

There was moderate evidence for short term improvement in infant attachment, no long term conclusions could be made from the review. Longitudinal research would be needed to support the current findings and careful consideration given to the use of appropriate outcome measures. Two papers suggested that further research should focus on using infant massage programmes to improve the mental wellbeing of mothers with previously recognised moderate mental health concerns.

We propose to complete further research by following up on the findings from Underdown et al.

The review they carried out suggested of possible link between women with mild to moderate mental health concerns have improved outcomes following the completion of a structured baby massage programme.

Focus will be on the elements that may or may not be important in this improvement.

Systematic Review Completed by

Rebecca Balakrishna

Melanie Teixeira

Roxanne Hart

Contact for full paper and references.

Rebecca.balakrishna@nhs.net