Maternal psychological distress in primary care and association with child behavioural outcomes at age three

The key components of a successful model of midwifery-led continuity of carer, without continuity at birth: findings from a qualitative implementation evaluation

BACKGROUND

Recent UK maternity policy changes recommend that a named midwife supports women throughout their pregnancy, birth and postnatal care. Whilst many studies report high levels of satisfaction amongst women receiving, and midwives providing, this level of continuity of carer, there are concerns some midwives may experience burnout and stress. In this study, we present a qualitative evaluation of the implementation of a midwife-led continuity of carer model that excluded continuity of carer at the birth.

METHODS

Underpinned by the Conceptual Model for Implementation Fidelity, our evaluation explored the implementation, fidelity, reach and satisfaction of the continuity of carer model. Semi-structured interviews were undertaken with midwives (n = 7) and women (n = 15) from continuity of carer team. To enable comparisons between care approaches, midwives (n = 7) and women (n = 10) from standard approach teams were also interviewed. Interviews were recorded, transcribed and analysed using thematic analysis.

RESULTS

For continuity of carer team midwives, manageable caseloads, extended appointment times, increased team stability, and flexible working patterns facilitated both care provided and midwives' job satisfaction. Both continuity of carer and standard approach midwives reported challenges in providing postnatal continuity given the unpredictable timing of labour and birth. Time constraints, inadequate staffing and lack of administrative support were reported as additional barriers to implementing continuity of carer within standard approach teams. Women reported continuity was integral to building trust with midwives, encouraged them to disclose mental health issues and increased their confidence in making birth choices.

CONCLUSIONS

Our evaluation highlighted the successful implementation of a continuity of carer model for ante and postnatal care. Despite exclusion of the birth element in the model, both women and midwives expressed high levels of satisfaction in comparison to women and midwives within the standard approach. Implementation successes were largely due to structural and resource factors, particularly the combination of additional time and smaller caseloads of women. However, these resources are not widely available within the resources of maternity unit budgets. Future research should further explore whether a continuity of carer model focusing on antenatal and postnatal care delivery is a feasible and sustainable model of care for all women.

Social and Behavioral Difficulties in 10-Year-Old Children With Congenital Heart Disease: Prevalence and Risk Factors

Children with congenital heart disease (CHD) may be at increased risk for neurodevelopmental impairments. Long-term behavioral profiles and respective risk factors are less frequently described. The aim of this study was to evaluate multidimensional behavioral outcomes and associated medical, psychological, and social risk factors in children with complex CHD. At 10-years of age, 125 children with CHD were assessed for general behavioral difficulties, attention deficit hyperactivity disorder (ADHD)-related behavior, and social interaction problems and were compared to normative data. Medical and cardiac factors, IQ, maternal mental health at 4 years of age and parental socioeconomic status were tested as predictors for all behavioral outcomes. Children with CHD showed no significant differences in general behavioral difficulties. However, increased ADHD-related symptoms (p < 0.05) and difficulties in social interaction (p < 0.05) were observed. In 23% of the children, a combination of ADHD-related symptoms and social interaction problems was reported by parents. In multivariate analyses, IQ (p < 0.01) and maternal mental health (p < 0.03) at 4 years of age were found to be predictive for all behavioral outcomes at 10 years while medical and cardiac risk factors were not. Our findings reveal significant difficulties in ADHD-related symptoms and social interaction problems with a significant comorbidity. Behavioral difficulties were not detected with a screening tool but with disorder-specific questionnaires. Furthermore, we demonstrate the importance of maternal mental health during early childhood on later behavioral outcomes of children with CHD. This underlines the importance of identifying and supporting parents with mental health issues at an early stage in order to support the family and improve the child's neurodevelopment.

The LifeCycle Project-EU Child Cohort Network: a federated analysis infrastructure and harmonized data of more than 250,000 children and parents

Early life is an important window of opportunity to improve health across the full lifecycle. An accumulating body of evidence suggests that exposure to adverse stressors during early life leads to developmental adaptations, which subsequently affect disease risk in later life. Also, geographical, socio-economic, and ethnic differences are related to health inequalities from early life onwards. To address these important public health challenges, many European pregnancy and childhood cohorts have been established over the last 30 years. The enormous wealth of data of these cohorts has led to important new biological insights and important impact for health from early life onwards. The impact of these cohorts and their data could be further increased by combining data from different cohorts. Combining data will lead to the possibility of identifying smaller effect estimates, and the opportunity to better identify risk groups and risk factors leading to disease across the lifecycle across countries. Also, it enables research on better causal understanding and modelling of life course health trajectories. The EU Child Cohort Network, established by the Horizon2020-funded LifeCycle Project, brings together nineteen pregnancy and childhood cohorts, together including more than 250,000 children and their parents. A large set of variables has been harmonised and standardized across these cohorts. The harmonized data are kept within each institution and can be accessed by external researchers through a shared federated data analysis platform using the R-based platform DataSHIELD, which takes relevant national and international data regulations into account. The EU Child Cohort Network has an open character. All protocols for data harmonization and setting up the data analysis platform are available online. The EU Child Cohort Network creates great opportunities for researchers to use data from different cohorts, during and beyond the LifeCycle Project duration. It also provides a novel model for collaborative research in large research infrastructures with individual-level data. The LifeCycle Project will translate results from research using the EU Child Cohort Network into recommendations for targeted prevention strategies to improve health trajectories for current and future generations by optimizing their earliest phases of life.

Child mental health and resilience in the context of socioeconomic disadvantage: results from the Born in Bradford cohort study

Socioeconomic disadvantage has been linked to mental health difficulties in children and adolescents, although many children appear to do well despite exposure to financial adversity in childhood. Our study looked at the effects of family financial difficulty on children's mental health outcomes (n = 636) at 4-5 years in a multi-ethnic UK cohort, the Born in Bradford cohort. We considered potential parent and child variables promoting resilience in this population. Univariate linear regression was used to identify associations between family financial difficulty measured antenatally and child mental health difficulties measured by teacher-rated Strengths and Difficulties (SDQ) scores at 4-5 years. Hierarchical multivariate regression was used to test for potential moderating effects of parent and child factors. Mothers completed the General Health Questionnaire-28, Kessler-6 Questionnaire and questions related to parenting warmth, hostility and confidence. Parent-rated Infant Characteristic Questionnaires and teacher-rated Early Years Foundation Stage scores provided information on child temperament, literacy and physical development as potential moderators. Financial difficulty was associated with worse mental health outcomes in children. High parent warmth, high child literacy scores and physical development scores were all associated with positive child mental health outcomes at 4-5 years. In terms of protective effects, only maternal warmth was found to significantly moderate the relationship between financial difficulty and child mental health difficulties. The current study demonstrates that family financial difficulty is associated with poorer child mental health outcomes in a UK cohort of mothers and their school-aged children. It provides evidence of the positive relationships between warm parenting, child literacy and child physical development with mental health in young children. The study supports the finding that warm parenting moderates the relationship between family financial difficulty and interventions supporting this aspect of parenting may therefore provide particular benefit to children growing up in this context.

Growing up in Bradford: protocol for the age 7-11 follow up of the Born in Bradford birth cohort

BACKGROUND

Born in Bradford (BiB) is a prospective multi-ethnic pregnancy and birth cohort study that was established to examine determinants of health and development during childhood and, subsequently, adult life in a deprived multi-ethnic population in the north of England. Between 2007 and 2010, the BiB cohort recruited 12,453 women who experienced 13,776 pregnancies and 13,858 births, along with 3353 of their partners. Forty five percent of the cohort are of Pakistani origin. Now that children are at primary school, the first full follow-up of the cohort is taking place. The aims of the follow-up are to investigate the determinants of children's pre-pubertal health and development, including through understanding parents' health and wellbeing, and to obtain data on exposures in childhood that might influence future health.

METHODS

We are employing a multi-method approach across three data collection arms (community-based family visits, school based physical assessment, and whole classroom cognitive, motor function and wellbeing measures) to follow-up over 9000 BiB children aged 7-11 years and their families between 2017 and 2021. We are collecting detailed parent and child questionnaires, cognitive and sensorimotor assessments, blood pressure, anthropometry and blood samples from parents and children. Dual x-ray absorptiometry body scans, accelerometry and urine samples are collected on subsamples. Informed consent is collected for continued routine data linkage to health, social care and education records. A range of engagement activities are being used to raise the profile of BiB and to disseminate findings.

DISCUSSION

Our multi-method approach to recruitment and assessment provides an efficient method of collecting rich data on all family members. Data collected will enhance BiB as a resource for the international research community to study the interplay between ethnicity, socioeconomic circumstances and biology in relation to cardiometabolic health, mental health, education, cognitive and sensorimotor development and wellbeing.

Assessing community readiness for early intervention programmes to promote social and emotional health in children

Objective

Evidence for early intervention and prevention‐based approaches for improving social and emotional health in young children is robust. However, rates of participation in programmes are low. We explored the dynamics which affect levels of community readiness to address the issues of social and emotional health for pregnant women, young children (0‐4 years) and their mothers.

Setting

A deprived inner‐city housing estate in the north of England. The estate falls within the catchment area of a project that has been awarded long‐term funding to address social and emotional health during pregnancy and early childhood.

Methods

We interviewed key respondents using the Community Readiness Model. This approach applies a mixed methodology, incorporating readiness scores and qualitative data. A mean community readiness score was calculated enabling the placement of the community in one of nine possible stages of readiness. Interview transcripts were analysed using a qualitative framework approach to generate contextual information to augment the numerical scores.

Results

An overall score consistent with vague awareness was achieved, indicating a low level of community readiness for social and emotional health interventions. This score suggests that there will be a low likelihood of participation in programmes that address these issues.

Conclusion

Gauging community readiness offers a way of predicting how willing and prepared a community is to address an issue. Modifying implementation plans so that they first address community readiness may improve participation rates.

An Item Response Theory Analysis of the Strength and Difficulties Questionnaire (SDQ)

Abstract. The Strengths and Difficulties Questionnaire (SDQ) assesses five subscales for measuring child adjustment. In the present study, an item response theory approach was used to analyze the parent version of the SDQ subscales and the total difficulties score (TDS), which is obtained by summing up the scores of the four problem subscales. Analyses are based on two data sets: The German Family Panel “Panel Analysis of Intimate Relationships and Family Dynamics (pairfam, N = 1,078)” and the survey “Growing up in Germany” (Aufwachsen in Deutschland: Alltagswelten; AID:A, N = 1,346). Partial credit and generalized partial credit models were estimated for each subscale and a bifactor model was applied to the TDS. The results showed satisfying psychometric properties in both samples for each of the five subscales, except for the “Hyperactivity/Inattention” subscales which seemed to have a two-dimensional structure. Item discrimination and category threshold parameters were broadly comparable between the samples. According to the bifactor models, there is evidence for multidimensionality in the TDS, but the general factor was strong. Thus, the TDS can be treated as essentially unidimensional, although some subscales may be of additional value.

Temporal effects of maternal psychological distress on child mental health problems at ages 3, 5, 7 and 11: analysis from the UK Millennium Cohort Study

BACKGROUND

Psychological distress is common among women of childbearing age, and limited longitudinal research suggests prolonged exposure to maternal distress is linked to child mental health problems. Estimating effects of maternal distress over time is difficult due to potential influences of child mental health problems on maternal distress and time-varying confounding by family circumstances.

METHODS

We analysed the UK Millennium Cohort Study, a nationally representative sample with data collected throughout childhood. Adopting a marginal structural modelling framework, we investigated effects of exposure to medium/high levels of maternal psychological distress (Kessler-6 score 8+) on child mental health problems (Strengths and Difficulties Questionnaire borderline/abnormal behaviour cut-off) using maternal and child mental health data at 3, 5, 7 and 11 years, accounting for the influence of child mental health on subsequent maternal distress, and baseline and time-varying confounding.

RESULTS

Prior and concurrent exposures to maternal distress were associated with higher levels of child mental health problems at ages 3, 5, 7 and 11 years. For example, elevated risks of child mental health problems at 11 years were associated with exposure to maternal distress from 3 years [risk ratio (RR) 1.27 (95% confidence interval (CI) 1.08-1.49)] to 11 years [RR 2.15 (95% CI 1.89-2.45)]. Prolonged exposure to maternal distress at ages 3, 5, 7 and 11 resulted in an almost fivefold increased risk of child mental health problems.

CONCLUSIONS

Prior, concurrent and, particularly, prolonged exposure to maternal distress raises risks for child mental health problems. Greater support for mothers experiencing distress is likely to benefit the mental health of their children.

Availability, use of, and satisfaction with green space, and children's mental wellbeing at age 4 years in a multicultural, deprived, urban area: results from the Born in Bradford cohort study

BACKGROUND

It is unknown whether the quantity or quality of green space is more important for mental wellbeing. We aimed to explore associations between availability of, satisfaction with, and use of green space and mental wellbeing among children aged 4 years in a multi-ethnic sample.

METHODS

We did a 4-year follow-up assessment of participants in the Born in Bradford longitudinal cohort study, which recruited children and mothers at the city's main maternity unit from 2007 to 2011. The primary outcome was parent-reported mental wellbeing for children aged 4 years, assessed with the standardised Strengths and Difficulties Questionnaire. Total, internalising, and externalising behavioural difficulties and prosocial behaviour scales were computed (with higher scores indicating greater difficulties or more prosocial behaviour). Residential green space around participants' home addresses and distance to major green spaces were computed with the normalised difference vegetation index (NDVI). A subsample of participants completed additional questionnaires on measures of satisfaction with, and use of, local green spaces. Multiple regressions examined associations between green space and children's mental wellbeing and explored moderation by ethnicity (white British vs south Asian) and socioeconomic status.

FINDINGS

Between Oct 1, 2012, and June 30, 2015, 2594 mothers attended a follow-up appointment during which they completed a detailed questionnaire assessing the health of their child. 1519 (58%) participants were of south Asian origin, 740 (29%) of white British origin, and 333 (13%) of another ethnicity. Data on ethnicity were missing for two participants. 832 (32%) of 2594 participants completed additional questionnaires. Ethnicity moderated associations between residential green space and mental wellbeing (p<0·05 for total and internalising difficulties). After adjusting for all relevant variables, more green space was associated with fewer internalising behavioural difficulties (mean NDVI 100 m: β -2·35 [95% CI -4·20 to -0·50]; 300 m: -3·15 [-5·18 to -1·13]; 500 m: -2·85 [-4·91 to -0·80]) and with fewer total behavioural difficulties (100 m: -4·27 [-7·65 to -0·90]; 300 m: -5·22 [-8·91 to -1·54]; 500 m: -4·82 [-8·57 to -1·07]) only for south Asian children across all three buffer zones. In the subsample of participants, the effect of NDVI on wellbeing was rendered non-significant after controlling for satisfaction with, and use of, green space. Among south Asian children, satisfaction with green space was significantly associated with fewer total behavioural difficulties across all three buffer zones (β -0·59 [95% CI -1·11 to -0·07]), fewer internalising behavioural difficulties within 100 m (-0·28 [95% CI -0·56 to -0·003]) and 300 m buffer zones (-0·28 [-0·56 to -0·002]), and greater prosocial behaviour across all three buffer zones (0·20 [0·02 to 0·38]); no such associations were observed among white British children.

INTERPRETATION

Positive effects of green space on wellbeing differ by ethnicity. Satisfaction with the quality of green space appears to be a more important predictor of wellbeing than does quantity of green space. Public health professionals and urban planners need to focus on both quality and quantity of urban green spaces to promote health, particularly among ethnic minority groups.

FUNDING

European Community's Seventh Framework Programme.

Mother-infant interaction assessment at discharge and at 6 months in a French cohort of infants born very preterm: The OLIMPE study

Objectives

The principal aim was to investigate the feasibility of assessing mother-infant interactions at discharge and at 6 months infant corrected age in singletons born before 32 weeks of gestation. The secondary aims were to describe these interactions and their disorders, explore the association between maternal emotional state and the interactions, and assess the relationship between disordered interactions and infant social withdrawal behaviour.

Methods

OLIMPE is an ancillary study of the population-based study EPIPAGE 2, which recruited preterm neonates in France in 2011. 163 dyads participated at discharge and 148 at 6 months. Interactions were observed with the Attachment During Stress (ADS) scale, which includes two behavioural subscales, for the mother (m-ADS) and her infant (i-ADS). Two professionals independently completed the ADS scales for one third of the observations. Maternal emotional state was assessed using self-administered questionnaires of depression, anxiety, and stress. Infant’s social withdrawal behaviour at 6 months was measured by the Alarm Distress Baby scale.

Results

At discharge, 15.3% of the m-ADS scales and 43.3% of the i-ADS scales had at least one unobserved component. At 6 months, all items on both scales were noticeable in >90% of the dyads. Reliability, estimated by the kappa coefficient, ranged between 0.39 and 0.76 at discharge, and between 0.21 and 0.69 at 6 months. Disordered interactions were indicated on 48.6% of the m-ADS scales and 36.5% of the i-ADS scales at discharge. At 6 months, these rates were 32.6% and 26.0%. Disordered interactions at 6 months were associated with identified disorder at discharge. Insecure infant attachment was not influenced by maternal mental health but was strongly associated with infant social withdrawal behaviour.

Conclusions

The ADS scale can be used to screen for early interaction disorders after premature birth and may help to target dyads that would most benefit from early intervention.