Collaborative health visiting leads to better relationships
The National Institute for Health and Care Excellence (NICE) (
The National Institute for Health and Care Excellence (NICE) (2014) says that more than one in ten women will experience mental health problems during pregnancy and following the birth of a child. The need for more specialist health visitor posts in perinatal and infant mental health has been highlighted recently in new guidance for health commissioners, published by Health Education England (HEE) (2016).
This guidance recognises that health visitors are best placed through the universal service to identify those families requiring additional support; for example, where the mother or father may experience perinatal mental illness or where the parent-infant bond is compromised.
It also underlines that health visitors have many other roles to fulfil during this critical period of every infant’s life and would benefit from specialist support.
Local early attachment service
In Tameside, Manchester, health visitors trained in perinatal and infant mental health are collaborating with the local early attachment service (EAS) run by Tameside Hospital NHS Foundation Trust, and family support charity Home Start, to improve support for new parents with mild to moderate mental health issues. The health visitors deliver four-week training to the charity’s volunteers to improve their mental health awareness and understanding of services they could suggest to families.
All volunteers attend the charity’s ten-week initial preparation course before being invited to attend the four-week perinatal infant mental health training. They are supported throughout and after the training by Home Start parent-infant mental health (PIMH) co-ordinator Nancy Bradshaw.
‘The volunteer training is designed as a gentle way for volunteers to support families,’ says Ms Bradshaw. ‘It encourages parents to open up and talk about their feelings. We offer non-judgemental support and, as our volunteers are all parents themselves, it helps to put families at ease.
Volunteer family support
'We encourage positive parent and infant relationships and raise awareness of the importance of early attachment. Our expertise is in providing volunteer family support and, through this collaboration, we have been able to build closer links with the EAS and the health visiting service.’
The four-week volunteer training covers attachment theory, infant brain development, emotions experienced by patients during the antenatal period and the parent-infant relationship.
Parents have reported improved relationships with their children since the introduction of the Home Start volunteer training last year. They have also expressed a feeling of enhanced support through the PIMH-trained volunteers.
‘We work towards visiting antenatally and hope to have fathers included in this visit too,’ says Mina Warden, a health visitor at Tameside Hospital NHS Foundation Trust involved with the delivery of training to Home Start volunteers.
Ms Warden has a special interest in perinatal and infant mental health and the parent-infant relationship. ‘We can identify at this visit if there are any external factors or stresses before the challenge of a new baby arriving begins. We can refer and signpost parents to different services antenatally including housing, finance and Home Start.
'If a mum-to-be does not have a partner or does not have social support in the community, a Home Start volunteer can start to make a relationship with her in preparation for her baby arriving.
‘Sometimes there is a stigma attached to professionals visiting families and new mums can be more accepting of a volunteer providing support on a peer level. It is a proactive and preventive approach as parents are supported from the earliest possible opportunity. By delivering the training, we are helping to increase the knowledge and skills of Home Start’s PIMH-trained volunteers, which includes identifying when to refer a family to us.’
Home Start’s volunteers see families for two hours every week. This regular contact helps to promote the parent-infant relationship and prevents the need for more intensive support, says Ms Warden.
‘Being able to talk regularly to someone may reduce the risk of developing postnatal depression or high levels of anxiety, which may require more intensive support.’
The collaborative approach has also helped to increase understanding of the health visitor’s role in the community.
All health visitors in Tameside are trained in the Brazelton Neonatal Behavioural Assessment Scale (NBAS) and Brazelton Newborn Behavioural Observations System (NBO) (www.brazelton-institute.com/clnbas.html). NBAS is a screening tool that assesses infant functioning in autonomic, motor, state and social interactive systems. It identifies infant strengths, personality and areas that would benefit from support.
NBO is a tool that provides an introduction to parents on their newborn’s behaviour and promotes the development of the parent-infant relationship. It is used with babies from birth to three months old.
‘NBO is our focus on the final visit,’ says Ms Warden. ‘We look at the baby’s behaviour and what the baby can do while the parents are observing too. It helps us to assess whether parents can understand what the baby needs.
'We felt the inclusion of the NBO and NBAS assessments was vital in delivering the volunteer training. One of the health visiting principles is to build community capacity. We want to strengthen the community through the volunteer training and reduce reliance and dependency on services where we can.’
Ms Warden adds: ‘Building the capacity of our community has been especially important in times of austerity. By providing initial support at community level, our aim is to prevent issues escalating. Finding time to see all families regularly is an issue and that is why it is good to be involved in this approach.’
The service is not about replacing health visitors with the volunteer support, says Ms Warden. ‘We want to strengthen the wider community to prevent serious perinatal mental health issues that will affect the parent-infant relationship from developing,’ says Ms Warden.
‘If problems do occur or we recognise a parent or infant has higher level needs, we continue to provide support. Our aim is to identity those families that would benefit from initial volunteer support – for example, a parent who is socially isolated or a one-parent family who may just need a friend.’
Ms Warden says the collaboration also helps to meet one of Public Health England’s seven public health priorities – ensuring every child has the best start in life. ‘The volunteer training is helping parents to respond to infants appropriately and this aids child development through those positive early interactions from birth to boost the likelihood of children being ready to learn at two and ready for school at five. It is proving positive for both families and services.’
Institute of Health Visiting viewpoint
Following NHS England’s announcement earlier this year that it would invest over £1 billion extra annually to tackle mental illness, the Institute of Health Visiting (iHV) has called for more investment in infant mental health. The institute says a strong research base demonstrates that the foundation for emotional wellbeing begins when babies are still in the womb, and is established in the early months of life. The impact of getting it right in the early years would help the NHS to reduce the incidence and impact of maternal depression and other perinatal mental health problems that can affect infant development, the iHV argues.
‘Recent iHV surveys show over 80% of health visitors use their antenatal visit to talk to parents about infant mental health,’ says iHV executive director Cheryll Adams. ‘However, post-birth, they do not have sufficient contact with mothers to give adequate ongoing support.’
Findings from the iHV’s most recent survey (February 2016) revealed that health visitor training on perinatal and infant mental health is inconsistent across the country. More than 26% of health visitors have never received any formal training and, for those who have, the iHV found this varies in terms of quality and duration.
Early identification is crucial if problems are to be addressed promptly and the impact on the parent-infant relationship is to be minimised. However, in many areas only one new birth visit is commissioned with the universal offer, according to the HEE guidance. The pressure on health visitors was also evident in findings from the iHV’s State of Health Visiting survey (November 2015). One in four health visitors stated they cannot provide every family with a postnatal mental health assessment at six to eight weeks and three in four said they cannot provide this assessment at three to four months, as recommended by the government.
iHV Survey into Infant Mental Health (February 2016)
- Survey carried out February 13-16
- 555 respondents
- 27% of health visitors have never received training in infant mental health
- 95% of health visitors know that infant mental health is about healthy attachment and healthy relationships
- 55% of health visitors think that parents do not talk to their babies enough
iHV State of Health Visiting Survey (November 2015)
- 1,413 members of the iHV completed the survey
- 68% of health visitors have seen an increase in postnatal depression over past two years
- One in four health visitors cannot provide every family with a postnatal mental health (PMH) assessment at six to eight weeks, and three in four cannot at three to four months as government recommends
Julie Penfold is a freelance health writer
For more information on the health visitors’ involvement in the collaborative approach, contact Mina Warden via email at firstname.lastname@example.org