Implementing the Maternal Postnatal Attachment Scale (MPAS) in universal services: Qualitative interviews with health visitors

Abstract

A secure parent-infant relationship lays the foundations for children’s development, however there are currently no measurement tools recommended for clinical practice. We evaluate the clinical utility of a structured assessment of the parent-infant relationship (the Maternal Postnatal Attachment Scale, MPAS) in a deprived, multi-ethnic urban community in England. This paper answers the question: what are health visitors’ views on the parent-infant relationship, and experiences of piloting the MPAS? It explores the barriers and facilitators to implementation, and complements the paper on psychometric properties and representativeness reported in Dunn et al (submitted).Semi-structured interviews were conducted with 11 health visitors and data were analysed using thematic analysis. Health visitors stressed the importance of the parent-infant relationship and reported benefits of the MPAS, including opening conversation, and identifying and reporting concerns. Challenges included timing, workload, the appropriateness and understanding of the questions and the length of the tool. Suggestions for improvements to the tool were identified.Our findings help to explain results in Dunn et al, and challenges identified would hinder routine assessment of the parent-infant relationship. Further work with health professionals and parents has been undertaken to co-produce an acceptable, feasible and reliable tool for clinical practice.Key findings and points for practitionersHealth visitors saw identification and support of the parent-infant relationship as an important part of their role, however there are currently no recommended tools for this.Health visitors report some benefits to using the MPAS, but also several challenges to using this tool in practice, including the length of time required, the complexity of the language, potential to trigger distress and perceived intrusiveness of some questions.Further work in collaboration with health professionals and parents is needed to develop an acceptable, feasible and reliable tool to assess the parent-infant relationship.Statement of relevance to the field of infant and early childhood mental healthA secure parent-infant relationship lays the foundations for children’s development, and identification of concerns and provision of support is a priority in the UK and internationally. However, no tools are currently recommended for assessing the relationship in clinical practice. Our findings on experiences, benefits and challenges of piloting a tool to assess the parent-infant relationship provide important directions for development of a short, clinically relevant and valid tool in clinical practice.Statement explaining how the research reflects an appreciation for diversity and an anti-racist approachThis pilot was conducted with a diverse, multi-ethnic community (half of new mothers are from Asian/Asian British Pakistani backgrounds, a quarter White British, and a quarter from other ethnic backgrounds). The health visiting service engages with the whole population in a culturally sensitive way, including ensuring staff speak key community languages and using interpreters. None of the authors spoke community languages, but we purposively selected the health visitors to include experience of using the MPAS in community languages. Our findings reflect experiences implementing the tool with women from different ethnic backgrounds, and we report detailed findings on language. We hope our findings can inform appropriate and equitable implementation of tools in diverse communities.

The feasibility of an objective measure of the parent-child relationship in health visiting practice: assessment of the Maternal Postnatal Attachment Scale

“…The MPAS was administered to a representative sample by health visitors, but acceptability was low, and the MPAS had poor psychometric properties. Qualitative research ( Bird et al , 2022 ) confirms that the MPAS was not fully understood by the sample, rendering it unacceptable for the Bradford context. Although health visitors welcomed the opportunity to discuss the parent infant relationship, there were also considerable challenges.…”

“…An additional research study has explored these explanations using qualitative interviews with health visitors during this pilot study. The linked paper by Bird et al (2022) explores these issues further. Key findings from this paper suggest that although health visitors welcomed the opportunity to discuss the parent infant relationship and there were benefits to using a structured tool, there were also considerable challenges that hindered implementation of the MPAS in a valid and reliable way.…”

“…Based on the findings from this paper, and Bird et al (2022) , the gap for a robust, valid measure to assess parent-child relationships in routine practice remains, at least in Bradford. Considering this, we coproduced a tool with health visitors, service staff and with input from parents, based on the learning from the current study, and have piloted it in routine care ( Bywater et al , 2022 ).…”

Born in Bradford’s Better Start (BiBBS) interventional birth cohort study: Interim cohort profile

“…Whilst assessment of, and support for, perinatal mental health is a key priority for universal midwifery and health visiting, the data systems do not support documentation of the assessments that are undertaken, with national systems unable to report on the prevalence of perinatal mental health. We have undertaken steps to improve this situation locally, including the assessment of an existing measure of the mother-child relationship 27,28 and the co-production and validation of a new measure for this outcome 29 , development of a proxy measure for perinatal mental health 30 , as well as additional data collection within the cohort and use of data collected within the existing interventions.…”

The Measurement Properties and Acceptability of a New Parent–Infant Bonding Tool (‘Me and My Baby’) for Use in United Kingdom Universal Healthcare Settings: A Psychometric, Cross-Sectional Study

“…The 19-item MPAS, which has preliminary evidence of reliability and validity ( Kane, 2017 ; Wittkowski et al, 2020 ) is the most used tool when linking maternal-infant bonding to later child development outcomes ( Le Bas et al, 2019 ). The MPAS was piloted (with the involvement of the first and second authors) with 347 mothers in universal health visiting services ( Bird et al, 2021 ; Dunn et al, 2021 ) as part of Better Start Bradford – a 10-year National Lottery Community Fund project aimed at improving the socio-emotional development, nutrition and communication skills of children aged 0–3 living in deprived multi-ethnic communities ( Dickerson et al, 2016 ). The pilot concluded that the MPAS could not be recommended for use in health visiting services in Bradford to assess parent-infant relationship due to; little variation in the responses of the 225 who completed the MPAS in English; an unexpected ceiling effect; issues with scoring, parental acceptability and understanding.…”