Published 14 April 2009, doi:10.1136/bmj.b974
Cite this as: BMJ 2009;338:b974

Research

Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial

¹ School of Psychology, University of Reading, Reading RG6 6AL, ² Health Systems Research Unit, Medical Research Council, and University of Cape Town, 7505 Tygerberg, South Africa, ³ Department of Psychology, Stellenbosch University, Matieland 7602, South Africa, ⁴ Parent Centre and Stellenbosch University, Matieland, ⁵ Department of Psychiatry and Mental Health, Groote Schuur Hospital, Cape Town, South Africa, ⁶ Department of Psychiatry, University of Oxford, Oxford OX3 7JX, ⁷ Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford University, Oxford OX3 9DU

Objective To assess the efficacy of an intervention designed to improve the mother-infant relationship and security of infant attachment in a South African peri-urban settlement with marked adverse socioeconomic circumstances.

Design Randomised controlled trial.

Setting Khayelitsha, a peri-urban settlement in South Africa.

Participants 449 pregnant women.

Interventions The intervention was delivered from late pregnancy and for six months postpartum. Women were visited in their homes by previously untrained lay community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother. Women in the control group received no therapeutic input from the research team.

Main outcome measures Primary outcomes: quality of mother-infant interactions at six and 12 months postpartum; infant attachment security at 18 months. Secondary outcome: maternal depression at six and 12 months.

Results The intervention was associated with significant benefit to the mother-infant relationship. At both six and 12 months, compared with control mothers, mothers in the intervention group were significantly more sensitive (6 months: mean difference=0.77 (SD 0.37), t=2.10, P<0.05, d=0.24; 12 months: mean difference=0.42 (0.18), t=–2.04 , P<0.05, d=0.26) and less intrusive (6 months: mean difference=0.68 (0.36), t=2.28, P<0.05, d=0.26; 12 months: mean difference=–1.76 (0.86), t=2.28 , P<0.05, d=0.24) in their interactions with their infants. The intervention was also associated with a higher rate of secure infant attachments at 18 months (116/156 (74%) v 102/162 (63%); Wald=4.74, odds ratio=1.70, P<0.05). Although the prevalence of maternal depressive disorder was not significantly reduced, the intervention had a benefit in terms of maternal depressed mood at six months (z=2.05, P=0.04) on the Edinburgh postnatal depression scale).

Conclusions The intervention, delivered by local lay women, had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development. If these effects persist, and if they are replicated, this intervention holds considerable promise for use in the developing world.

Trial registration Current Controlled Trials ISRCTN25664149 [controlled-trials.com] .

© Cooper et al 2009
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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