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PAPERS: C Jane Morrell, Helen Spiby, P Stewart, S Walters, and A Morgan Costs and effectiveness of community postnatal support workers: randomised controlled trial BMJ 2000; 321: 593-598 [Abstract] [Full text]

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A question of bias

D Freire   (11 September 2000)

Breastfeeding support needs further study.

Jim Sikorski   (22 September 2000)

Application to the general community

Tracy Russell   (22 September 2000)

Costs and effectiveness of community postnatal support workers

Jane Barlow, Sarah Stewart-Brown   (27 September 2000)

Study of high risk groups would be useful

Jim Hardy   (29 September 2000)

A question of bias 11 September 2000
D Freire, Health Consultant Washington DC Send response to journal: Re: A question of bias	A question please: Doesn't excluding women who do not speak English well present an enormous bias given you are evaluating social work intervention? This is probably the group that would benefit most and cost the NHS most in the future without such post natal services? I would have thought use of an advocate or interpreter would have been justified Just a thought. Thanks
Breastfeeding support needs further study. 22 September 2000
Jim Sikorski, GP Research Fellow Department of General Practice. GKT School of Medicine Send response to journal: Re: Breastfeeding support needs further study.	EDITOR - We read with interest Morrell et al's report (1) on the effectiveness of community support workers. We were surprised by the relative prominence given to the finding of a statistically non- significant difference in breastfeeding rates between intervention and control groups at 6 weeks and 6 months. The authors themselves acknowledge, late in their discussion, that this trial was of insufficient size to reliably identify the expected effects of a supportive postnatal intervention on breastfeeding rates. Although statistically non- significant, Morrell et al's findings are in fact compatible with up to one extra woman in eight exclusively breastfeeding at 6 weeks as a result of extra postnatal support. Preliminary work being undertaken by the first author to update a Cochrane review of support for breastfeeding mothers (2) has identified three small trials (3,4,5) of lay support which have reported breastfeeding rates at 2 months. Meta-analysis indicates an effect size suggesting benefit but with wide confidence intervals. This denotes continuing uncertainty as to the effectiveness of this intervention. The potential value of lay support for breastfeeding mothers has been highlighted by the recent Effective Health Care bulletin (6). In view of the public health importance of breastfeeding and its low prevalence in this country, a large randomised trial is needed to clarify the effectiveness of such a policy. Jim Sikorski, GP Research Fellow Naomi Raikes, Research Midwife Sarah Clement, Lecturer in Health Services Research Nicky Britten, Senior Lecturer in Medical Sociology Department of General Practice and Primary Care, GKT School of Medicine, London SE11 6SP jim.sikorski@kcl.ac.uk Carol Dezateux, Clinical Senior Lecturer in Paediatric Epidemiology Angie Wade, Senior Lecturer in Medical Statistics Department of Paediatric Epidemiology and Biostatistics, Institute of Child Health, London WC1N 1EH Jean Rowe Department of Organisational Development Lambeth, Southwark and Lewisham Health Authority, London SE1 7NT Jane Henderson Health Economic Researcher National Perinatal Epidemiology Unit, Institute of Health Sciences, Oxford, OX3 7LF Competing interests: We are joint applicants to the MRC for a trial of lay breastfeeding support. 1. Morrell CJ, Spiby H, Stewart P, Walters S, Morgan A Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000;321:694-6. 2. Sikorski J,Renfrew MJ . Support for breastfeeding mothers. (Cochrane Review). The Cochrane Library, Issue 3, 2000 Oxford: Update Software. 3. Mongeon M, Allard R. Essai controle d'un soutien telephonique regulier donne par une benevole sur le deroulment et l'issus de l'allaitment. Revue Canadienne de Sante Publique 1995;86(2):124-127. 4. Dennis C-L A randomised controlled trial evaluating the effect of peer support on breastfeeding duration among primiparous women. Toronto. University of Toronto doctoral dissertation.1999. 5. Gross SM, Caulfield LE, Bentley ME, Bronner Y, Kessler L, Jensen J, Paige DM. Counseling and motivational videotapes increase duration of breastfeeding in African-american WIC participants who initiate breastfeeding. J Am Diet Assoc 1998;98:143-48. 6. NHS Centre for Reviews and Dissemination. Promoting the initiation of breastfeeding. Effective Health Care. 2000;6(2).
Application to the general community 22 September 2000
Tracy Russell, 4th Year Medical Student Newcastle University Medical School Send response to journal: Re: Application to the general community	EDITOR - Morrell et al conducted a randomised-controlled trial into the cost and effectiveness of community postnatal support workers. They reported no health benefits or reduction in costs to the NHS. The need for postnatal support is often unrecognised by health professionals. In this study, support workers offered ten visits in the first 28 postnatal days. It is not clear whether this regime has been tested and whether or not it is optimal. A pilot study investigating care packages could have been beneficial prior to starting such a large trial. One of the main objectives was to assess the effect of the intervention on women's general health. Some socio-economic factors were taken into account. However, many baseline measurements were not recorded, in particular intention to breast feed and maternal morbidity. Breast- feeding rates and general health status were used as outcomes, but the lack of an established baseline makes the results inconclusive. A large number of participants (n=623) were enrolled in the trial . Exclusion criteria, however, prevented a more representative sample being used. Mothers under 17 years old, with babies requiring special care or with language problems were excluded. These women may have benefited the most from additional support. Their inclusion may have highlighted the advantages of having a support worker. In view of this, the conclusions drawn by the authors cannot be applied to the general community. Tracy Russell 4th year medical student T.L.Russell@ncl.ac.uk Naomi Burn 4th year medical student Marianne Clarke 4th year medical student Michael Waller 4th year medical student Department of Epidemiology and Public Health, Newcastle University Medical School, NE2 4HH
Costs and effectiveness of community postnatal support workers 27 September 2000
Jane Barlow, Primary Care Career Scientist, Director Health Services Research Unit, University of Oxford, Sarah Stewart-Brown Send response to journal: Re: Costs and effectiveness of community postnatal support workers	Dear Editor, There has been little research into the effectiveness of home visiting programmes in the UK, and the trial described by Morrell et al is therefore important and welcome. The evidence from primary studies outside the UK suggests that home-visiting programmes can produce a range of beneficial effects on infant and maternal health including the number of instances of abuse and neglect,1,2 number of A&E visits,2 accident rates,2,3 number of hospitalisations,4 parental knowledge about child development and child-rearing attitudes,5 and language and cognitive development.6,7 Long-term follow-up of home-visiting programmes has shown a reduction in the criminal behaviour of children,8 and of internalising and externalising symptoms in both adolescent girls and boys.9,10 A number of reviews of the effectiveness of home-visiting programmes have also been conducted.11-19 While there is once again evidence of positive findings from individual studies, the overall findings from the reviews are mixed. Based on these review findings, it has been concluded that the success of home visiting programmes depends on the population selected, the success with which the skills of the staff have been matched to the needs of the family, and the duration of the programme.11 The authors of the paper do not report on these aspects of their intervention, but it is possible that the disappointing results of their trial are attributable to the first two factors in particular. Perhaps most significantly it is possible that the intervention may have been inappropriate for this group of mothers. There is evidence that home visiting programmes can have different effects on different groups of subjects, and that these can be negative. Support of this nature which is offered to mothers who are already coping, or to mothers who are not experiencing adversity can not only fail to produce positive outcomes but can also lead to regression.20 Most trials of home visiting programmes have researched the impact of intensive support to disadvantaged mothers or to women who have been identified as being at increased risk of poor outcomes. It seems possible that the value of providing a home visiting programme to mothers who are already coping, must be questioned. In contrast, parents who are coping have been shown to benefit from other types of supportive intervention. Universal community-based programmes, offered to mothers in groups in the pre and early post-natal period, have been shown to be effective in improving the psychological well-being of the mother, her confidence as a parent, and her satisfaction with the couple and parent-infant relationship. Second, and just as importantly, no attention was given in the analysis of the current trial data, to the possibility that the support workers could be a source of variance as regards the outcome. It is now recognised that the success of interventions of this nature depends on the capacity of the person providing the intervention to establish a trusting and respectful partnership with the mother. This suggests that future evaluations of the effectiveness of home visiting programmes should measure the quality of the relationship established between the mother and the support worker, and the analysis of the data should include the provider of the intervention (in this case, the support workers)as an independent variable. It is important that the results of this trial are not used to suggest that all home visiting prgrammes are ineffective. Given their potential impact on public health, further UK research is urgently needed to establish the effectiveness of such programmes with high risk mothers. Yours sincerely Jane Barlow (Primary Care Career Scientist) Sarah Stewart-Brown (Director, Health Services Research Unit) References 1. Hardy JB, Street R. Family support and parenting education in the home: an effective extension of clinic-based preventative health care services for poor children. Journal of Pediatrics 1989:115:927-931. 2. Olds DL, Henderson C, Tatelbaum R, Chamberlin R. Preventing child abuse and neglect: A randomised trial of nurse home visitation. Pediatrics 1986;78:65-78. 3. Larson CP. Efficacy of prenatal and postpartum home visits on child health and development. Pediatrics 1980;55:363-377. 4. Hardy JB, Street R. Family support and parenting education in the home: an effective extension of clinic-based preventative health care services for poor children. Journal of Pediatrics 1989:115:927-931. 5. Taylor DK, Beauchamp C. Hospital-based primary prevention strategy in child abuse: a multilevel needs assressment. Child Abuse and Neglect 1988;12:343-354. 6. Bryant DM, Ramey CT. An analysis of the effectiveness of early intervention programs for invironmentally at-risk children. In Guralnick (Ed) The effectiveness of early intervention for at-risk and handicapped children. New York: Academic Press, 1987. 7. Bronfenbrenner U. A report on longitudinal evaluation pre- schoolprograms: Vol 2. Is early intervention effective? (Hew Publication No. OHD74-25). Washington, DC: HEW, 1974. 8. Olds DL, Eckenrode J, Henderson CR, Kitzman H, Powers J et al. Long- term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomised trial. Journal of the American Medical Association 1997;278(8):637-643. 9. Aronen E, Kurkela SA. Long-term effects of an early home-based intervention. Journal of the American Academy of Child and Adolescent Psychiatry 1996;35(12):1665-1673. 10. Aronen E. The effect of family counselling on the mental health of 10 -11 year old children in low and high risk families: A longitudinal approach. Journal of Child Psychology and Psychiatry 1993; 34:155-165. 11. Cox AD. Preventing Child Abuse: A Review of Community-Based Projects II: Issues Arising from Reviews and Future Directions. Child Abuse Review 1998;7:30-43. 12. Cox AD. Preventing Child Abuse: A Review of Community-Based Projects I: intervening on processes and outcome of reviews. Child Abuse Review 1997;6:243-256. 13. Guterman NB. Early Prevention of Physical Child Abuse and Neglect: Existing Evidence and Future Directions. Child Maltreatment 1997;2(1):12- 34. 14. Roberts I, Kramer MS, Suissa S. Does home-visiting prevent childhood injury? A systematic review of randomised controlled trials. British Medical Journal 1996;312:29-33. 15. Ciliska D, Hayward S, Thomas H, Mitchell A, Dobbins M et al. The effectiveness of a home-visiting as a delivery strategy for public health nursing interventions: A systematic overview. Working Paper Series 94-7, McMaster University, University of Toronto, 1994. 16. MacMillan HL, MacMillan JH, Offord DR, Griffith L, Macmillan A. Primary Prevention of Child Physical Abuse and Neglect: A Critical Review. Part 1. Journal Child Psychology and Psychiatry 1994;(35) 5:835-856. 17. Olds DL, Kitzman H. Review of Research on Home-visiting for pregnant women and parents of young children. The Future of children 1993;(3)3:53- 91. 18. Wekerle C, Wolfe DA. Prevention of Child Physical Abuse and Neglect: Promising New Directions, Clinical Psychology Review 1993;13:501-540. 19. Kendrick D, Elkan R, Hewitt M, Dewy M, Blair M, Robinson, J, Williams D, Brummell K. Does home visiting improve parenting and the quality of the home environment? A systematic review and meta analysis. Archives of Disease in Childhood 2000;82:443-451. 20. Gough D. Child Abuse Interventions. HMSO: London, 1993. 21. Afflect, Tenne H, rowe J, Roscher B and Walker L. Effects of formal support on mother's adaptation to the hospital to home transition of high risk infants; The benefits and costs of helping. Child Development 1989;60: 488-501. Cited in Gough op cit 22. Stevenson J and Bailey V. A controlled trial of post natal mothers groups as psychosocial primary prevention. II: Evaluation of outcome' Unpublished paper, University of Surrey, 1988. Cited in Gough op cit. 23. Parr M. A new approach to parent education. British Journal of Midwifery 1998;6(3):160-165. 24. Davis H and Spurr P. Parent Counselling: An Evaluation of a Community Child Mental Health Service. Journal of Child Psychology and Psychiatry 1998;39(3):365-376.
Study of high risk groups would be useful 29 September 2000
Jim Hardy Send response to journal: Re: Study of high risk groups would be useful	Editor - Morrell and colleagues (1) have made an important start on the issue of cost effective support for women in the post natal period. It was not surprising that their findings were inconclusive because they mistakenly chose to study a "normal" group of women. A group which by their own admission had insufficient power to demonstrate the effect they sensed they might find. A more useful study would have taken a group of women with risk factors for postnatal morbidity and randomised them into intervention and control groups. This is work which needs to be done and I wish them well should they decide to pursue this line. Jim Hardy, General Practitioner Bethnal Green Health Centre, 60 Florida Street, London E2 6LL. 1. C Jane Morrell, Helen Spiby, P Stewart, S Walters, A Morgan; Costs and effectiveness of community postnatal support workers: randomised controlled trial. BMJ 2000; 321:593-597.