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

BMJ 2009; 338 doi: (Published 14 April 2009) Cite this as: BMJ 2009;338:b974
  1. Peter J Cooper, professor in psychopathology1,
  2. Mark Tomlinson, specialist scientist2, associate professor3,
  3. Leslie Swartz, professor of psychology3,
  4. Mireille Landman, clinical psychologist4,
  5. Chris Molteno, professor5,
  6. Alan Stein, professor of child and adolescent psychiatry6,
  7. Klim McPherson, visiting professor of public health epidemiology7,
  8. Lynne Murray, professor in developmental psychopathology 1
  1. 1School of Psychology, University of Reading, Reading RG6 6AL
  2. 2Health Systems Research Unit, Medical Research Council, and University of Cape Town, 7505 Tygerberg, South Africa
  3. 3Department of Psychology, Stellenbosch University, Matieland 7602, South Africa
  4. 4Parent Centre and Stellenbosch University, Matieland
  5. 5Department of Psychiatry and Mental Health, Groote Schuur Hospital, Cape Town, South Africa
  6. 6Department of Psychiatry, University of Oxford, Oxford OX3 7JX
  7. 7Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford University, Oxford OX3 9DU
  1. Correspondence to: P J Cooper p.j.cooper{at}
  • Accepted 9 December 2008


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.


  • We are grateful to the Parent Centre, a Cape Town based non-governmental organisation, for providing the infrastructure for the recruitment and training of the community workers. We thank Marjorie Feni, Nomabili Siko, Nokwanda Sikana, and Lephina Makhanya, the community workers in this study; Nosisana Nama and Busisiwe Magaze, who assisted in the assessment of the mothers and infants; Thulani Njengele and Agnese Fiori-Cowley for coding of the video recordings; and Timothy Freeth for help with data entry and general administration. We are especially indebted to the mothers and children who took part in this study.

  • Contributors: PJC designed the study and supervised its overall conduct, managed the data analysis, and took the lead in writing the paper. MT was the trial manager and trained and supervised the assessors. LS assisted in training the assessors. ML trained and supervised the community workers and assisted in drafting the treatment manual. CM assisted in setting up recruitment procedures. AS assisted in the development of the intervention and the overall supervision of the study. KMacP supervised the data analysis. LM developed the intervention manual and assisted in training the community workers, doing the assessments, and training the assessors. All authors took an active role in writing the submitted paper and approved the final version. PJC is the guarantor.

  • Funding: This study was supported by a grant (B574100) from the Wellcome Trust. MT was supported by a fellowship from the Vlotman Trust.

  • Competing interests: None declared.

  • Ethical approval: The research ethics committees of the University of Reading and the Health Sciences Faculty of the Medical School of the University of Cape Town approved this study.

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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