A Family Focused and Optimized Postpartum Programme at the Obstetric Department and Across Sectors for Vulnerable Families. - A Mixed-method Study of the Obstetric Care Delivered to Vulnerable Families in Order to Foster an Early Healthy Relationship Formation.

Background The formation of the early relation between parents and infant has a significant impact on the infant's mental, social and cognitive development and competencies. Parental psychopathology may interfere with a healthy interaction by reducing the ability to be sensitively attuned to the infant's signal and needs due to the nature of the psychiatric symptoms. A healthy psycho-social development starts in the perinatal period in which the parent-infant interactions comprise of one of the most influential experiences which make infants vulnerable and exposed to mental health risks in a lifespan perspective. International research has found that the consequences of being born by a mother suffering from mental illness influences on the infant's risks of developing psychopathology, developmental disorders, and problems related to the social negative heritage. In order to initiate preventive programs, the long-term effects of being born by a vulnerable mother need to be investigated to target and design effective interventions. In a Danish context it is also of interest to investigate how the proportions of children with poorer developmental outcomes are distributed between vulnerable and not-vulnerable families.

It is well-documented that early intervention improves the prognosis for infants of vulnerable families and short-term programs consisting of a moderate number of sessions aimed at improving interaction are especially effective in enhancing parental sensitivity and infant attachment security. Furthermore, the World Health Organization recommends that new families are supported in the development of a healthy parent-infant relationship. The postpartum period has been identified as particularly important for the establishment of early healthy parent-infant relationship and health professionals at the obstetric department (obs. dept.) and health visitors in the primary health care sector are in a perfect position to initiate intervention programs that enhances this. Understanding and identifying the quality of the parent-infant relationship is important in both hospital setting and in the primary health care sector which also demands knowledge-sharing across sectors to create coherence. In Denmark the antenatal care is differentiated according to the recommendations from the National Board of Health, offering families categorized as level three and four an extended stay at the obs. dept. following birth. Level three covers vulnerable families comprising of families experiencing social, medical or psychological problems such as e.g. anxiety or depression. Level four covers families experiencing complicated and severe problems with drug abuse or severe psychiatric disorders. These families are offered an extended stay at the obs. dept. which in most Danish hospitals are 5 days.

It is estimated that around 10-14 percentage (n= 980) of families giving birth at Hvidovre Hospital (HVH) are vulnerable. The care and the content of the extended stay is based on recommendations, and is not standardized. Further it has not been investigated what the families' preferences and wishes for the extended stay consists of or what the health professionals experience when taking care of vulnerable families at the obs. dept. The transition to the primary health care sector is also not standardized and trading of information and observation are not ensured.

Vulnerable families need support in the relationship formation . A mentally ill mother demands activation and involvement of the family as a resource to facilitate the best possible prerequisites for a healthy relationship formation with the infant. Substantial evidence have formed an understanding that treatment of postnatal depression might require specific parenting components to benefit child outcome. In addition, some studies have found that intervention programs designed specifically towards improvement of the mother-infant relationship in the context of postnatal depression benefit both the relationship formation and reduces the negative effects of maternal depression on child development. Therefore it is assumed that a combination of a family approach assessing family resources and a relationship based tool that helps parents read their infants self-regulatory cues resulting in an enhanced relationship-formation may decrease the prevalence of maternal post-partum depression.

Aim The aim of this study is to investigate how the extended postpartum stay at the obs. dept. and the transition to the primary health care sector can be optimized for vulnerable families. Furthermore, to develop and test an intervention program that aim to increase parental sensitivity and facilitate a healthy early relationship formation with their infant which may reduce depressive symptoms among vulnerable mothers.