Key learning points:
– The Antenatal-Postnatal Promotional Guides promote early infant development and early parenting
– Practitioners use these materials to structure and facilitate personalised ‘guided conversations’ with parents that explore key topics and priorities during pregnancy and early infancy
– The guides help parents and practitioners make accurate, well-informed decisions about families’ needs at a crucial time of life
Pregnancy and early infancy are the beginning of life in which the very essence of each human being grows and develops. Scientific knowledge of early life and parenthood has grown rapidly, resulting in a better (though imperfect) understanding of the ways in which biological and environmental factors interact to shape early development, and its effects on childhood and adult life.1,2 These advances are reflected in the expansion of the health visitor workforce and recent innovations in practice. These aim to help families – particularly those with the most complex needs – give their babies the best possible start in life.3,4,5
Every baby is exposed to a range of risk and protective factors that combine to influence early development.6 Four inter-related constellations of factors are particularly influential in shaping early development (see Box 1). Early development is directly affected by the health and wellbeing of the baby, mother and father. For example, alongside maternal smoking, diet and alcohol consumption exposure to ‘toxic’ stress from pregnancy onwards adversely affects fetal, infant and later outcomes. The baby’s developing sense of security, attachment, and bodily and emotional regulation is inextricably bound up with their parents’ capacity to offer affectionate emotional bonds, sensitivity and responsiveness, consistency and protection, receptive play, communication and interaction.7 Parental couple relationships protect against maternal postnatal depression.8 Similarly, emotional and practical support from family and friends can lower maternal stress and increase her self-efficacy.9 Broadly, factors within the baby and the immediate parenting environment have the most direct influence while wider environmental factors tend to be influential through their impact on parents and parenting.
What are the guides?
The Antenatal/Postnatal Promotional Guides,10,11,12 initially known as promotional interviews, were first produced in 2000 for the European Early Promotion Project (EEPP)13 – a primary health promotion and prevention programme provided by health visitors and other community health nurses across the United Kingdom, Finland, Greece, Serbia and Cyprus. The guides have been subsequently updated over the last 15 years to ensure that their content reflects the latest developmental science and practice. They are available from the Centre for Parent and Child Support (see Resources section).
The guides aim to promote three things:
1.The early fetal and infant development.
2.The health and wellbeing of mothers and fathers.
3.Accurate, well-informed decisions about family needs, health behaviours and early intervention.
The promotional guide system is both structured and tailored to the needs of individual families. It has three core components:
1.The antenatal promotional topic guide, guidance notes and
2.The postnatal promotional topic guide, guidance notes and
3.The family strengths and needs summary.
EEPP research outcomes showed that mothers receiving the project’s intervention were more responsive towards their babies, had better parent-infant relationships and provided more appropriate play materials than similar mothers receiving routine care.14,15 Mothers were also more satisfied with health visiting care.
The promotional guide approach is consistent with the values and best practice of health visiting, as it incorporates the latest findings from developmental science into a manualised, evidence based set of practitioner materials. It enables practitioners to work in a tailored, personalised and flexible way. They avoid a ‘tick box’ approach in favour of a partnership approach, focused on an accurate and constructive understanding of the strengths and needs of each baby and their family. The extensive practice use of the materials by health visitors has been vital in informing their further development and adaptation.
Antenatal topic guide and topic cards
The antenatal topic guide and topic cards focus on the following:
1.A mother and fathers’ experience of pregnancy.
2.The parents’ developing bond and understanding of their baby.
3.Knowledge about fetal and infant development.
4.Preparation for labour and birth.
5.Expectations of early infancy, parenthood and family life.
6.The impact of current and past life experiences and circumstances.
These issues are translated into 11 topics (see Box 1) that are explored by the parent and practitioner in order to identify key priorities, goals and plans prior to the arrival of their baby.
The topic guide uses conversational prompts to structure and facilitate a ‘guided conversation’ of each topic with parents. The intention is to avoid a prescriptive, rigid ‘question and answer’ style in favour of a partnership approach that respects and uses the combined knowledge, experience and expertise of parents and the practitioner to explore the guide topics. The topic guide prompts a ‘guided conversation’, linking the parents’ experience, priorities and needs with the developmental content of the guides and the health promotion and assessment tasks of the practitioner.
The antenatal topic cards complement the topic guide and consist of a pack of 11 A6-size cards. The health visitor lays out and explains each of the cards, inviting parents to select topics cards of the most immediate relevance and importance. These become the initial focus of the ‘guided conversation’. The practitioner then draws in other topics as the conversation unfolds so that eventually all are covered. The cards are an easy and straightforward way for parents to understand the purpose and content of the contact. They reinforce partnership working by enabling mothers and fathers to influence the way in which they and the practitioners’ priorities are approached and explored.
Parents generally prefer the openness and ease of using the cards rather than solely relying on the conversational dialogue of the topic guide. Practitioners often have to get used to incorporating the topic cards into their everyday practice. Once achieved, the materials allow practitioners to be able to concentrate on guiding, listening and focusing parents on key developmental topics.
While the antenatal materials can be used at any point, it is recommended that they are used as early as possible in the second trimester (13-27 weeks), once a viabile pregnancy has been established. This is because parents are in a better position to explore and reflect on the guide topics. Delaying until late in the third trimester (week 28 to birth) coincides with the narrowing of most parents’ interest onto the coming labour and birth. Exploring wider parenting and ecological issues becomes more difficult and potentially frustrating for parents and practitioners alike. Use in late pregnancy reduces the opportunity for early identification of health needs and the promotion of maternal, paternal and fetal health and wellbeing. Later use means that family risk factors and difficulties can become entrenched, have a longer adverse impact and may be less amenable to change. Earlier use means that families and practitioners have the maximum time and opportunity to identify need, build resilience and address factors that affect early development and parenting capacity.
Postnatal topic guide and topic cards
Postnatal guide and topic cards are designed to be used four to eight weeks after birth and provides the basis for a ‘guided conversation’. This allows parents to reflect on their baby, themselves and key postnatal experiences, identifying family strengths and concerns, priorities and effective plans after the baby has arrived. They are organised and used in a very similar way to the antenatal material. The 10 topics (see Box 1) include the following:
1.Experiences and meaning of labour and birth.
2.The health and wellbeing of the mother.
3.Partner and infant early parenting experiences.
4.The baby’s emerging temperament.
5.Capabilities and needs.
7.Care and interaction.
9.Family and social support.
10.The impact of current and previous life experiences.
Using the postnatal guide beyond the eight-week period delays the promotional value of the guide and the early identification of potential needs, risks and difficulties. Experienced practitioners integrate elements of the topic guides into all of their early postnatal contacts. They then use the full guide at the six-to-eight week point to reflect on the family’s experiences since birth, analyse and assess need and jointly identify priorities, goals and plans for the immediate future. Although heath visitors are very familiar with postnatal contacts, practice feedback shows that the postnatal guides enable them to deepen their exploration of key topics with parents using a participative, partnership-based approach. For some, the flexible structure and use of the topic cards requires some practice and adaptation.
The family strengths and needs summary
The Family Strengths and Needs Summary supports practitioners’ analysis of the information gained through the use of the topic guides and cards. The summary, similar to the promotional guides, is based on an ecological model of early development6 and references key antenatal and postnatal risk and resilience factors. This analysis provides the basis for a shared understanding between parents and their health visitor and mutual decision-making about appropriate goals and actions. Research shows that its use improves the accuracy of the assessment of family needs.16 The summary should be completed by practitioners after each antenatal and postnatal guide contacts.
How are the guides used?
The guides can be used at a universal level with all mothers and fathers during pregnancy and in early infancy. They provide the core structure for antenatal and postnatal contacts with other required health visiting tasks being integrated into the approach.17 Routine use of the guides should take no longer than one hour. Practitioners may use a number of contacts with families who have more complex needs rather than trying to prolong individual contacts beyond an hour.
Continuity of the health visitor across antenatal and postnatal contacts enables practitioners and parents to take account of the dynamic changes that occur in each family during pregnancy and after the baby has been born.
The antenatal/postnatal promotional guide system is a, evidence-based approach that enables health visitors to systematically promote early fetal and infant development and early parenting. The guides also help parents and practitioners develop personalised and effective plans.
Centre for Parent and Child Support–
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4. Department of Health. Health Visitor Implementation Plan 2011-2015: A call to action. DH: London, 2011.
5. Wave Trust/Department of Education. Conception to the Age 2: The Age of Opportunity. Framework for Local Area Service Commissioners. Wave Trust: Croydon, Surrey, 2011.
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10. Davis H et al. European Early Promotion Project: Primary Health Care Worker Training Manual. Belgrade, FRY: Institute of Mental Health, 2000.
11. Day C. Antenatal Promotional Guide, Guidance Notes and Strengths and Needs Summary. 2nd Edn. King’s College, London/South London & Maudsley NHS Foundation Trust, 2012a.
12. Day C. Postnatal Promotion Guide and Guidance Notes. 2nd Edn King’s College, London/South London & Maudsley NHS Foundation Trust, 2012b.
13. Roberts R, Loxton R, Campbell J, Frame M, Kirkum M, Lake M, Wood M, Ross T, Davis H. The European Early Promotion Project: transition into parenting. Community Practitioner 2002;75:464-468.
14. Davis H, Dusoir T et al. Child and Family Outcomes of the European Early Promotion Project. International Journal of Mental Health Promotion 2005;7:63-81.
15. Puura K, Davis H et al. The outcome of the European Early Promotion Project: mother-child interaction. International Journal of Mental Health Promotion 2005;7:82-94.
16. Papadopoulou K, Dimitrakaki C et al. The effects of the European Early Promotion Project training on primary health care professionals. International Journal of Mental Health Promotion 2005;7:54-62.
17. Morton A, Wigley W. Beyond “Train and Hope”: identifying factors that affect the implementation of the Promotional Guide in health visiting practice. Journal of Health Visiting 2014;2(12):670-680.