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Born to Bond: Psychosocial wellbeing for mothers and babies [Updated 6 January 2015]

Born to Bond is intended to develop materials and research impacts of an approach that includes elements of maternal mental health and infant play to contribute to the physical, neurological and psychosocial wellbeing of infants, and reduce postnatal depression. It addresses the problem of supporting maternal mental health and optimal infant development that is commonly lacking in low resource settings by taking a multi-sectoral approach to maternal and newborn health. Community Health Workers in West Bank will be trained in an Enhanced Timed and Targeted Counselling program that will integrate support for physical health, maternal mental health, creative play and infant stimulation to optimise the holistic wellbeing of mothers and babies.

Photo of Andrew Binns

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Depression is the third leading contributor to the global disease burden and the leading cause of disability, affecting more than 121 million people. Mothers living in low and middle income countries (LAMIC) are at higher risk of maternal depression. Conflict in the West Bank, combined with poverty and high rates of unemployment adds to the burden of mental illness. When mothers are depressed during pregnancy, stress hormones are raised in their bodies and brains, which has physical effects on both the pregnant women and her unborn child. Following birth, mothers with depressive symptoms are often less engaged with their children and reduce their responsiveness to meeting their children’s needs. Such infants tend to become apathetic or irritable and less able to gain their mother’s attention in positive ways, risking a cycle that can lead to child neglect and underachievement for the infant in all areas of their development. For example, mothers with depressive symptoms can be intrusive, forceful or withdrawn in their interactions with their infants. They sometimes struggle to bond with their infants resulting in children developing insecure attachments, potential social difficulties, and behavioral problems leading to long term mental health issues, including their own risk for depression later in life. [updated 6 Jan. 2015]
In 2011, World Vision Jerusalem, West Bank, Gaza (WV JWG) implemented a maternal child health home-visitor project titled “Towards Nourished Infants” using a timed and targeted counselling (ttC) model. Evaluation of this project showed a 23% increase in Palestinian mothers applying improved childcare practices (improved hygiene, feeding and immunisation practices), increased awareness of child rearing needs and an unintended benefit of improving mother to mother-in-law and sister-in-law relationships. Mothers reported that the home-visitor model was culturally sensitive, personalised and they felt comfortable discussing their needs with Community Health Workers (CHWs) who delivered the ttC program. This was further affirmed in recent key informant interviews that reiterated the home visitor approach was helpful for mothers of newborns [updated 6 Jan. 2015].  Despite the successes of ttC, the evaluation also indicated that greater awareness of psychosocial needs for mothers and their infants was needed in order to reduce symptoms of postnatal depression and to maximise the psychosocial development and potential of infants. This was additionally confirmed in the recent qualitative study [updated 6 Jan. 2015] with mothers reporting a desire to know more about holistic development needs of their infants and CHWs stating their need for being able to provide stronger support to mothers who needed to play and engage more with their infants.  This also supports recent research findings that have demonstrated multiple benefits of maternal mental health and infant stimulation activities for optimal child development. Thus, a systematic model of combining physical, mental and psychosocial support for both mother and infant is needed for future scale-up of interventions. 
Based on the success of ttC in West Bank, and known benefits of maternal psychosocial wellbeing and infant stimulation/play this project will take a multi-sectoral approach by developing an Enhanced ttC (EttC) model.  EttC will comprise physical development and health messages for mother and child (based on stand-alone ttC), as well as the 5-pillars approach to reduce symptoms of depression amongst mothers.  The 5-pillars approach, known as the Thinking Healthy Program, includes empathic listening, family engagement, guided discovery with pictures, behavioural activation and problem solving.  This will be combined with parent-infant stimulation initiatives using Learning Through Play (LTP) and regular child development indicators based on the Nipissing District Development Screen (NDDS). 
The pilot of EttC and subsequent research hypothesises posits that Enhanced ttC will reduce Edinburgh Postnatal Depression Scale (EPDS) scores in the intervention arm versus control, after 1-year of intervention in West Bank (occupied Palestinian territories - oPt).  Secondarily, it is expected that (1) fewer children will report ‘no-responses’ on the NDDS after 12 months of EttC; (2) the physical health of children in the intervention arm will be greater than the control (e.g. growth monitoring, supplement intakes, breastfeeding and complementary practices, proper management during illness); (3) improved social emotional outcomes in infants will be observed; and (4) improvements in Early Childhood Development Knowledge, Attitudes and Practices (based on the ECD-KAP measure) will be demonstrated.

Who will benefit from this idea and where are they located?

The immediate and direct benefits will be 400 Palestinian mothers living in West Bank (oPt) of any age in their third trimester of pregnancy. The project will implement a Cluster Randomised Control Trial [updated 6. Jan 2015] where half of the mothers will benefit from stand-alone ttC while the other half will benefit from the EttC intervention. For both groups, a further 400 Palestinian infants will benefit from the program. The project will train approximately 40 data collectors for the research as well as approximately 20 community health workers in the EttC training program. Various other people will benefit from the program indirectly, including fathers, sister and mother-in-laws, and siblings of the infants benefiting from ttC/EttC. All participants will be from West Bank (oPt) villages that surround Bethlehem, Hebron, Nablus & Ramallah. [Updated 6 Jan. 2015]

How could you test this idea in a quick and low-cost way right now?

In a one-month testing opportunity for this idea, the first three things to hone in on would be: • Development of the EttC package – combining the stand-alone ttC manual and program with the aspects of the thinking healthy program (using the 5-pillars approach), learning through play and developmental screener checks. Based on learnings from the key informant interview study into this concept, development of the EttC package will also need to examine ways for strengthening the engagement of fathers and extended family members in the program, possible ways of utilising technology as an alternative support system and materials that may be helpful for continued education of mothers about child development (e.g. family ‘hand-outs’/brochures). This process will require the dedicated work of one individual for at least one month and most likely, design-workshops with West Bank women, CHWs and partners to finalise the EttC package. [Updated 6. Jan 2015]

What kind of help would you need to make your idea real?

This project will be dependent upon various partnerships, including, but not limited to the following groups: • Palestinian Ministry of Health so that the approach is monitored for future scalability in West Bank and potentially Gaza. • Al Quds University for local assistance on translations and testing of research measurement instruments. Data collectors may also be recruited from the university and their support in data analyses and reporting of findings will be critical. This local university will also be used to support ethics approval for the research and ensure compliance with ethics protocols. • Human Development Research Foundation (HDRF) in Pakistan, working in partnership with the University of Liverpool, have been global leaders in establishing a low cost, low resource Cognitive Behavioural Treatment, using the 5-pillars approach, for women experiencing post natal depression. HDRF and University of Liverpool will be substantial technical partners in the development of the EttC program and piloting of its implementation; • Learning Through Play (LTP) partners will support the integration of play initiatives for parents as part of the EttC model to be developed. This will be in collaboration also with staff from the Nippising District Development Screener (NDDS) association, so that measures relevant to the psychosocial wellbeing of infants can be monitored throughout the project and implementation of EttC model. • West Bank women and CHWs to contribute to the overall design of the EttC package, and particularly, to help strengthen elements of the proposed EttC package to ensure greater inclusion of fathers and extended family members; [updated 6 Jan 2015] • Possible information technology support to explore ways that modern technology and social media may be able to augment the program for ease of delivering key messages, providing social support to families and supporting the efficient work of CHWs; [updated 6 Jan 2015] • Support from a local artist to ensure readability of the EttC materais and the design and development of educational materials for families. [updated 6 Jan 2015]

Is this an idea that you or your organization would like to take forward?

  • Yes. I am ready and interested in testing this idea and making it real in my community.
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Attachments (5)

Born to bond story board user experience map.pdf

Born to bond - story board user experience map

Born to Bond Refinement QandAs.pdf

Born to bond - refinement QandAs

Key Informant Interviews summary report.pdf

Born to bond - Key informant interviews summary report

Born to Bond Refinement Process Notes.pdf

Born to bond - Refinement process notes

Born to bond title brainstorm notes.pdf

Born to bond - title brainstorm notes


Join the conversation:

Photo of Jessica Burg

Hi Andrew,

Thank you so much for this contribution. I think we sometimes get so caught up in the health of the child (with very good reasons), but often the mother is left to her own devices. The postnatal period is such a difficult time for many mothers, but they support they need is so difficult to access.

I'm curious how you will be involving fathers or other family members in this program, so that the mothers are able to focus on being mentally well?

Thank you again for this valuable addition to the discussion. If we want our children to thrive, we really do need to make sure that the caregivers are healthy as well.


Photo of Alison Schafer

Thanks for your encouragement Jessica. Currently, the program is formally targetted for mothers and their babies, however, the inclusion of fathers and other extended family members is informally encouraged - so we don't specifically exclude them, but the program is yet to identify ways to be more deliberate in their inclusion. Our brief concept study showed us, that like you say here, there appears to be a need to more deliberately include fathers and other family members in the process; and indeed, this is something we wish to examine further during design phases. In particular, we need to explore options for greater inclusion of fathers and extended family members during the design and development process when the final EttC manuals/materials are created. We would welcome any suggestions you or others might have in how we might better achieve this outcome. Alison

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