Evidence regarding the effectiveness of other group-based models of supporting vulnerable women in pregnancy (i.e. Centring Pregnancy) in terms of a range of health outcomes, alongside other briefer group-based preparation for parenthood programmes, suggest the value of examining which programme factors appear to be most strongly associated with better outcomes, in order to enhance the existing gFNP model.
Data from the current RCT should be used to identify those women who may be most likely to benefit from future provision of gFNP. This would involve identifying the characteristics of women who showed some change from gFNP pre to post intervention. It would also involve mapping those characteristics against the quality of the gFNP that was provided, as has been done elsewhere with infant massage.169 It is encouraging that breastfeeding was enhanced in the intervention families and that in the process evaluation important learning about weaning was obtained. This suggests the potential value of postnatal group support that focuses mainly on infant feeding and weaning, possibly to complement one-to-one FNP, where no impact of weaning was identified. However, it should be noted that breastfeeding was only one of eight secondary outcomes. Thus, this finding would need replicating.
It should be noted when making any plans for trials into early interventions, starting in pregnancy, that there are different recording systems and restricted access for primary care and maternity care, which will mean that the identification of potential participants will be challenging.
Conclusions
This trial failed to show any benefit of gFNP compared with receiving care as usual during pregnancy and until infants were 1 year of age, except for an increased likelihood of breastfeeding up to 6 months. Our study results indicate that gFNP is unlikely to represent a cost-effective use of resources targeted at high-risk mothers and their children, but it must be noted that these findings may not be generalisable to gFNP delivered to larger groups, running for the full 44 weeks. The study also indicates that usual care within the NHS in the UK, which is more accessible and potentially more extensive than the medical attention received by participants in the US trials of FNP, is likely to achieve similar outcomes to the offer of a more intensive service.
Given the additional cost involved in delivering gFNP, it does not appear that this programme, in its current form and with the current target population, can be supported as a way of improving parenting or
reducing the likelihood of holding views about parenting and children’s development that place the infant at risk of abuse or neglect. However, data from our economic evaluation can be used to inform future health economic studies in this area.
The study was well designed, on the basis of previous knowledge of FNP and on the implementation valuations of gFNP and was rigorously conducted and analysed. However, many months of preparation notwithstanding, it proved challenging to identify potential participants for the study so that they could be approached. The main consequence of this was that almost all the groups delivered were suboptimal in terms of the number of clients, even with the addition of‘buffer’clients. Thus, some dynamic exchange between group members in terms of beliefs or parenting practices, and between group members and the FNs facilitating the groups, may have been lost. The groups delivered in feasibility work were larger and many participants perceived substantial benefits, in particular in terms of one of the secondary outcomes in this study, social support, which was not shown to be affected by gFNP.
The smaller sample size, despite amending randomisation part way through so that more would be allocated to the intervention, also reduced the power of the study; this was especially true for the primary outcome (maternal sensitivity), when only just under two-thirds of study participants agreed to being video-recorded.
Not only were overall trial numbers reduced, but of those allocated to receive gFNP a substantial proportion did not receive the intervention, in many cases because insufficient numbers were recruited to make running a group viable. This is challenging for any future research. To establish larger groups, women need not only to live in close proximity, but also to have similar due dates and possibly fewer eligibility requirements. However, this would produce a less vulnerable group who would be less likely to show benefit from the programme. Careful consideration is needed to work out the best focus for this kind of group programme, which could have potential. Peer support has proved successful in helping parents to deal with older children’s challenging behaviour.175It remains to be seen how gFNP can be developed so that it can make a difference for potentially vulnerable parents, either in pregnancy or in infancy, or in both.
DISCUSSION AND CONCLUSIONS
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