Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland - Late Pregnancy and Postpartum

4 FNP PROGRAMME CONTENT IN THE LATE PREGNANCY TO POST-PARTUM PHASE

Introduction

4.1 This chapter presents findings on perceptions of the appropriateness and impact of the FNP programme content in the period from late pregnancy to the first few months after birth, drawn primarily from qualitative interviews with FNP clients and the NHS Lothian, Edinburgh Family Nurse team. It also briefly summarises data from analysis of the monitoring forms returned by Family Nurses on coverage of specific topic domains during visits.

4.2 Key questions from the monitoring and evaluation framework addressed in this chapter include:

• Do family nurses conduct their consultations in line with the fidelity criteria?
• Is the FNP structure useful/appropriate?
• Is there any evidence that clients feel better prepared for birth?
• Is there evidence that the FNP results in improved knowledge/health behaviours in clients prior to/following birth of baby?
• How good are the pregnancy outcomes of those enrolled on the programme?
• Is there any evidence that the FNP engenders positive parenting practices and bonding?
• Is there evidence that the client knows about key hazards and engages in practices to keep child safe?
• Is there any evidence that mums feel more supported and less anxious/depressed because of the programme?

Visit content figures

4.3 The fidelity 'stretch' goals for FNP set out the suggested division of topic coverage during Family Nurse visits at different stages of the programme (pregnancy, infancy and toddlerhood). These figures are intended to reflect variation in the developmental needs of parents and infants at different stages - for example, the amount of time allocated to personal maternal health is highest during pregnancy, while after the birth more time is allocated to maternal role. As shown in Table 4.1, the actual average time Family Nurses in NHS Lothian, Edinburgh recorded spending on different topics during pregnancy came very close to the division suggested by the fidelity 'stretch' goals. The time recorded against personal health and life course development were both within the suggested range, while the amount of time spent on maternal role, relationships with family and friends and environmental health were all less than 2 percentage point outside of this range.

Table 4.1: Visit content figures, NHS Lothian, Edinburgh FNP site, pregnancy

Average Time Devoted to Content Domains during Pregnancy	Fidelity 'stretch' goal	NHS Lothian, Edinburgh site average
Personal Health	35-40%	38.3%
Environmental Health	05-07%	9.4%
Life Course Development	10-15%	11.4%
Maternal Role	23-25%	25.4%
Family and Friends	10-15%	15.5%

Perceived fit of the programme

4.4 The Family Nurse Partnership programme combines a manualised programme, containing detailed information materials, worksheets, etc. for each visit, with an approach that allows Family Nurses to use the programme flexibly to 'agenda match' with clients' needs at particular points in time. During the late pregnancy and immediate post-partum period, key topics covered in the programme include:

• Preparing for the labour and birth
• Infant feeding
• Parenting (including bonding and attachment, reading babies' 'cues', and sleeping and feeding routines), and
• Maternal health (including contraception, recovery from pregnancy, and Post Natal Depression).

4.5 In general, Family Nurses in NHS Lothian, Edinburgh felt the suggested programme content was well-matched to their clients' needs in late pregnancy, but that in the initial post-partum period (particularly the first 6 weeks after birth) it could be more difficult to deliver. In particular, it was felt that the programme content was very full in the post-partum period, and that, if delivered in its entirety, it might not leave room for other activities that Nurses felt might be of more value at that point (for example, use of the Partners in Parenting Education (PIPE) activities around parenting and 'reading' your baby). This was not, however, necessarily perceived to be a major problem, as by the post-partum period Family Nurses were more used to 'agenda matching' their delivery to the clients' specific needs at that point in time. One view was that in the first 6 weeks after birth, in particular, this agenda matching was particularly key and that the programme needed to be more 'mum-led'.

I will say that some of the stuff in the early infancy … just trying to fit everything in … was a problem, and sometimes things seemed to re-occur: 'Your baby's now a week old. Your baby's now 4 weeks old. Your baby's now 6 weeks old', you know? … So … often I would just leave facilitators and touch on the other things that were going on there. (Family Nurse 4)

I think towards the end of pregnancy it's fine … the emphasis is fine and where it should be in terms of practical and emotional … preparation for the baby. … I think for the first six weeks it's got to be quite mum-led … and … less amount of facilitators I think. (Family Nurse 6)

4.6 Family Nurses also observed that while the suggested programme content matches clients' needs well when they are in more settled circumstances, where an unexpected crisis occurs, it could be more difficult to cover the recommended content while also addressing this crisis. In these circumstances, agenda matching was again seen as essential, as it was for those clients who were more difficult to engage with the programme in general.

Yes, following the programme, but you know agenda-matching what these young women actually need or want from the programme, because in that case then you've got more chance of getting them to give you the commitment that the project needs. (Family Nurse 1)

4.7 A specific scenario where the programme materials were perceived to be less appropriate related to cases where a baby is taken into care as a result of child protection proceedings. In this situation (where it is uncertain whether the mother and baby will be reunited), it was suggested by the NHS Lothian, Edinburgh Family Nurse Team that the current FNP materials do not always lend themselves well to supporting Family Nurses with visits to mothers. For example, the materials might involve asking the client about what their baby did last night, or exploring attachment, both of which could be difficult and sensitive topics when the mother and baby were not living together.¹⁰ As this is the first cohort of FNP clients in Scotland, the confidence of Family Nurses to adapt the materials to fit this specific circumstance may improve as they become more familiar with the programme and materials and are working with a second cohort of families. However, participants' comments around the challenges of delivering the programme in the specific context where a baby has been taken into care may suggest that this is an area of programme design worthy of further exploration locally (possibly with social work or other colleagues, to develop an integrated approach to supporting mothers at this very sensitive time) or nationally. The new role of National Lead Supervisor also incorporates a remit to review educational materials used in the programme and, where required, to develop them to reflect the Scottish and national setting (in line with University Colorado Denver copyright agreements). The opportunity for FNP in Scotland to shape educational materials for FNP nationally is also offered via the FNP National Unit (DoH). NHS Lothian FNP team is represented by a Family Nurse to attend and contribute to this workstream.

4.8 Other suggestions from Family Nurses and key stakeholders about aspects of the programme content or materials that they felt could be improved included:

• Simplifying some of the materials relating to labour and delivery.
• Revising some of the sexual health materials to make them more appropriate to a UK context (topics like douching and use of diaphragms were seen as reflecting the US origins of the programme and as less appropriate for British teenagers).
• Reducing and simplifying the suggested content for the immediate post-partum period generally.
• Moving some of the data collection included in the immediate post-partum period (e.g. domestic violence) to later in the programme.
• Facilitators and educational materials around binge drinking, which was seen as an issue for some clients which was not fully reflected in the current materials developed for FNP in the UK.

4.9 As noted above, FNP in Scotland has the opportunity to shape educational materials for FNP via input to the FNP National Unit (DoH) materials workstream and via the new National Lead Supervisor role .

4.10 Clients interviewed around 3 months after their babies were born appeared to be very happy with the overall content of the programme. They reported that the balance of different topics seemed about right and commented positively on the dual focus on both the mother and baby in the post-partum period. Clients' comments also illustrate that they are aware that Family Nurses have to deliver particular content. However, they felt both that the topics covered by FNP generally matched their key concerns at particular points, and that there was sufficient flexibility for them to raise other issues where necessary.

She asks me that at the end of every session like, if there's anything else that we need to cover. But everything she covers or talks about, like, is what I need to know or what I want to know. (Client 11)

4.11 In reflecting on 'who decides' what they talk about in their meetings, clients described different means of 'agenda matching':

• their Family Nurse brings things she would like to talk about but also asks them what else they would like to discuss
• the Family Nurse asks clients whether the topics she has in mind are OK with them, or
• the Family Nurse raises topics, but the client feels confident enough to raise their own questions and concerns and their Nurse will adjust sessions to address these

4.12 There were, however, a few examples of exceptions to this generally positive picture, where clients suggested that they had not received elements of help or support they had wanted from their Family Nurse or that they preferred to go to other people for advice. These included:

• Family Nurses not following up on requests to provide information about other services, and
• A perception that Family Nurses did not always appear to clients to be as knowledgeable as friends or family members in relation to looking after a new born.

4.13 In part, these views appeared to be linked with either clients already being well supported (and therefore tending to rely on family and friends more) and/or with a lower level of contact with their Family Nurse during the post-partum period, which meant they tended to rely on them less. In fact, these two factors were explicitly linked by a client who was less happy with the amount and nature of support she had received in the post-partum period. She speculated that perhaps she had not seen as much of her Family Nurse in the post-partum period because she had good support from her family, while her Family Nurse might have other clients in different situations who needed more support:

… she knows I've got everybody here anyway, so I don't know if she's looking at it that way; that I've got everybody here. And some o' her folk have got nobody, so ... (Client 6)

4.14 In this scenario, the fact she had good support was seen (by the client) to be the cause of lower levels of contact with her Family Nurse, which in turn lead to her relying less on her Family Nurse and more on her family for advice and support.

I've spoke to my mum, and took him to the doctor's. I've never really phoned her about anything since he's been born. Or I've spoke to the Health Visitor when I've took him for his jags and stuff because I just dinnae think she (Family Nurse) knows what's going on fae when he's been born. (Client 6)

Specific topics covered in the late pregnancy to post-partum period

Preparedness for birth

4.15 Preparing for labour and birth is, unsurprisingly, a key focus of the FNP programme in late pregnancy. In terms of the perceived impact of FNP in preparing participants for the birth, clients mentioned:

• Feeling clearer about the different stages of labour. Clients were able to describe these in interviews and discussed, for example, how they had learned to count the spacing of their contractions in order to work out when to go to hospital. If in doubt, they were able to contact their Family Nurse for reassurance that they were 'reading' their contractions correctly.
• Feeling better able to assert their views with hospital staff during the delivery as a result of discussions with their Family Nurse.

So then she (Family Nurse) said to me, 'If they say like "Don't you push just now" then just say "Well d'you want to give me another vaginal examination, because I'm really feeling the need to push?". So then I said that to the woman. I was like "Look, I really need to push". I was like, "You can even check." … And then (I) started pushing and then (Baby) came out! (Client 12)

• Feeling more confident when the delivery does not go completely to plan as a result of information received from their Family Nurse about the different things that might happen in the delivery room (e.g. use of forceps).

4.16 There was also evidence of FNP helping partners to prepare for the birth, as illustrated by the following quote. The client in this case had not felt she needed much information from her Family Nurse about the birth, as she felt she already knew a lot about this. However, both the client and her partner felt FNP had helped him to prepare for the delivery.

Just telling me what happens at childbirth that was a big help, because I had not a clue what was happening or anything like that. Just … (client) was calm and her mum was calm but they never really told me what to expect. (Significant Other 2)

4.17 Family Nurses themselves suggested that discussions about roles in the labour room were among the most valuable sessions in the pregnancy period in terms of ensuring that any tensions and concerns are aired and addressed in advance, and in terms of helping fathers feel more comfortable and confident about their role.

4.18 Although one view among clients was that there was nothing else they either needed or wanted to know about the birth, there were a few suggestions of areas they would have liked to know more about, including:

• specific sorts of pain relief (e.g. spinal blocks)
• potential problems that might arise during labour or immediately after the birth (e.g. treatment if the baby is jaundiced, or the possibility that the baby would need help with breathing, as well as more information about tearing and stitches after delivery)
• information on particular labour symptoms (e.g. labour pains occurring mainly in the back)
• more detailed advice on what to take with them to the hospital, and
• more discussion around how the client might feel physically and emotionally immediately after the birth.

4.19 These areas are all covered in the FNP guidelines. However, those clients who mentioned them nonetheless felt they would have benefited from further information or discussion.

4.20 Birth outcomes are recorded for all FNP clients. 139 babies were born to 138 clients from the first NHS Lothian, Edinburgh FNP cohort who were still engaged at the time of the birth.¹¹

• Average gestation at delivery was 40 weeks (delivery is considered 'full term' at or after 37 weeks gestation).
• The average birth weight was 3291g
• 7.2% (10/139) of babies having a low birth weight (below 2500g). None were very low birth weight (less than 1500g). According to ISD figures for 2010, 5.1% of all babies born in Scottish hospitals had a low birth weight (below 2500g), with 0.7% having a very low birth weight (<1500g).¹² The Scotland-wide figures for 2010 are not broken down by maternal age, but as age is associated with low birth weight (with younger and older mothers more likely to have low birth weight babies - ISD 2011), these figures are likely to be higher for mothers under 20.
• 13% (18/139) of FNP babies were admitted to a Special Care Baby Unit.

Infant feeding

4.21 As discussed in the first report from the Scotland evaluation, FNP is a strengths-based programme. Rather than only advocating one approach to infant feeding, it emphasises working with clients' own feelings about and potential resistance to behaviours like breastfeeding. Feeding their baby was clearly an area clients felt anxious about in the early weeks after the birth - were they feeding their baby enough? Were they feeding them often enough or too often? Were they sterilising bottles correctly? What positions are best for breast feeding? Clients interviewed for the evaluation described seeking out their Family Nurse's advice on all these issues. Table 4.2 shows the kinds of information and support they identified as particularly helpful.

Table 4.2: Support with feeding

Breast feeding	Bottle feeding	Weaning	General
Demonstrating feeding positions Information about supplements to help with milk flow	Information about sterilising bottles Advice about how much to feed their baby Demonstrating how to hold the baby during feeding	Information about recommended guidance on weaning and reasons for leaving it to 6 months Support in dealing with family pressure to wean early	Reassurance that their baby is putting on the right amount of weight Information about feeding routines

4.22 This support was clearly believed to have made a difference - for example, information about supplements was seen by a client as having helped them to breastfeed for longer, while her Family Nurse's support in dealing with family pressure to wean early was viewed as having helped another mother both to hold off on weaning and to feel more confident in her own parenting skills and parental role.

4.23 Increasing breastfeeding has been a particular focus of health promotion in Scotland and the rest of the UK for a number of years now. Scotland has relatively low breastfeeding rates compared with other countries in the UK, while young mothers have much lower rates of breastfeeding than the population as a whole. A review of the research literature on young mothers and breastfeeding by the Department of Health, Social Security and Public Safety in Northern Ireland (2004) suggested that many young people have no knowledge of breastfeeding, lack access to key sources of information (from antenatal classes to support from friends and family) and lack assertiveness around asking for advice on breastfeeding. Embarrassment, a lack of role models, fear of pain and misconceptions about babies being able to gain enough weight through breastfeeding were also identified as potential barriers for young mothers.

4.24 FNP routinely collects data on clients' intentions regarding breastfeeding as well as whether or not they actually go on to initiate and sustain breastfeeding. Analysis of the data for the first NHS Lothian, Edinburgh FNP cohort shows that:

• 46% ever breastfed or expressed milk
• 13% were still breastfeeding at 6 weeks, and
• 7% were exclusively breastfeeding at 6 weeks.

4.25 Considerable caution should be applied in drawing any conclusions from comparisons between these figures and those for other mothers aged under 20 in Scotland. Differences in methodologies for assessing breastfeeding rates and potential differences in the profile of FNP clients in Edinburgh compared with all those aged under 20 in Scotland mean that any such comparisons can at best be tentative. However, for information, the proportion of mothers under 20 initiating breastfeeding was 33% according to the 2005 Growing Up in Scotland survey (Skafida, 2008) and 39% among the Scottish sample for the Infant Feeding Survey (NHS Information Centre/IFF Research, 2011). NHS Information and Statistics Division (ISD) figures for 2010/11 show that 8.0% of Scottish mothers under 20 were still breastfeeding at their 6-8 week health visiting review, while 4.7% were exclusively breastfeeding (ISD, 2011). The Building Blocks trial in England (Sanders et al, 2011) will provide more robust data on the impact of FNP on breastfeeding rates.

4.26 Family Nurses use motivational interviewing techniques to support clients over time in considering and making healthy decisions for themselves and their babies. There is interest in the potential for this kind of approach to encourage clients who are initially ambivalent or hostile to the idea of breastfeeding to at least try it after the birth. When they first joined FNP, 32% of clients in the first NHS Lothian, Edinburgh cohort definitely intended to breastfeed, while 42% were undecided and 26% said they definitely would not breastfeed. Among those who definitely intended to breastfeed, most (83%) went on to do so at least once. However, so too did 43% of those who were originally undecided and 8% of those who did not originally want to breastfeed - a 'conversion' rate of 28% of those who were initially ambivalent about or hostile to breastfeeding.

4.27 Family Nurses reflected on the ways in which FNP might help encourage clients to try breastfeeding. They that the structure of FNP was helpful - in particular, the fact that Family Nurses have repeat contact with clients during pregnancy allowed them to introduce information about feeding and revisit it later on. The approach of FNP in supporting clients to make their own decisions was also contrasted with the perceived approach of universal services:

So it wasn't about "Because I really want you to breastfeed", 'cos I think that that was a message that a lot of the girls felt was coming from other universal services, you know? … it was very much about giving all the information … And some girls that I thought that were definitely going to breastfeed didn't, and other girls that I thought weren't even going to think about it at least gave it a bash. So I don't know if I got it right, but I was listening to where they were, their starting point, and trying to fit in with that. (Family Nurse 4)

4.28 While this evidence suggest that FNP may have the potential to support more young women to at least try breastfeeding, the overall figures cited above indicate that while almost half clients attempted breastfeeding, there remain significant barriers to encouraging young mothers to continue breastfeeding for a longer period. The panel of clients interviewed in-depth for the evaluation included clients who had never breastfed, clients who initiated breastfeeding but stopped shortly after the birth, clients who breastfed for a week or more but were bottle feeding by the time of the interview (3 months after the birth) and clients who were still breastfeeding, either exclusively or in combination with bottle-feeding. Among those who were not breastfeeding at the time of their second evaluation interview (around 3 months after the birth), familiar barriers were identified, including:

• Feeling uncomfortable breastfeeding outside
• Soreness, and
• The baby not latching on.

4.29 In addition, there was some evidence that both clients and Family Nurses felt FNP mothers were not getting enough support, or not getting appropriate support with breastfeeding before they left the hospital. Family Nurses recognised that midwives in hospital were often very stretched and might not always have enough time to fully support tired new mothers to breastfeed. However, in some cases Family Nurses felt this may have undermined clients' intentions to breastfeed, and that some clients were later disappointed not to have either tried or persisted with breastfeeding.

I would say that some people said … they did but a lot of them said they didn't feel supported, and that would be one of the reasons why they didn't continue. (…) By the time I was coming in to see them, they'd stopped. (Family Nurse 2)

4.30 This was also reflected in comments from clients. Experiences of support with breastfeeding in hospital varied, with some positive comments about the support received from midwives in showing clients how to initiate breastfeeding or helping them express milk. However, there were also examples where clients described finding it too difficult and giving up before they were discharged, or where they were deterred from continuing by inappropriate support:

Well I found it quite embarrassing, but they kept on grabbing me and then like forcing it into (baby's) mouth and everything. (Client 14)

I had actually tried breastfeeding him at first in the hospital, but I found I didn't really get very much help in the hospital trying to do it … He never took to it, so it was scary for me … He's been bottle-fed since about the second day. (Client 16, paired interview)

4.31 One Family Nurse suggestion was that a volunteer breastfeeding scheme, where mothers are paired with other mothers who are breastfeeding or have breastfed prior to the birth, might be more effective in helping them with feeding immediately after the birth. It is also worth noting that the recently refreshed framework for maternity care in Scotland (Scottish Government, 2011) includes an emphasis on critically appraising breastfeeding rates and planning improvement measures for women in particular need of support.

4.32 Where clients had not initiated or maintained breastfeeding this time, one view among Family Nurses was that clients might be more likely to try it with subsequent babies as a result of the information received from FNP. Finally, both clients and Family Nurses commented on the fact that where young mothers had not continued breastfeeding, they sometimes needed additional support to avoid feeling a 'failure' and losing confidence in their parenting ability.

Bonding and attachment

4.33 Promoting parent and child bonding and attachment is a key aim of FNP. As discussed in the introduction to this report, attachment theory acknowledges the critical importance of bonding both in the child's subsequent development and in the mother's (and father's) ability to be responsive parents to their babies. It was suggested that discussing attachment in pregnancy was particularly valuable in terms of preparing FNP clients for parenthood:

I would say that … they've got much more … readiness of parenting … I think that's very clear whenever the babies are first born that they're much more in tune with their babies because that's been raised throughout the whole of the pregnancy. (Family Nurse 3)

4.34 Clients mentioned discussing a range of activities that can help support attachment with their Family Nurses, including skin to skin contact when the baby is first born, the best feeding positions to encourage bonding, the benefits of breastfeeding for bonding, hugging, playing with, talking and singing to their baby, and in general making sure they spent time together as a family and avoided having too many visitors in the immediate post-natal period. One view among clients was that they felt they would have done all these things anyway, either because they were already aware of them before their Family Nurse mentioned them, or because they thought it was a matter of instinct. However, clients and significant others did also report discovering or gaining confidence to try new things through their Family Nurse.

Well I already got to know - 'cos he's my baby, obviously - got to know his cries and his facial expressions and what they mean, but there were some ones, like extraordinary ones on there, like, you know, if a baby's in an active sleep or a quiet sleep, and, you know, you can tell the difference now. (Client 8)

I found it good that she was advising me to do skin-to-skin. I knew about skin-to-skin and I was planning on doing it anyway, but I needed that wee bit of confidence boost for me to do skin-to-skin and stuff like that. (Client 4)

She showed me how to play and everything with her, the way that she would respond when she's old enough, and then she started responding. (Significant other 2)

Baby health and safety and baby development

4.35 Baby and child health, safety and development is unsurprisingly a theme Family Nurses return to repeatedly throughout the FNP programme. Clients were generally perceived by Nurses to be both receptive to these topics and already very knowledgeable about some areas, particularly in relation to hazards. This was reflected in comments from clients that they did not necessarily feel the information they received from FNP around safety and hazards in particular was new to them. However, again there were examples of clients gaining new information and changing their approach because of their Family Nurse, including adopting safe sleeping positions, having 'tummy time', and sterilising dummies.

Just like things that I wouldnae have had a clue (about). Like … I thought that you would have them at the top of the cot … I was like, 'the cot's so big, surely her feet cannae go at the bottom', but she was like 'That is the safest way to do it because she canne wriggle down and go under the covers'. (Client 13)

4.36 Clients also suggested that even where they did already know about aspects of how to keep their baby safe and well, they valued being able to show professionals what they knew. The strengths-based approach of FNP and the ways in which this can improve clients' confidence was reflected in clients' accounts of the status of the information they received from their Family Nurse around baby health and safety, which was seen as one source (albeit a particularly respected one) of advice to help them make their own decisions.

I said that to (Family Nurse) and she was like 'well, it's up to you, whatever you feel most comfortable with.' … 'Cos then … I've got … two people's opinions so it's really up to me. So I just like to get the advice. (Client 1)

4.37 Clients reported the ways in which their Family Nurse encouraged them to trust in their own judgement about what their babies need and helped support them in challenging the parenting advice of other family members where this was unwelcome and/or outdated.

4.38 The other family members interviewed for the evaluation also reported appreciating the information the Family Nurse gave them, and recognising that this could be more up to date than their own knowledge. In common with findings reported above about preparing for the birth, in some cases, even where the client did not feel they had found out anything new about baby health and safety from their Family Nurse, their family members nonetheless felt that they had gained new knowledge, confidence or skills from FNP.

With the Family Nurse, she's given us confidence to do … to do things that we wouldn't normally think of doing … Yeah, some of them are scary. Some of them aren't so scary. But at the same time then we know that, if it happens, this is how you deal with it. (Significant Other 1)

Mother's health and wellbeing

4.39 Making space for the mother's own health and wellbeing in the weeks after birth was viewed by Family Nurses as extremely important, although sometimes challenging because clients are so focused on their new baby. Clients themselves valued being able to ask their Family Nurse for advice about their own health as well as their baby's both during the pregnancy and after the birth.

4.40 In addition to discussing their physical health (recovery from the birth, stitches and infections, and checking for breast lumps - something client comments suggest they might not otherwise have considered doing), mental and emotional health and wellbeing is clearly a key focus of FNP in the post-natal period. All clients are assessed for potential post-natal depression. Based on data for 130 clients engaged with the programme at the time this data was recorded, ¹³ the mean Edinburgh Postnatal Depression Score was 7.3 (with scores ranging from 0 to 26). The SIGN guidelines for Scotland note that a cut off of greater than 9 has been suggested for possible postnatal depression and a cut off of greater than 12 for probable postnatal depression (SIGN, 2002).¹⁴

4.41 Clients in the qualitative panel who had experienced issues around their emotional or mental health either during pregnancy or after the baby was born talked about the support their Family Nurses had given them in coping with this. This ranged from general advice about coping with stress and reassurance that their feelings were normal, to assessment and referral to their GP for treatment for post-natal depression. Family members interviewed for the evaluation also described having contacted the client's Family Nurse with concerns about potential post-natal depression, and the Family Nurse being able to raise this with the client and support them in getting either professional help or help from their families.

It was that night (after the Family Nurse's visit) that (client) said to me, 'I need help', kinda thing … It was the first time she's actually asked for help properly, you know? (Significant other 3)

4.42 Maternal health behaviours - drinking, smoking, drugs, diet, exercise and sexual health - are also threaded throughout the FNP programme, including the late pregnancy and post-partum period. FNP collects information about smoking, alcohol consumption and drug use at a number of time points. Table 4.3, below, shows the proportion of clients who were smoking, drinking or using drugs at intake, 36 weeks gestation and 6 weeks after the birth.

Table 4.3: Maternal smoking, drinking and drug use

Time point	Current smoker (last 48 hours)	Current drinker (past 14 days)	Drug use (past 14 days)
Intake to FNP	43% (61/141)	6% (9/141)	4% (5/141)
36 weeks gestation	38% (40/133)	2% (3/133)	3% (4/133)
6 weeks post-natal	43% (58/134)	N/A	N/A

4.43 The smoking patterns in Table 4.3 do not fully reflect the level of change in clients' smoking behaviour, however. Of the 130 clients in the first NHS Lothian, Edinburgh cohort for whom information about smoking at both intake and 36 weeks gestation was collected,¹⁵ 58 (45%) reported that they smoked at intake.¹⁶ By 36 weeks gestation:

• 14 of these had not changed their smoking behaviour at all
• 10 reported smoking more
• 24 reported smoking less, and
• 10 had stopped smoking.

4.44 Among clients who had not reported smoking at intake, 2 had started smoking during pregnancy. Comparison of 36 week data with that collected 6 weeks post-natally shows that:

• 70 out of 130 remained non-smokers
• 4 were smoking in late pregnancy but had stopped by 6 weeks after the birth
• 15 had decreased their smoking
• 11 were smoking the same amount
• 19 had increased their smoking since late pregnancy
• 9 had stopped smoking during pregnancy but resumed smoking since, and
• 2 former non-smokers had started smoking by 6 weeks after the birth.

4.45 Among the small number of clients (n = 9) who drank alcohol at intake, most (n = 7) had stopped drinking by 36 weeks gestation, while one client who did not drink at intake had started drinking by this point.

4.46 Without a control group, it is not possible to establish what proportions of these changes in client's smoking and drinking behaviour result from participating in FNP. Qualitative interviews with both Family Nurses and clients suggest that they did not always attribute any such changes wholly to FNP - for example, clients described having made decisions about stopping or changing their smoking habits in advance of joining FNP, while Nurses suggested that in some cases clients had already decided to cut down on drinking before joining and FNP was just supporting them in 'continuing along that path'. However, there was also evidence of the potential for FNP to raise clients' awareness of the risks of smoking and drinking during and after pregnancy, which could lead to changes in behaviour.

Just obviously being pregnant I though 'Oh, I'm not gonna smoke as much', but I was still smoking about maybe 6 a day. But with the Family Nurse telling me the risks it could have caused, I cut right down to about maybe 2 a day … Sometimes I didnae even have a fag during the day. (Client 19)

I used to think that, 'oh, as soon as I'm not pregnant, I can have a wee drink'… but I've just like not anyway, I've just left it because I know it can make the baby more sleepy (Client 3, describing perceived impact of information from Family Nurse about drinking while still breast feeding)

4.47 There were also examples of clients attributing changes in their eating habits during or after pregnancy to the information they had received from their Family Nurse - for instance, reporting drinking more water and eating better because of information about the importance of this for their milk supply.

4.48 Finally, sexual health was another topic that Family Nurses felt needed to be introduced in late pregnancy, rather than after the birth when most mothers were too tired to give contraception any serious thought. The involvement of FNP before the birth was seen as a 'great advantage' in this respect. Again, interviews with clients provide examples of Family Nurses raising their awareness of the range of contraceptive options available to them:

I would have thought about something, but I don't know if I would have went for the implant … 'Cos I never knew there was so much stuff, but there obviously is! (Client 2)

Future plans around work and education

4.49 Supporting parents to be financially independent and reducing reliance on benefits is a key aim of FNP. Work and education tend to be less of a focus of the programme around the late pregnancy and post-partum period, where preparing for the birth and caring for a newborn baby take precedence. However, clients mentioned having discussed work and education with their Family Nurses either before or after the birth. In addition to encouraging them to think about where they wanted to be in five years time, FNP had provided them with practical information about courses and about crèches and nurseries to allow them to attend work or college. Family Nurses also had offered help with filling in application forms.

4.50 Reflecting on their experiences of delivering FNP in general in the last 12 months, Family Nurses suggested that the recession had meant they had to think more creatively about how to support clients towards becoming more financially self-reliant in a context where there are fewer jobs available:

We're building these clients up to have … the confidence and the ability to go out and try and get themselves jobs and move on in the world, and as the recession is biting that's becoming more and more difficult … So we're trying to now think about … 'OK, let's try and think about part-time work … let's think about maybe doing some voluntary stuff, let's think about doing education and training' rather than … going straight into full-time work. (Family Nurse 3)

Challenging topics

4.51 Clients and Family Nurses interviewed for the evaluation were asked whether there were any particular topics they found difficult to discuss with each other. One view (expressed by both clients and Family Nurses) was that by late pregnancy or the early weeks after the birth, there were no such topics as they had built such a strong relationship by then. However, various topics that had the potential to be uncomfortable or difficult were also identified, including:

• Mental health and wellbeing. Clients described feeling awkward discussing how they were feeling because they were not used to doing so. Similarly, there was a view among clients that it was easier to talk about their baby's health rather than how they themselves were feeling, although they also appreciated that it was part of the Family Nurse's job to assess them for post-natal depression. Family Nurses suggested that mental health usually became easier to discuss once they had established a relationship with their client. They also felt that the FNP facilitators and the fact that mental health is revisited at various points during pregnancy helped make it easier to raise it in the post-natal period. Where clients had missed visits during pregnancy, however, it was suggested that it could be more difficult for Nurses to discuss post-natal depression after birth, as they did not have this foundation (either in terms of the relationship or having already introduced it as a topic).
• Maternal health behaviours. Family Nurses noted that clients could be resistant to talking about issues like smoking. A non-judgemental approach, as well as knowing when to leave a topic and when to revisit it, were seen as key here.

I had a client who, at the beginning of pregnancy, the minute that smoking was mentioned in any shape or form clammed up … I tried to raise it a couple of times after that and I really did think 'If I talk about this again, she's going to stop me from coming', so I didn't raise it for a good while, and then she then mentioned it to me … and I went in very softly softly and she now has completely stopped. (Family Nurse 3)

• Domestic violence. Family Nurses suggested that there was a particular need to be very flexible about when domestic violence is discussed, rather than rigidly following suggested dates for assessing it in the manual. Bringing it up in the third person, rather than asking clients about their experiences directly, was also seen as a useful strategy for encouraging clients to open up if domestic violence is suspected.

I would keep it until an opportune moment came up, and quite often with the domestic violence material you would wait until you got the client by themselves … You choose your moment really … I've had quite a few disclosures …when I've said 'a lot of us in our lifetime will come across somebody who suffers from domestic violence' … So bringing it up … in that objective way … seemed to make it easier for them. (Family Nurse 5)

4.52 Family Nurses also described how the skills they had learned through FNP had helped them handle potentially challenging conversations or issues where they and the client had a different view of what was best for the baby. The non-judgemental approach of FNP was also reflected in clients' observations about areas where they had differences of opinion with their Family Nurse - rather than feeling they had fallen out over this, it was described in terms of their Family Nurse providing them with information to make an informed decision but then supporting them with their choice.

Even something as simple as somebody choosing to take their baby into the bed with them … I mean, it's not such a challenge now because I feel I now have the skills to explore that without being judgemental, without being directive … I can introduce information and give them the place to make their own decisions on it. (Family Nurse 5)

She's just advised me like on stuff …so it's not that we've disagreed. We've just got different opinions … She's very supportive … I think it was leaflets she gave me … what they're there for and all that, so she has gave me advice, and she knows that it is my choice. (Client 1)

Key points

Do family nurses conduct their consultations in line with the fidelity criteria?

• The average time Family Nurses in NHS Lothian, Edinburgh recorded spending on different topics during pregnancy was very close to the division suggested by the fidelity 'stretch' goals.

Is the FNP structure useful/appropriate?

• In general, Family Nurses felt that the suggested programme content during pregnancy was well matched to clients' needs. The content for the post-partum period was viewed as very full, however. It was suggested that a degree of flexibility was required to create space to deliver other relevant activities and to agenda match.
• In cases where a baby is taken into care, it was suggested that (where a final outcome has not yet been determined) the programme materials may not always lend themselves particularly well to supporting Family Nurse visits to mothers, since they focus on issues like attachment which can be very sensitive in this situation.
• Other aspects of the programme materials that Family Nurses felt could be improved or enhanced related to labour and delivery, sexual health and binge drinking.
• Clients appeared to be very happy with the overall content of the programme and with their ability to raise additional issues with their Family Nurses as required.
• Challenging topics identified by clients and/or Family Nurses included mental health and wellbeing, maternal health behaviours and domestic violence. Factors that facilitated discussing these issues included an established relationship between client and Family Nurse, a non-judgemental approach, and flexibility around when these topics were introduced.

Is there any evidence that clients feel better prepared for birth?

• Both clients and their partners gave examples of the ways in which they felt more knowledgeable and confident about labour and delivery, including feeling clearer about the stages of labour, feeling better able to assert their views during delivery and feeling more confident when the delivery did not go completely to plan.

Is there evidence that the FNP results in improved knowledge/health behaviours in clients prior to/following birth of baby?

• Examples of positive health behaviours and knowledge clients' attributed to FNP in the late pregnancy/post-partum period included: breastfeeding for longer; resisting pressure to wean early; greater awareness of the risks of smoking and drinking during and after pregnancy; changes to eating habits during or after pregnancy; and awareness of a greater range of contraceptive options.
• Overall, 46% of NHS Lothian, Edinburgh FNP clients breastfed at least once.
• Among FNP clients who were hostile to or ambivalent about breastfeeding when they joined the programme, 28% went on to breastfeed at least once.
• There was some evidence that both clients and Family Nurses felt they were not always receiving either enough or appropriate support with breastfeeding in hospital, and that in some cases this might undermine clients' intentions to breastfeed.

How good are the pregnancy outcomes of those enrolled on the programme?

• Average gestation of babies born to the first FNP cohort in Scotland was 40 weeks (well above the threshold for a birth to be considered full term).
• Average birthweight was 3,291g, with 7.2% having a low birthweight. None had a very low birthweight.

Is there any evidence that the FNP engenders positive parenting practices and bonding?

• In relation to bonding with their new baby, while one view was that clients and partners would have engaged in bonding activities without their Family Nurse, clients and partners also reported discovering or gaining confidence to try new activities to support attachment in the post-partum period.

Is there evidence that the client knows about key hazards and engages in practices to keep child safe?

• Family Nurses generally felt clients were very knowledgeable about hazards and safety. While clients did not necessarily feel that the information they received from FNP around safety and hazards was new to them, there were also examples where they felt they had changed their approach because of their Family Nurse - for example, in relation to safe sleeping positions or sterilising dummies.

Is there any evidence that mums feel more supported and less anxious/depressed because of the programme?

• It is not possible in this evaluation to compare how supported FNP clients feel in comparison with how they would have felt without the programme (since there is no control group who are not receiving the programme). However, clients in the qualitative panel who had experienced issues around their emotional or mental health around the birth and post-partum period were positive about the support they had received from their Family Nurse, ranging from general advice about coping with stress to assessments and referrals to GPs for treatment for post-natal depression.

Other findings

• Exceptions to this generally very positive picture of the support received around the birth/post-partum period included comments that clients had not received elements of support they had expected or wanted (including specific information relating to birth) or that they preferred to go to other people for advice.