Key role in the prevention of child neglect and abuse in Germany: continuous care by qualified family midwives

Objective: the aim of two related studies was an in-depth knowledge of psychosocially and health-related vulnerable families and the 'portfolio' of care that family midwives (FM) provide. Besides factors which influence acceptance and access from the mothers' perspective, the effectiveness of FM with regard to care, infant nutrition, and parent-child relationship as well as multidisciplinary collaboration were of interest, especially against the backdrop of Germany's national aim to strengthen prevention of neglect and abuse of infants. In addition, the reasons why families did not want FM care were explored.

Design: two FM model projects in Saxony-Anhalt (SA) and Lower Saxony (LS), Germany, were evaluated. Quantitative data were prospectively collected on 93% of vulnerable families being cared for by FM (SA) and regarding vulnerable families that declined FM care (LS). These data were complemented by problem-focused interviews with 14 mothers and six social workers (LS).

Setting and interventions: the 33 FM in SA and 11 FM in LS are community-based and visit vulnerable families from pregnancy up to the first birthday of the child, maximally. They provide health promotion, maternal and infant care, and multidisciplinary support geared towards early prevention of child neglect and abuse.

Participants: from May 2006 until 2008 (SA) and from January 2008 until December 2009 (LS) 814 and 235 vulnerable families, respectively, were cared for by FM. Complete data on 734 families were analysed (SA) as were 30 questionnaires on 'non-compliant' families (LS). Problem-focused interviews were conducted with 14 mothers and 6 social workers (LS).

Measurements and findings: many families exhibited a high vulnerability score of complex risk factors. Four vulnerability patterns were statistically extracted explaining 40% of the total variance. The highest frequencies of care activities related to infant care and nutrition, giving advice on the Mother-Child relationship, and psychosocial support. The Youth Welfare Services (YWS) were significant collaboration partners, especially regarding families whose child was taken out for safety reasons. By conclusion of care, significantly higher mean scores were observed regarding 'parent-child relationship' and 'maternal care for child' (compared to the outset of care) when mean duration of care was at least 6 months. The children who were taken out of their families had significantly lower scores in nutritional care, and were given solids at a significantly earlier time. From the mothers' perspective it was important to have early access to the FM and easy between-visits communication via phone calls, or text messages. They appreciated the physical and psychosocial care for the infant and herself, an uncomplicated transition from caseload midwifery, and collaboration among providers. Families who declined FM care wanted to stay with their self-chosen midwife, were afraid of external control, or felt they were able to cope without professional support.

Key conclusions and implications for practice: when families can access FM early on and home-visits are sustained, maternal competencies in caring for, and relating to, the child can potentially be strengthened. FM seem to fill a gap between standard care by caseload midwives ending at 8 weeks postpartum and YWS whose personnel is not skilled in the assessment of health-related problems, such as inadequate infant nutrition. As a relatively high percentage of the families were challenged by domestic violence, drug addiction, and teenage pregnancy, ongoing educational activities should address these topics.