Starting with the baby: putting the newborn at the centre of the transition to parenthood

In recent times, papers published in the journal have concerned the experience, needs and wellbeing of parents, most often mothers. Less often are infant behaviour and outcomes in focus. This is most true in relation to the newborn and their contribution to the developing relationship. Often constructed as less able, immature creatures, newborns are really effectively adapted individuals, good at communicating their needs.

The transition to parenthood involves at least two actors: babies and their parents as mothers, fathers, and couples. Becoming a parent is life-changing and infants have an active role, with early behaviour and learning as critical elements. The importance of how newborns behave at birth and during their early weeks was long ago recognised by Dr Berry Brazelton, an American paediatrician and researcher. The Newborn Behavioural Assessment Scale (NBAS; Brazelton, 1973) was developed as a comprehensive neurobehavioral assessment, focusing on visual and auditory responses, habituation abilities, state control, alertness, tone and motor activity, thus providing considerable detail about individual babies for clinical and research purposes. Used with term babies up to about 2 months of age and those developmentally delayed, it is sufficiently sensitive to identify differences between groups as a baseline or outcome measure in comparisons following, for example, prenatal exposure to toxic substances, preterm birth or different types of care (Brazelton & Nugent, 2011). Others have used it as a point of comparison, looking for continuities and links at later stages of development. Essentially, the NBAS documents individual differences, indicating what a baby brings to the dynamic and developing relationship. First face-to-face encounters with your baby are unique events that parents remember and value enormously. Early contact provides opportunities to start relationship-building, though for many couples emotional attachment begins before birth. Just over half of recent mothers first felt ‘that their baby really belonged to them’ during pregnancy and a further fifth immediately after birth (Henderson et al., 2016). Attachment does not happen in the same way or at the same point, particularly in more complex situations when mothers or babies are unwell.

What happens during the transition to parenthood? To psychologists, researchers and professionals working in healthcare, there are many psychosocial processes at work: changes in identity, self as parent, as ‘mother’, ‘father’; building and accepting a different self-image; developing self-efficacy and agency in this new role; maintaining well-being at a time of marked change; and connecting with social groups within and across generations. For health professionals, a key question is ‘How should we work with and support parents in this transition?’

Pregnancy, childbirth and the early weeks with a new baby are a life stage that is a recognised window of opportunity for intervention. In working in this area, Berry Brazelton and Kevin Nugent have always argued that sharing a new baby with parents is an underlying principle of care, with dual goals of facilitating understanding, enjoyment and confidence and supporting parental mental health and wellbeing (Brazelton & Nugent, 2011). A variety of parenting programmes have been developed, though generally not focusing on the newborn and early weeks and used mostly in high-income countries, targeting children and families where there may be developmental or health concerns. The Newborn Behavioural Observations (NBO), building on the earlier NBAS, was developed as a brief intervention, focusing on the infant as an individual and their capacities while supporting the developing parent–infant relationship and that with care providers (Nugent et al., 2007). Recommended to be repeated several times over the early weeks, the NBO has fewer items scored on a shorter scale using similar descriptive phrasing to that employed in the NBAS. Training, certification and a high degree of fidelity are required.

A systematic review of published studies on possible impacts of the NBAS and NBO on caregivers and infants showed only low-quality evidence of effectiveness for mostly low-risk parents and their infants (Barlow et al., 2018). Other randomised controlled trials (RCTs) since then have measured the impact of NBO, with possible benefits for mothers, particularly for those with perinatal mental health issues. A recent Australian study supports using the NBO with mothers experiencing perinatal distress or with a history of mental health problems (Nicolson et al., 2022). A reduction in distress, and higher sensitivity and less intrusiveness in interaction with their infant was evident in follow-up at 4 months of age.

Integrating the NBO into the care provided for newborns, parents and families is now being tried and put into practice. Pathways of care, building on the early weeks of behaviour and shared observation, aiming to support the parent–infant relationship, require evaluation. Standard measures can be of limited use early on. Using more sensitive methods with mothers or co-parents, as occurred with the Nicholson et al. study (Nicolson et al., 2022), has the potential to show differences in outcomes. Working with new parents together with the newborn is also about transformation and fundamental changes in practice for health professionals. Education, training and supervision are intrinsic to pathway development with the introduction of ‘birth visits’, ‘new baby home visits’, later follow-up and parent groups. What happens after the newborn period and the first 3 months depends on the needs of babies and parents and the broader scope of schemes in the locality, some of which are targeted. Others may involve wider community contexts, with health professionals signposting and parents themselves choosing the level and type of engagement for them. Starting with the newborn and moving from ‘bumps to babies’ in the transition to parenthood is a first step on the post-birth pathway in which newborn behaviour and communicative skills and parents’ understanding and interpretation of these are potential areas for further research. Specific research questions and the associated theoretical contexts need further exploration, possibly using the kind of positive interventions and evaluations described, with better understanding the needs of parents and families at this time being an underlying goal.