Clinical Psychology Review 28 (2008) 1125–1137

Contents lists available at ScienceDirect

Clinical Psychology Review

Psycho-education to enhance couples' transition to parenthood ☆

Jemima Petch ⁎, W. Kim Halford
Centre for Psychological Health, Griffith University, Brisbane, Australia

a r t i c l e i n f o a b s t r a c t

Article history: A substantial proportion of couples struggle to adapt to parenthood, feel stress in caring for
Received 25 October 2007 their infant, and experience a significant decline in their couple relationship adjustment.
Received in revised form 11 March 2008 Moreover, there is a substantial association between effective parenting of infants and
Accepted 13 March 2008
sustaining a mutually satisfying couple relationship. This paper reviews randomized controlled
trials of psycho-education to assist new parent couples with parenting and their couple
Keywords: relationship. The majority of programs target either the couple relationship or parenting, with
Couple interventions
few programs addressing both areas. The best outcomes seem to be achieved when programs
Parenting interventions
are accessible by couples at home, when skill-training is provided, and possibly when programs
Review
Relationship education target couples at high-risk of maladjustment to parenthood.
Transition to parenthood © 2008 Published by Elsevier Ltd.

Contents

1. The rationale for couple psycho-education for parenthood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1126

2. Psycho-education to assist new parent couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1128
2.1. Universal programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1128
2.1.1. Couple interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1128
2.1.2. Parenting interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1131
2.2. Selective interventions for high-risk couples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1131
2.2.1. Home-visiting studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1132
2.2.2. Other programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133
3. Suggestions for future education programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133
3.1. Proposed content of future interventions for the transition to parenthood . . . . . . . . . . . . . . . . . . . . . 1133
3.2. Targeting couples at risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1133
3.3. Delivery of transition to parenthood programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1134
3.4. Future research suggestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135

☆ Preparation of this paper was supported by a National Health and Medical Research Council of Australia grant to W. Kim Halford and Debra Creedy entitled
Promoting a Positive Transition to Parenthood.
⁎ Corresponding author. School of Psychology, M24 Mt Gravatt Campus, Griffith University, Messines Ridge Rd., Mt Gravatt, QLD 4111, Australia. Tel.: +61 7 3735
3359; fax: +61 7 3735 3465.
E-mail address: j.petch@griffith.edu.au (J. Petch).

0272-7358/$ – see front matter © 2008 Published by Elsevier Ltd.

doi:10.1016/j.cpr.2008.03.005
1126 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137

Parenthood brings an avalanche of change – some positive, some negative – to a couple's1 life together. Watching your baby coo
as he or she falls asleep, seeing your partner gently cuddle the baby you created together, walking together as a threesome — all can
be wonderful experiences. At the same time, struggling to wake in the middle of the night to yet more incessant crying, arguments
with your partner triggered by exhaustion, and wondering if you will ever again have time together as a couple, can stress both
partners, erode the quality of their relationship and their enjoyment of life. Cowan and Cowan (1995) reviewed the very limited
research available to that time on psycho-education programs designed to assist couples manage the challenges of new
parenthood, and called for further efforts to develop and evaluate such programs. The current paper reviews the considerable
research that has occurred in the intervening 13 years.

1. The rationale for couple psycho-education for parenthood

Most couples report that the birth of their first child is associated with feelings of joy and pleasure (Gottman & Notarius, 2000).
Parenthood brings many rewards, including: (a) fulfilment of strong needs to reproduce; (b) fulfilment of social expectations; (c) a
sense of achievement; (d) fun, affection and companionship; and (e) is often seen as a symbol of love and stability in the couple
relationship (Feeney, Hohaus, Noller, & Alexander, 2001). At the same time, approximately 50% of couples report deterioration in
relationship satisfaction after having a baby (Belsky & Kelly, 1994; Feeney et al., 2001; Shapiro, Gottman, & Carrere, 2000). A recent
meta-analysis reported that average relationship adjustment is substantially lower among parents of young infants than couples at
other life stages (Twenge, Campbell, & Foster, 2003).
Many parents are surprised by the reality of caring for a newborn that requires constant, 24-hour care, and is totally dependent
upon them for food, shelter, clothing, and love (Vanzetti & Duck, 1996). Although most newborns sleep 16–20 h a day, their sleep
pattern is haphazard and when awakened they typically require feeding or parental soothing (Anders, Halpern, & Hua, 1992; Sadeh,
1996). Parental fatigue and exhaustion are typically high among parents of infants (Killien, 1998; Newman, 2000), and extreme for
the 13–35% of parents of infants and toddlers with sleep disturbances (Kuhn & Weidinger, 2000).
Parents typically state that the most distressing aspect of infant care is coping with crying, which occurs on average 2 h a day (or
more in the case of the 20% of infants who are diagnosed with colic) up until the age of 3 months, after which time crying usually
slowly reduces in duration (Ahlborg & Standmark, 2001; Brazelton, 1962; Lindberg, Bohlin, & Hagekull, 1991; Lupton, 2000). Infant
feeding is another challenge. While more than 85% of women can successfully breastfeed, the demands of breastfeeding for the
mother are quite high (Fairbank, O'Meara, Renfrew, Woolridge, Sowden, & Lister-Sharp, 2000) and only 60–70% of women
breastfeed at birth and about 30% breastfeed until 6 months (Blyth, Creedy, Dennis, Moyle, Pratt, & De Vries, 2002). Transient
feeding problems are common and chronic feeding problems affect 25–35% of infants (Manikam & Perman, 2000).
Along with infant care demands, there are at least five other major changes that new parenthood brings, which seem to
contribute to deteriorating couple relationship satisfaction. First, gender roles become more traditional (Cowan & Cowan, 2000).
Care of an infant adds approximately 35 h of work per week to the average couple household (Craig & Bittman, 2005). Irrespective
of occupational status, women perform two to three times more of this work than men (Bianchi, Milkie, Sayer, & Robinson, 2000;
Shelton & John, 1996). While fathers' participation is modest in infant related chores, they often increase their hours of paid work
after the birth of a child (Aldous, Mulligan, & Bjarnason, 1998; Bianchi et al., 2000).
Second, there is less time for couple-focused communication free from distraction, less self-disclosure, less praise, and
increased negativity and conflict (Belsky & Kelly, 1994; Cowan, Cowan, Heming, & Miller, 1991; Gottman & Notarius, 2000). Third,
most couples report a decline in disposable income (Thomas & Sawhill, 2005), often associated with increased costs, and
sometimes decreased income as the woman changes to working part-time or not at all. Particularly for couples on modest incomes,
the financial squeeze can substantially erode their opportunities for individual and shared leisure activities (Thomas & Sawhill,
2005). Fourth, there is reduced frequency and quality of couple time (Belsky, Spanier, & Rovine, 1983). Finally, almost all new
mothers report some discomfort or pain in their initial experiences of intercourse after childbirth, and combined with the tiredness
associated with infant care, most couples report a decline in their sexual relationship. Up to 50% of women and 20% of men report
reduced sexual responsiveness for 6–12 months postpartum, and one third of couples report continuing sexual problems 3–4 years
after birth (von Sydow, 1999).
Almost all couples experience some role strain from the competing demands of work, being a spouse and parenting (Feeney
et al., 2001), and women tend to be more affected than men (Pancer, Pratt, Hunsberger, & Gallant, 2000; Thompson & Walker,
1989). The impact of parenthood is higher among women than men at least partly because pregnancy, birth and breastfeeding
place major physical demands on women's bodies (Cowan & Cowan, 2000). In addition, women are more likely than men to be the
primary care-giver of their infant (Pancer et al., 2000), and often feel that the task of protecting the foetus, infant, and growing child
are primarily their responsibility (Stern, 1998).
Accumulation of hormonal, physical, and psychological changes experienced by women across the transition to parenthood
probably causes the mild depression, frequently termed the “baby blues”, experienced by 80% of mothers in the 2 weeks after birth
(Halbreich, 2005; Hoffbrand, Howard, & Crawley, 2001). There are higher rates of depression (between 10 and 30%) and other
psychological disorders in women with young children than at any other time periods in women's lives (Webster, Linnane, Dibley,
& Pritchard, 2000).

1
A small but important number of new parents are not in a relationship with a partner. They also could benefit from assistance to adjust to parenthood.
However, because their needs are somewhat different from couples, we focus this review on the most common arrangement of a couple adjusting to parenthood.
 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137 1127

Table 1
Universal randomized controlled trials for the transition to parenthood

Author(s)/Year Participants Outcome Intervention Key findings

Cowan and Cowan (1992); 72 pregnant couples, Relationship satisfaction, 24 weekly group sessions focused INT couple showed less
Schulz et al. (2006) INT = 36 couples, couple separations after on parenting and couple relationship satisfaction decline,
Control = 36 couples. 5 years. relationship information, group were less likely to separate than
Unreported uptake. support. control couples.
Doherty et al. (2006) 132 pregnant couples. 5 minute father–infant Four antenatal and 4 postnatal INT fathers higher on quality of
INT = 65; Control = 67. interaction, parental sessions on parenting and couple father–infant positive interaction
Unreported uptake. responsibility self-report, time relationship, group discussion and (effect size .47 at 6 months and .31
Attrition 15% at follow- spent with child diaries; skill-training sessions held at 12 months) and spending more
up. 12 month postpartum follow- monthly. time with their child than control
up. fathers.
Hawkins et al. (2006). 155 pregnant couples. Self-report of relationship INT 1 = Five weekly antenatal No significant intervention effects.
‘Marriage Moments’ INT 1 = 51; INT 2 = 55; adjustment, strengths and classes with relationship education
Control = 50% uptake. satisfaction, parenting homework activities. INT 2- = same
Attrition 24% at follow- adjustment; 9 month as INT 1 delivered as self-paced
up. postpartum follow-up. education.
Matthey et al. (2000) 268 pregnant couples. Mental health, partner and social INT 1 = extra antenatal class, At 6 weeks INT 1 women with low
INT 1 = 78; INT 2 = 89; support, parenting competence, information and group discussion self-esteem, relative to control,
Control = 101. 78% self-esteem, partner awareness; on couple adjustment. INT 2 = extra reported more positive mood,
uptake. Attrition 27% at 6-month postpartum follow-up. antenatal class, information and higher parenting competence and
follow-up. education on baby play. satisfaction with partner support,
but effects were lost by follow-up.
Midmer et al. (1995) 70 pregnant couples. Anxiety, relationship Two extra antenatal workshops of INT women reported reduced
INT = 41; Control = 29. adjustment, postpartum role information, skill-training and anxiety compared to prenatal
54% uptake. Attrition adjustment; 6 month group discussion on mental health, scores and compared to control
26% at follow-up. postpartum follow-up. role changes, couple adjustment, women. INT couples reported less
parenting. decline in relationship satisfaction
and greater postpartum
adjustment than control.
Petch, Halford, & Creedy 71 pregnant couples. Relationship adjustment, Two antenatal, and four postnatal INT women reported less decline in
(submitted for publication). INT = 35; mental health, parenting, sessions, relationship and relationship adjustment, greater
‘Couple CARE for Parents’ Comparison = 36. 40% couple communication parenting skill-training, effort in maintaining their
uptake. Attrition 35% at observation; 11-month information and support. relationship than control. INT
follow-up. postpartum follow-up on self- Comparison: Six sessions of couples demonstrated less
report data. parenting information and support negative communication than
phone calls to mother only. control couples. No INT effects on
Sessions held monthly. mental health and parenting.
Shapiro & Gottman (2005) 38 pregnant couples. Relationship quality, mental Extra two-day antenatal classes No immediate INT effects, but at
INT = 18; Control = 20. health, couple communication providing relationship follow-up INT couples reported
Unreported uptake. observation; 12 months information, education, group higher relationship satisfaction,
Attrition ~ 10% at postpartum follow-up. discussion and skill-training, showed less hostile affect, and INT
follow-up. parenting information. women reported lower depression
symptoms than control.
St. James-Roberts et al. 610 mothers recruited Infant sleep and crying INT 1 = Leaflet and verbal INT 1 increased number of infants
(2001) at birth. INT 1 = 205; INT behavior; 3, 6 and 9 month instructions to follow a structured sleeping through night at 12 weeks
2 = 202; Control = 203. postpartum follow-up. parenting program. INT 2 = Written postpartum (77%, INT 2 = 68%,
35% uptake. Attrition parenting information and control = 66%) but effect was lost by
19% at follow-up. telephone support. Both follow-up. INT 1 reduced health-
interventions delivered in first two care visits for infant problems
weeks postpartum. between 3 and 12 month
postpartum. Neither INT reduced
infant crying or fussing.

Note. INT stands for Intervention group. All control groups received the usual 6 session antenatal classes except in the trial by St. James-Roberts et al. (2001) where
mothers received standard care consisting of one home-visit by a nurse and access to clinic visits and a family doctor.

There seems to be a reciprocal influence of maternal depression and quality of the couple relationship. Maternal reports of
parenting stress, depression and worry are lower when couple relationship satisfaction is high and when women perceive their
male partner as supportive (Feldman, Greenbaum, Mayes, & Erlich 1997; Florsheim, Sumida, McCann, Winstanley, Fukui, Seefeldt,
& Moore, 2003; Wicki, 1999). If maternal depression does develop, recovery is predicted by a satisfying and supportive couple
relationship (Pope, Evans, McLean & Michael, 1998). Conversely, maternal depression predicts deteriorating relationship
adjustment (Belsky & Kelly, 1994).
The observed increase in couple conflict after parenthood is associated with negative parenting practices. There is a moderate
effect size association of the couple characteristics of communication negativity and lack of mutual partner support with harsh and
inconsistent discipline, low parenting efficacy, insensitive parenting, and low expression of parental affection (Erel & Burman,
1995; McElwain & Volling, 1999; Krishnakmuar & Buehler, 2000). Poor parenting practices, in turn, predict a high lifetime risk of
child attachment insecurity, depression, conduct disorder, poor social competence, health problems, and academic under
achievement (e.g., Amato, 1996; Cowan & Cowan, 1990; Cummings & Davies, 1994; Fincham 1998). In contrast, parents in
1128 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137

satisfying, low conflict relationships report higher parenting competence and sensitivity, and lower maternal stress and worry
(Feldman et al., 1997; Florsheim et al., 2003; Wicki, 1999). Overall, findings on couple relationship satisfaction, sensitive parenting
of infants and maternal adjustment suggest mutual, reciprocal influences between these factors.

2. Psycho-education to assist new parent couples

Psycho-education for new parent couples can be defined as any educational attempt to enhance couple relationship functioning
or parenting, or to prevent relationship deterioration after the birth of a first child. We focused the current review on randomized
controlled trials of programs that provided education to couples during pregnancy or in the first 6 months of a child's life. Although
our particular interest lies in reviewing programs for couple psycho-education across the transition to parenthood, the reciprocal
relationship between the couple relationship and parenting lead us to include studies with a couple or parenting focus, or a
combination of the two. We excluded trials of programs that sought to treat or prevent re-occurrence of psychological disorders in
parents (usually mothers) like postnatal depression or substance abuse. Such interventions have been well reviewed elsewhere
(e.g., Boath, Bradley, & Henshaw, 2005; Ogrodniczuk & Piper, 2003), and their specialized content addressing the needs of
participants with particular disorders are often of limited relevance to the general population of couples having a child together.
Multiple search strategies were used to identify relevant studies published between January 1995 and June 2007. First, the
computerized databases Medline, ProQuest (Psychology, Nursing), Ovid, and PsychInfo were searched using the search terms
psycho-education, intervention, prevention AND couple, relationship, parenting, care-giving, attachment and infant. Second, the
references from relevant papers located through database searches were examined. Third, references were identified through
citations from meta-analytic and review papers (e.g., Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003; Kendrick, Elkan,
Dewey, Blair, Robinson, Williams, & Brummell, 2000; Sweet & Applebaum, 2004).
Twenty-five studies meet the selection criteria. Eight provided universal programs, meaning that programs were directed at all
couples expecting a child, with the aim of decreasing the prevalence of couples reporting parenting problems, psychological
distress or couple relationship problems across the transition to parenthood. Seventeen programs were selective, meaning that
programs were directed at couples whose risk of adjusting poorly to new parenthood was judged to be high, though they did not
show current signs of distress. The universal programs are summarized in Table 1, and the selective programs in Table 2.

2.1. Universal programs

Although antenatal education is widely available, and is currently the key source of information about childbirth and
parenthood for expectant mothers (and less frequently, fathers), there is no evidence that antenatal education achieves its most
commonly stated aims of reducing distress during birth or enhancing parenting (Gagnon, 2001). In an attempt to improve
effectiveness of antenatal education researchers have examined whether adding psycho-education on couple adjustment and
parenting skills improves adjustment to parenthood. Of the eight universal transition to parenthood interventions identified (See
Table 1), five studies focused on improving couple relationship functioning (Hawkins, Fawcett, Carroll, & Gilliland, 2006; Midmer,
Wilson, & Cummings, 1995; Petch et al., submitted for publication; Schulz, Cowan, & Cowan, 2006; Shapiro & Gottman, 2005), and
three studies on improving parenting skills (Doherty, Erickson, & LaRossa, 2006; Matthey, Barnett, Ungerer, & Waters, 2000; St.
James-Roberts, Sleep, Morris, Owen, & Gillham, 2001).

2.1.1. Couple interventions

One of the five couple psycho-education programs was very brief, involving only about 1 h of professional contact (Hawkins
et al., 2006). In contrast, Cowan and Cowan (1992) provided extensive contact of about 50 h. (The five year follow-up results from
that program were reported by Schulz et al., 2006). The other three programs were relatively brief (12–16 h of professional
contact). Three of the programs were delivered exclusively as antenatal sessions, while Petch et al. (submitted for publication) and
Cowan and Cowan (1992) provided couples with antenatal and postnatal sessions. The five programs had a substantial degree of
content overlap that included promoting couple communication, effective conflict management, realistic expectations, sharing of
roles and responsibilities, couple intimacy, couple time, and promoting parenting sensitivity.
The process of learning within the programs varied considerably. Hawkin's et al. (2006) Marriage Moments program consisted
of watching a 7-minute video clip in each of 5 weekly antenatal education classes, followed by educator encouragement to
complete self-administered homework activities. In the next class educators made a brief inquiry about ‘how things had gone’, but
there was little or no discussion of ideas. The other four programs presented provided much more opportunity for in-session
discussion and exercises. Skill-training via modelling, rehearsal and feedback was explicitly emphasized in three programs
(Midmer et al., 1995; Petch et al., submitted for publication; Shapiro & Gottman, 2005). The Petch et al. (submitted for publication)
program also included structured self-administered components. These consisted of couples watching a DVD to gain key
knowledge and skills, undertaking structured exercises to apply the ideas to their couple relationship and parenting, and reviewing
these exercises in a series of telephone calls from a psychologist who provided individualised support and skill-training.
Three of the five couple-focused interventions enhanced couple relationship satisfaction relative to a no intervention control
(Cowan & Cowan, 1992; Midmer et al., 1995; Shapiro & Gottman, 2005). The fourth study compared the Couple CARE for Parents
program (CCP) with a mother-focused parenting program and found CCP prevented declining relationship satisfaction in women,
but not men (Petch et al., submitted for publication). The fifth trial by Hawkins et al. (2006) found adding the very brief Marriage
Moments program to antenatal classes did not enhance relationship satisfaction. In two of the five studies, couple communication

Table 2
Selective randomized controlled trials for the transition to parenthood
Author(s)/Year
Ammaniti et al. (2006)
Armstrong, Fraser,
Dadds, & Morris (1999)
‘Family C.A.R.E.’
Buist et al. (1998)
Constantino et al. (2001)
Daro & Harding (1999)
Summary of 2 ‘Healthy Families
America (HFA)’ trials.
Duggan, McFarlane, Windham,
Rhode, Salkever, & Fuddy (1999). (recruited during pregnancy or physical health, parenting
‘Hawaii's Healthy
Start’ Program
Heinicke et al. (1999)
Kitzman, Olds, Henderson, Hanks, 1139 primarily African-
Cole, Tatelbaum et al. (1997)
‘Nurse-Family Partnership’
Memphis Trial
Koniak-Griffin, Anderson,
Verzemnieks, & Brecht (2000).
‘Early Intervention Program’
J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137
Participants
91 high-risk pregnant
women. INT = 47;
Control = 45% uptake.
Attrition 17% at 3 months
postpartum.
181 high-risk families
recruited at birth. INT = 90;
Control = 91. 46% uptake.
Attrition 24% at 12 month
postpartum follow-up.
38 pregnant women with
previous depression,
marital or childhood problems. adjustment; 6 month follow- (weekly) of parenting
INT = 20; Control = 19% uptake.
Attrition 26% at 6 month
follow-up.
148 low-income mothers
(recruited postpartum).
INT = 93; Control = 55. 42%
uptake. Attrition 39% at
follow-up.
(Hawaii): 324 high-risk
women. INT = 157;
Control = 167. (Virginia): 619
high-risk women. INT = 422;
Control = 197. Women recruited social support; 12 month
in pregnancy or at birth. ~ 25% follow-up.
uptake. Attrition ~ 20%.
643 high-stress families
birth). INT = 390; Control = 340. competence and stress,
Uptake 76%. Attrition 19%.
70 low-income and low
support women (recruited in
pregnancy). INT = 35;
Comparison = 35. Uptake
unreported. Attrition 9%.
American pregnant
adolescents. INT 1 = 230; INT
2 = 228; Comparison = 681. 88% 36 month follow-up.
Uptake. Attrition unreported.
121 pregnant minority and
impoverished adolescents.
INT = 62; Control = 59. 84%
uptake. Attrition 16.5%.
1129
Assessment Intervention Key findings
Adult attachment, parent– Antenatal and postnatal INT women showed
child interaction greater sensitivity during
home-visits (fortnightly till
observation; 12 month 12 months postpartum), parent–child interactions
postpartum follow-up. parenting information and at the 6 month
skill-training. assessment relative to
control.
Parenting self-report and Postpartum home-visits At 6 weeks postpartum
observation, maternal (maximum = 20 until primiparous INT women
mental health, child health; 12 month postpartum) reported lower depression
18 month follow-up. providing parenting and than control, and all INT
maternal mental health women had lower parenting
information counselling, stress and more positive
support, and referral. parent–infant interaction,
than control; effects lost by
12 months postpartum.
Maternal mental health, Eight antenatal, two INT women reported a
social support, relationship postnatal group sessions decrease in anxiety at
6 weeks and control
up. information and discussion. women reported a
Control: Standard 6 weekly decrease in satisfaction with
session antenatal classes. social support at 6 months.
Parent report of child Ten weekly postpartum INT women showed a
behavior, parent sensitivity, group sessions of parenting trend in improvement in
parent–child interaction information, skill-training, reading child emotional
observation; 6 month and support. cues at 6 months
follow-up. postpartum.
Child development, child Intensive postpartum home- Hawaii: INT mothers
protection reports, parenting visiting providing parenting higher on parenting
knowledge, parent–child information, support and knowledge and maternal
interaction observation, referral up to five years involvement; INT infants
postpartum (Number of more responsive.
visits determined by family). Virginia: INT infants
higher on physical health
and parent–child
interactions more
positive than control.
Maternal mental and Intensive postpartum home- INT mothers reported
visiting providing parenting modest reduction in child
information, crisis neglect and abuse. INT
parent–child interaction management, support, skill- reported less depression
observation, social support, training and referral up to at one agency, maternal
partner violence, Child five years postpartum alcohol use, partner
health and safety; 24 month (Number of visits violence (for families
follow-up. determined by family risk receiving N 75% of HV).
level). Effects lost by follow-up.
Maternal mental health, Postpartum home-visiting INT mothers higher on
social-, family-, and partner (M = 17 sessions up until two social support, parenting
support, parent–child years postpartum) parenting sensitivity, less intrusive
interaction observation, support, information, skill- and encouraging of child
child attachment, child training, community referral, autonomy, INT infants
development; 12 month and group discussions. more autonomous, task-
follow-up. Control = paediatric oriented and securely
assessment, information and attached than controls.
referral.
Parenting observation, child INT 1=One ante-, one post- Both INT 1 and 2 improved
development, maternal natal home-visit of parenting some mother and infant
mental and physical health; and health information, skill- physical health outcomes,
training, support. INT 2=INT 1 and INT 2 improved
content delivered in 30 (ante- mother–child interaction
and post-natal) home-visits. relative to control.
Control=usual hospital
services and referral.
Parent–child interaction Four ante- and 17 post-natal INT infants hospitalized
observation, child health, home-visits providing skill- less, INT mothers more
social competence, maternal training, health education, educational attainment,
mental health; 36 month support, counselling, less drug abuse and
postpartum follow-up. parenting information and pregnancy's than control.
case management.
(continued
(continued on
on next page)
1130 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137

Table 2 (continued)
(continued)

Author(s)/Year Participants Assessment Intervention Key findings

Lagges & Gordon (1999).
‘Parenting Adolescents Wisely’
Love et al. (2005).
‘Early Head Start’
Luster et al. (1996).
‘Family TIES’ program
Olds et al. (2002).
‘Nurse-Family Partnership’
Quint et al. (1997);
Reichman & McLanahan (2001).
‘New Chance’
Stevens-Simons et al. (2000)
‘CAMP’
St. Pierre & Layzer (1999)
‘Comprehensive
Child Development Program’
Wagner & Clayton (1999)
Summary of ‘Parents as Teachers
(PAT’ (trial 1) and
‘Teen PAT’ program (trial 2)
62 adolescents (recruited during
pregnancy or one year
postpartum). INT=33;
Control=29. Uptake unreported.
Attrition 16%.
3001 low-income women
(recruited in pregnancy or one
year postpartum). INT=1513;
Control=1488. Uptake
unreported. Attrition 30%.
83 low-income pregnant
adolescents. INT = 43;
Comparison = 40. Uptake
unreported. Attrition 42%.
735 (mostly Hispanic), low SES Parenting observation, child 22 to 27 ante- and post-natal INT 1 and 2 reported more
pregnant women. INT 1 = 245; development, maternal
INT 2 = 235; Comparison = 255. mental health, child
62% uptake. Attrition 48%.
2322 adolescent mothers
(recruited up to 12 months
postpartum). INT =1714;
Control=608. Uptake
unreported. Attrition ~10% at
follow-up.
145 adolescents (recruited
postpartum). INT=58;
Comparison=88% uptake.
Attrition 12% at follow-up.
4410 low-income families
(pregnant or first 12 months
postpartum). INT = 2,213;
Control = 2,179. 89% uptake.
Attrition 24% at follow-up.
Trial 1: 497 minority and low
SES women (pregnant to first
6 months N birth). INT 1 = 298;
Comparison = 199. Trial 2: 704 child development, child
adolescents (pregnant or early health; 24 month
postpartum). INT 1 = 177; INT
2 = 174; INT 3 = 175;
Control = 178. Uptake
unreported. Attrition 27% in
trial 1, 48% in trial 2 at follow-
up assessment.
Self-report of parent
knowledge, attitudes,
empathy, time spent with
child, and discipline used;
2 month follow-up.
Observation of child
language and cognitive
development; parent report
of child behavior, child
health, parent–child
observation; 36 month
postpartum follow-up.
Parent-report of self-esteem, Weekly ante- and post-natal
depression, support, and
infant irritability, parent– information, emotional and
child observation; 12 month instrumental support and
postpartum follow-up.
protection report; 24 month counselling, community
postpartum follow-up.
Parenting self-report and
observation; 40 months
postpartum follow-up.
Child maltreatment, maternal Control=hospital-delivered
health and child, parenting
observation, child
development; 24 month
postpartum follow-up.
Parenting self-report and
observation, maternal and
child health; 5 year
postpartum follow-up.
Self-report of parent
knowledge and competence, (monthly postpartum home- benefit in child social
parent–child observation,
postpartum follow-up.
Six postpartum hours of INT much higher parenting
group parenting information, knowledge (d = 1.38) and
discussion and skill-training. parenting attitudes (d = .80),
maintained at follow-up,
than control.
Predominantly postpartum At follow-up INT children
parenting education, physical had slightly higher cognitive
and mental health services, (d = .12) and language
professional and peer support (d = .13) performance,
provided as fortnightly home- less parent-reported
visits and/or centre-based child aggression
program until 20 months (d = .11), and more effective
postpartum. and stimulating parenting
(d = .11) than control.
INT adolescents had
home-visits, parenting higher observed parenting
skills and self-reported
child-rearing empathy,
community referral. and INT infants showed
Control=phone support, less irritability, relative to
parenting information, referral. comparison families.
home-visits; parenting and positive maternal health
health education, support, behaviours; INT 2 mothers
showed responsivity to
referral delivered by infants, less negative child
paraprofessionals (INT 1) or mood, and was better
nurses (INT 2) up to 2 years language and mental
postpartum. Control=hospital development (for women
appointments. with low psychological
resources) than control.
INT=Weekly group parenting At 31/2-year follow-up
education, life skill-training INT mothers reported more
and information up to 18 parenting stress and child
months postpartum behavior problems, and less
(M=6 months). Control= child positive behavior, than
received family aid. control.
No significant
parenting and maternal intervention effects on
education, support and referral parenting.
program. INT=control plus
weekly home-visits, parenting
skill-training and counselling
for 5 years.
Fortnightly home-visits from No intervention effects.
birth until five years
postpartum providing case
management, parent
education, skills-training.
INT 1 = PAT program INT 1 produced modest
visits until three years development (trial 1, d = .25),
postpartum) plus case and child cognitive
management (referral, development (trial 2, d = .26)
parent education, skill- relative to control. In
training, support group). INT trial 2 INT 1 (combined) and
2 = case management alone. 2 (case management) were
INT 3 PAT alone; associated with significantly
Control = given age- fewer cases of child abuse
appropriate toys. and neglect (effect size −.31)
relative to comparison.

Note. INT stands for Intervention group. The participants were described as ‘high-risk’ (e.g., Ammaniti et al., 2006; Armstrong et al., 1999; Daro & Harding, 1999)
because they included participants who met one or several of a large variety a risk factors such as: low income, low educational attainment, unmarried, young age,
unstable housing, African American, current stressful life events, current elevated symptoms of depression, alcohol or drug abuse, domestic violence, personal or
family history of abuse or psychological disorder, low social support, and ambivalent feelings about pregnancy.

was assessed, and education enhanced couple communication in both studies (Petch et al., submitted for publication; Shapiro &
Gottman, 2005). Couple psycho-education also enhanced adult well-being in two of the three studies in which it was assessed,
with reduced maternal depressive symptomatology (Midmer et al., 1995; Shapiro & Gottman, 2005). However, Petch et al.
(submitted for publication) found couple psycho-education had no additional benefits on psychological distress compared to a
 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137 1131

mother-focused parenting program, with low levels of distress evident in both conditions. The use of no treatment controls in the
Midmer et al. (1995) and Shapiro and Gottman (2005) trials raises the possibility that any form of support might reduce adult
distress somewhat, rather than there being a specific effect of a couple-focused program.
Surprisingly, despite these couple interventions targeting the transition to parenthood and including at least some parenting
content in all the programs, only one study examined intervention effects on parenting. Petch et al. (submitted for publication)
found that, compared to a mother-focused parenting program, couple psycho-education had no additional benefit. However, the
shared parenting content of the two interventions, which included evidence-based tip sheets on infant sleep, crying, feeding, child
development, and interpreting infant cues, might explain this effect. Consistent with this possibility, parents in both conditions
reported high parenting adjustment. Future couple psycho-education evaluations need to better test the effects of parenting
education on parenting adjustment, and parent–infant interaction.
The positive effects of four of the five universally implemented couple psycho-education programs in preventing erosion of
relationship satisfaction after parenthood are encouraging. However, there are several limitations to these studies. Almost all
participants were highly educated, and the generalizability to less well-educated couples is unknown. Second, there were no
effects observed at all for the lowest dose couple program (Hawkins et al., 2006). Third, long-term effects beyond one year of
programs have only been tested in one study. While the 5-year follow-up data showed sustained effects of psycho-education on
relationship satisfaction (Schulz et al., 2006), these impressive results were obtained with an intensive program of 24 weekly
sessions involving about 50 h of professional contact per couple. The intensity of the program makes it expensive to deliver and
possibly difficult for many couples to attend. The long-term effects of couple psycho-education less intensive than Schulz et al.
(2006) program are unknown.

2.1.2. Parenting interventions

Universal parenting interventions focused on increasing parenting competence, and measured intervention effects on parent
self-report of competence (Matthey et al., 2000), observational measures of infant behavior (St. James-Roberts et al., 2001) or
parent–child interaction quality (Doherty et al., 2006). St. James-Roberts et al.'s (2001) parent skill-training intervention consisted
of one group antenatal class encouraging parents to adopt a set of strategies to increase infant sleep and decrease crying. Their
behavioral instructions (e.g., give a focal feed, lay infant in cot while awake but calm) produced short-term (3 months postpartum)
improvements in infant sleep duration but had no effect on infant crying or fussing. The prescriptive nature of the instructions
might not appeal to many parents, as there was low adherence to some of the recommendations (e.g., less than 50% of parents
introduced the focal feed that was hypothesised to be a key intervention strategy).
A less prescriptive but more intensive parent skill-training intervention delivered across eight sessions (4 antenatal and 4
postnatal sessions held monthly) enhanced father–infant interaction quality at 6- and 12-months postpartum (Doherty et al., 2006).
Even a single extra antenatal parenting class improved self-reported parenting competence among women with low self-esteem
6 weeks postpartum (Matthey et al., 2000), though it did not reduce maternal depression or anxiety, or enhance any outcomes for
the men. In sum, parenting intervention with low-risk parents had different foci and produced short-term improvement in their
respective outcomes, which included infant sleep, fathering sensitivity up until 12 months, and self-reported maternal competence
with low self-esteem women. None of these parenting programs assessed intervention effects on couple adjustment.

2.2. Selective interventions for high-risk couples

Selective interventions differed widely in length and intensity (e.g., from 1 to more than 100 sessions); as well as program delivery
style (e.g., information, skills-training); delivery mode (e.g., one-on-one, group); place of delivery (e.g., home visit, hospital); and the
professional training of the person delivering the intervention (nurses, paraprofessional, community volunteers). The studies also
varied greatly on target outcome (e.g., parent, child, physical health, child abuse, social-emotional health, parent–child interaction
quality); and how they measured those outcomes (e.g., self-report, observational, hospital records, etc). Finally, studies were also
heterogeneous in respect to the comparison or control condition, which included no intervention (e.g., Ammaniti, Speranza, Tambelli,
Muscetta, Lucarelli, Vismara et al., 2006; Koniak-Griffin et al., 2000), antenatal classes (e.g., Buist, Westley, & Hill,1998), the provision of
toys (Wagner & Clayton, 1999) or paediatric appointments (Heinicke, Fineman, Ruth, Recchia, Guthrie, & Rodning, 1999). The many
differences between studies make it difficult to identify the characteristics of successful programs.
To enhance comparisons across studies we considered the outcomes of home-visiting programs (n = 13) separately from clinic-
or hospital-based (other) programs (n = 4). Most home-visiting programs were of greater duration than other programs, often
providing 20 or more contacts with staff and following-up participants for 2 or even more years. In comparison, other programs
typically provided 10 fewer sessions, with follow-ups of 6 months or less. One exception was the intensive ‘New Chance’ program
that had a 40-month follow-up (Quint, Bos, & Polit, 1997). Second, home-visiting programs typically reported client engagement
that lasted longer than other programs. For example, the weighted average attrition of the 13 home-visiting programs was 25%
(range 9–48%) at the average follow-up time of 23 months (range 3–40 months). A similar average attrition rate (26%, range 16–39%)
was observed among non-home-visiting studies at half the follow-up time (12.5 months rather than 24 months). Third, while the
costs of program delivery were not explicated in most studies, it is likely that home-visiting programs are much more costly to
deliver than other programs. Home visiting programs provide, on average, more than double the number of sessions per client than
other programs. They also provide these home-based sessions individually to clients, rather than in the group format that is
common in other programs. In addition to the costs of the providing a large number of sessions in home visiting programs, there are
the costs of travel by the professionals delivering the program.
1132 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137

2.2.1. Home-visiting studies

The majority of home-visiting studies (9/13) reported home-visiting improved parenting. For example, home visiting increased
parenting knowledge (Daro & Harding, 1999), lowered parenting stress (Armstrong et al., 1999), increased infant secure attachment
(Heinicke et al., 1999) and child responsiveness (Daro & Harding, 1999), and deceased child irritability (Luster, Perlstadt, McKinney,
Sims, & Juang, 1996) and aggression (Love, Kisker, Ross, Raikes, Constantine, Boller et al., 2005). Home visiting provided by nurses
(but not by paraprofessionals) also decreased child negative affect (Olds et al., 2002). Most of the positive outcomes on parenting
have maintained to follow-up assessments of 6- or 12-months after birth. Two studies assessed even longer-term outcomes. Olds
et al. (2002) reported improved maternal responsiveness to infant cues up until 24 months (for nurse-visited families compared to
control group families), and Love et al. (2005) reported lower child aggression up until the 3-year follow-up.
The reported effects of home visiting on maternal health include lower drug and nicotine intake from pregnancy to postpartum, and
fewer subsequent pregnancies (Koniak-Griffin et al., 2000; Olds et al., 2002) than no treatment controls, though these effects only occur
when nurses and not paraprofessionals do the home visits (Olds et al., 2002). Home visiting also is associated with increased ratings of
social support relative to usual paediatric care (Heinicke et al.,1999), higher maternal educational attainment at 36 months relative to a
no-treatment control (Koniak-Griffin et al., 2000), and lower maternal depression scores at 6 weeks postpartum relative to a no-
treatment control (Armstrong et al., 1999).
Some studies also reported small, but lasting intervention effects (at up to 36 months postpartum) on child cognitive
development (Love et al., 2005; Wagner & Clayton, 1999), social development (Wagner & Clayton, 1999), language development
(Love et al., 2005), child abuse and neglect (Duggan et al., 1999; Wagner & Clayton, 1999), infant hospitalizations (Koniak-Griffin
et al., 2000), and infant health (Kitzman et al., 1997). Olds et al. (2002) also found that, for mothers with lower mental health and
intelligence scores, nurse home-visiting produced large and important improvements in child language and motor development
relative to a routine care control condition.
In contrast to the positive effects summarised above, numerous home-visiting studies have found null or inconsistent results on
a range of outcomes. For example, in a large two-site trial (Healthy Families America) home visiting improved child health and
maternal sensitivity at one site (Virginia) but not the other (Hawaii), and there were no effects at either site on child abuse and
neglect, child development, or social support (Daro & Harding, 1999). Armstrong et al., (1999) reported no effects of home visiting
on use of community services, parental distress associated with infant feeding and sleep, or immunisation rates, and only transient
effects that failed to maintain to 12-month follow-up on maternal mood, parenting stress and parent–child interaction quality.
Similarly, in various studies home visiting did not improve maternal self-esteem, symptoms of depression and anxiety (Heinicke
et al., 1999; Luster et al., 1996), child cognitive development (Heinicke et al., 1999), or child health (Love et al., 2005).
Even with home-visiting programs that produced positive effect in early trials, it has proved difficult to replicate some of these
benefits. The Nurse-Family Partnership program2 of Olds and colleagues was the first rigorously evaluated home visiting program
(Olds, Henderson, Chamberlin, & Tatelbaum, 1986), and remains the most well known program. However, later replications
(Kitzman et al., 1997; Olds et al., 2002) have not produced as many positive intervention effects as in the original study (Olds et al.,
1986). The original trial found home visiting improved women's use of ancillary services during pregnancy, employment at 4 years
postpartum, child temperament at 6 months (poor, unmarried adolescents only), and for poor, unmarried women lower rates of
child behavioral problems and maternal use of welfare that were maintained at the 15 year follow-up (Olds, 2006). However, none
of these effects were replicated, even at much shorter follow-ups, in two subsequent trials (Kitzman et al., 1997; Olds et al., 2002).
The inconsistent findings on the benefits of home visiting are likely attributable several factors. First, the average effect size of
home visiting on child outcomes is quite small, d = 0.2 (Gomby, 2005), and many studies had low power to detect such small effects.
Second, obtaining positive effects from home visiting seem to require highly skilled program delivery by professionals. Program
delivery by professional staff (usually nurses) produces substantially more positive effects on parent and child outcomes than
delivery by para-professionals or volunteers (Olds et al., 2002). When professional staff training and quality control is intensive
(Duggan et al., 1999; Olds et al., 1986; Stevens-Simons, Nelligan & Kelly, 2000), then more positive home-visiting effects are found
than when these things are less intensive (Duggan et al., 1999; Love et al., 2005; Olds et al., 2002). Third, it seems that there needs
to be an adequate dose of home visits to obtain benefits. More positive effects are evident when there are frequent home visits
scheduled (e.g., two a month), that continue through to the child's second year of life (Olds et al., 2002; Quint et al., 1997), and
when professionals manage high rates of participant retention so that participants receive 75% or more of scheduled sessions
(Duggan et al., 1999; Stevens-Simons et al., 2000). Fourth, home visiting benefits seem to be greater for the most high-risk mothers
(e.g., mothers with mental ill health, low intelligence, poor, unmarried) (Olds, 2006), and the null results reported in some studies
might reflect a low proportion of these most at-risk mothers. Finally, home visiting overall is more likely to produce improvements
related to parenting, rather than in child health and development, or maternal health and life skills (Gomby, 2005).
The small effect sizes reported by most of the home-visiting studies, combined with the high cost of providing frequent home visits
over an extended period, plus the need for extensive training and quality control, means the cost-effectiveness of home-visiting remains
modest (Gomby, 2005). However, magnitude of benefit for the children of the most at-risk mothers (those with multiple difficulties) is
considerable. The cost-effectiveness of home visiting is likely to be enhanced by offering this expensive service selectively to these most
high-risk mothers, where it is likely to produce the most benefits. Other suggestions to improve future home-visiting programs include
increasing the use of skills-training when delivering parent education (Duggan et al., 1999); liaising with community services (St. Pierre

2
Olds and colleagues have conducted numerous replications of the Nurse-Family Partnership program, but only some of those trials were randomised trials
and only these met our inclusion criteria and are reviewed.
 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137 1133

& Layzer, 1999); addressing the contextual difficulties of high-risk families (e.g., housing, employment); addressing one or two factors
intensively (e.g., parenting, contextual difficulties, or mental health) rather than modestly addressing many factors (Quint et al., 1997);
and including support people (i.e., partners, grand-parents) in the intervention (Stevens-Simons et al., 2000).

2.2.2. Other programs

As with home-visiting programs, the majority of ‘other’ programs were delivered to mothers of new born or young infants
ranging from birth to 18 months postpartum, but focused mainly on the first six months of life (Buist et al., 1998; Constantino et al.,
2001; Lagges & Gordon, 1999; Quint et al., 1997). Findings from these programs generally reported no or small intervention effects
on parenting outcomes. The briefest non-home-visiting intervention, ‘Parenting Adolescents Wisely’ (PAW; Lagges & Gordon,
1999), recruited pregnant adolescents and adolescent mothers and examined parenting skills after the adolescents had viewed an
interactive video-disc on parenting, and received individual feedback on their performance. PAW adolescents reported improved
parenting knowledge and attitudes, and a modest, non-significant increase in adaptive parenting behavior (e.g., using less coercive
skills). The results from this trial need to be interpreted cautiously because PAW used outcome measures without published
validity and reliability and lacked follow-up data beyond 2 months (Lagges & Gordon, 1999).
Three hospital-based parenting programs (Buist et al., 1998; Constantino et al., 2001; Quint et al., 1997) reported no significant
differences between intervention and control groups in either parent–child interaction quality or other parenting measures. Buist
et al. (1998) also examined intervention effects on female relationship satisfaction and symptoms of depression and anxiety, but at
both 6 weeks and 6 months postpartum there were no significant group differences on these measures between women who
completed standard antenatal classes compared to women who received the standard antenatal classes and an additional four
parenting classes. The New Chance demonstration also created some unplanned, small, and troubling effects for mothers who were
initially at high-risk of clinical depression (Quint et al., 1997). At follow-up these mothers reported higher depression, parenting
stress and more negative evaluations of child social behavior than control group mothers. These negative parenting outcomes were
most pronounced at sites which reported high attrition, which might reflect that many women experienced these interventions as
unhelpful, or possibly that attending sessions added stress to their already busy lives.
In sum, clinic- and hospital-based programs were less successful in improving parenting in high-risk mothers than home-
visiting programs. Only one out of the four studies of non-home visiting programs reported a significant intervention effect on
parenting skills (Lagges & Gordon, 1999). The predominantly null results might reflect the counteracting effect of any benefit from
the content by the stress and inconvenience of attending sessions, or inappropriate content in the programs.

3. Suggestions for future education programs

In comparison to parenting interventions, there are few couple psycho-education programs for the transition to parenthood.
While supporting mothers, especially if they are identified as high-risk is very worthwhile, most children are born to couples. One
of the risks of providing parenting information to mothers alone is the discrepancy this can foster in couples' parenting
expectations, knowledge, and competence. Divergent expectations can lead to couple conflict, especially when the less educated
father is advised about ‘what to do’ by the mother (Tomlinson, Bryan, & Esau, 1996). Since parenting is typically a joint couple
endeavour, and both partners are valuable influences in the child's development, educating the couple on parenting, and focusing
on couple issues which impact on parenting practices, seem likely to enhance interventions for the transition to parenthood.

3.1. Proposed content of future interventions for the transition to parenthood

Content of future psycho-education for the transition to parenthood should be based on potentially modifiable risk factors that
predict adjustment, and these modifiable risk factors fall into three broad classes: (1) parenthood-specific factors, (2) context, and
(3) couple processes (Petch, 2006). Table 3 presents key risk factors, grouped into these three classes, which we recommend as
targets for couple psycho-education at the transition to parenthood. For each risk factor we describe, based on the literature
reviewed earlier in this article, the rationale for targeting that factor. Table 3 also presents example activities couples could
complete in order to gain knowledge and skills in each key risk factor area. For example, lack of sensitive and responsive infant care
is a parenthood specific risk factor, and education that includes skill-training in interpreting infant states of arousal enhances
parenting sensitivity and competence (e.g., Ammaniti et al., 2006; Heinicke et al., 1999). Lack of social support is a contextual risk
factor, and promoting the effective seeking and use of social support by new parent couples is an example of addressing that key
contextual factor. Lastly, negative communication is a couple processes risk factor, and programs that include communication skill-
training enhance couple adjustment (e.g., Petch et al., submitted for publication; Shapiro & Gottman, 2005).

3.2. Targeting couples at risk

As noted earlier, about half of all couples report no decline in relationship satisfaction across the transition to parenthood, and few
ongoing problems with infant care. Consequently, psycho-education for the transition to parenthood might only be necessary for some
couples. Establishing which couples benefit from couple psycho-education is an important future goal for research. With large samples
it would be possible to assess a range of risk factors for future adjustment difficulties and test whether these risk factors moderate the
effects of psycho-education on couple, individual, and parenting outcomes. For example, negative family-of-origin experiences (e.g.,
parental divorce, parental alcohol abuse), and a history of psychological disorder (Halford, Sanders, & Behrens, 2000; Sanders, Halford,
1134 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137

Table 3
Suggested content and rationale for the content of couple-focused education programs for the transition to parenthood

Variable Topic Rationale for topic Example activities

Parenthood- Infant care (e.g., infant Infants with sleep or feeding difficulties, excessive crying (a) Provide skill-training in basic infant care tasks.
specific feeding, sleep, crying, or irritable temperament, increase parenting stress. (b) Provide skill-training in strategies to promote infant
factors safety) affect regulation.
Parenting expectations Unrealistic or divergent expectations of sharing infant (a) Individual partners complete a checklist of who will do
(e.g., gender role) care are associated with low mutual support, low key infant care tasks (e.g., crying, settling) and household
affection in parent–child interaction, maternal distress, tasks (e.g., cooking, cleaning), which couple discuss and
less father involvement with child, perceived inequity, negotiate shared parenting expectations.
couple conflict and relationship dissatisfaction.
Parenting competence/self- Parenting efficacy predicts low parental stress, high (a) Educate on normal variations in infant behavior (e.g.,
efficacy (e.g., sensitive and parenting satisfaction, and positive perceptions of varying patterns of a sleep for different aged infants).
responsive parenting) parenthood.
Parenting competence predicts secure parent–child (b) Provide skill-training in interpreting infant arousal,
attachment. over-stimulation, and interacting with different aged
infants.
Context Social support (e.g., friends Low social support predicts relationship distress, low (a) Couples develop a list of support needs, how well they
and extended family) maternal self-efficacy, insensitivity, postnatal depression, are met, and problem-solve ways to access additional
and parenting stress, and exacerbates the negative effects social support.
of low parenting competence.
Couple Communication and Couple criticism and hostility predict decline in (a) Practice effective couple communication and conflict
processes conflict management. relationship satisfaction, low paternal sensitivity and management skills.
insecure infant attachment.
Mutual support (e.g., level Husband support is associated with maternal parenting (a) Couple lists the support desired from each-other and
of partners' practical, efficacy, low stress, and couple affection and intimacy. how well partner is currently meeting these mutual
emotional support). Maternal support is associated with relationship support needs.
satisfaction and father involvement in childcare. (b) Couple practices implementing new or additional
mutual support behaviors.
Affection and intimacy Affection and intimacy predict increased maternal (a) Couple lists caring behaviors they give and receive
(e.g., caring behavior, warmth and sensitivity and paternal satisfaction and from each-other encourage increasing caring behaviors in
sexual satisfaction) involvement in infant care-giving. the relationships.
(b) Identify common post-partum sexual difficulties and
problem-solve how couple can address difficulties.

& Behrens, 1999) predict declining relationship satisfaction. Low antenatal relationship satisfaction also predicts declining post-natal
satisfaction (e.g., Cowan et al.,1991; Cox, Owen, Lewis, & Henderson,1999; Knauth, 2000). These assessed risk factors might be the basis
of selective targeting of these couples for more education and support across the transition to parenthood.
One caveat to the recommendation of selectively targeting education to couples assessed as high-risk for future adjustment
problems is that our accuracy of predicting relationship outcome is still modest. Some published studies have claimed to predict, with
high accuracy over a number of years, outcomes such as whether couples stay together or separate (up to 95% correct classification)
(e.g., Gottman, Coan, Carrere, & Swanson, 1998; Gottman & Levenson, 1999). However, these predictions were based on algorithms
derived post hoc, once the outcomes were known, and the equations produce much less accurate predictions when applied to
independent samples (Heyman & Slep, 2001). The utility of selective targeting of education is determined in part by the accuracy with
which we can identify those couples most likely to benefit.
A stepped-care approach might allow selective targeting of couples while not over-relying on assessment of risk factors that
have limited predictive accuracy. In a stepped-care approach all couples could receive a minimum level of intervention (e.g.,
complete a brief assessment that provides a report on couple and parenting strengths and challenges, plus perhaps some brief
information about adjusting to parenthood). This minimal intervention could be very cheap to deliver and could be used to help
couples evaluate if they desire further education or support. Couples could be offered a brief program of 4 to 6 sessions focused on
skill-training in couple processes and parenting skills, with an option for a further intensive program that might involve home-
visiting for couples assessed at high-risk for adjustment problems.

3.3. Delivery of transition to parenthood programs

One significant challenge in delivering couple psycho-education for the transition to parenthood is making programs accessible to
couples. The immediate postpartum period is often very busy for couples and attendance at clinic or hospital group sessions is lower
when compared to home-visiting programs. However, convenience of access of home-visiting programs for couples comes at a
considerable cost associated with the professional travel, and the large number of sessions required, to provide effective home visiting.
Programs that are at least partially self-administered at home, such as that evaluated by Petch et al. (submitted for publication),
might provide some of the benefits of ease of couple access that exists with home visits, but at less cost. Self-administered program
content eliminates travel demands, which is convenient for couples, and can make participation possible in otherwise inaccessible
programs for couples living in remote areas (Halford & Simons, 2005). Self-administered programs have been successfully applied to
enhancing both couple relationships (Halford, Moore, Wilson, Dyer & Farrugia, 2004) and parenting (Webster-Stratton, 1988).
Moreover, self-directed programs allow for privacy, flexible scheduling, self-pacing and self-control, which appeals to many people
 J. Petch, W.K. Halford / Clinical Psychology Review 28 (2008) 1125–1137 1135

who prefer this mode of psycho-education to attending face-to-face sessions (Doss, Rhoades, Stanley, & Markman, in press). However,
self-directed programs usually need some support from professional educators to sustain engagement and ensure skill development
(Laurillard, 1995). More research is needed to evaluate how effective self-administered psycho-education is for new parent couples,
and what forms of professional support (e.g., telephone calls, e-mails, some home visits) might enhance program effectiveness.

3.4. Future research suggestions

Three methodological refinements in future research would greatly enhance evaluation of the value of couple psycho-
education in enhancing adjustment to parenthood. First, given the importance of enhancing the couple relationship and parenting,
programs need to be assessed for their effects in both these domains. Second, given the importance of the development of skills in
couple psycho-education, future evaluation research needs to include measures of skill acquisition in the couple relationship and
parenting. This would enable testing of whether programs produce change in targeted skills, and whether such skill acquisition
mediates other outcomes, such as sustained couple relationship satisfaction.
A third important methodological refinement is to compare the effects of couple psycho-education with other forms of support
for new parent couples. For example, it might be cost-effective to provide practical support to new parent couples, such as
subsidizing the costs of domestic workers to assist with the heavy workload associated with infant care, or subsidizing costs of
child care to enhance opportunities for positive shared couple time. It is already known that providing respite care for parents of
infants with a developmental disability helps reduce parental stress (Chan & Sigafoos, 2001). Similar forms of practical assistance
might help many couples with high parenting stress, and reduced stress might enhance couple relationship satisfaction, parenting
sensitivity or parenting competence.

4. Conclusion

The majority of transition to parenthood interventions target mothers and focuses on enhancing parenting competence.
Universal parenting interventions and selective home visiting (which is intensively and well delivered) have modest but reliable
effects on parenting knowledge and skills. Of the five universally targeted couple psycho-education programs, four prevented the
decline in relationship satisfaction typically associated with becoming a parent. We recommend that more transition to
parenthood interventions include both partners in their interventions (rather than mothers alone). Both infant care and couple
processes should be included in couple psycho-education at the transition to parenthood with focus on skills training and an
assessment of objectively measurable outcomes. A stepped-care approach might cost effectively address the needs of different
couples at varying risk levels and help get education to those who most need it. Provision of effective psycho-education has the
potential to greatly enhance couples' experience of becoming a parent.

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