Exploring health visitors’ experiences of supporting the mother-infant relationship

March 2025

Elizabeth Milne presents the results of a thematic analysis exploring responses from focus groups conducted among HVs working with mothers and their young children.

Introduction

Mothers are usually infants’ primary caregivers (England and Farkas, 2017). The mother-infant relationship is said to be crucial for child development (Rocha et al, 2020). Though the Department of Health and Social Care (DHSC) emphasises the importance of the health visitor’s role in supporting parent-infant relationships (DHSC), 2021, it lacks a robust implementation plan. The perspectives of HVs on aspects of their work, such as effective practices and challenges, remain unaddressed. Gaining an understanding of these aspects is essential for positive relational outcomes.

Aim and purpose

The government emphasises its commitment to giving infants the ‘best start in life’ (DHSC, 2021). The DHSC guidance highlights the importance of attachment but overlook parents’ understanding of infants’ relational capacities. Though the DHSC (2024) published a guide on parent-infant relationships, this approach has not been researched. HVs are integral to the healthy child programme (DHSC, 2009), but the programme lacks key messages and a relational lens.

There is a dearth of research on how HVs support mother-infant relationships. One study found that HVs assessed the relationship through observation, using their knowledge of risk factors, norms and ‘intuition’ (McAtamney, 2011). However, this approach seems insufficiently systematic. Some HVs also report a lack of competency and training (Appleton et al, 2013; McAtamney, 2011; Wilson et al, 2008).

HVs primarily focus on women, young children and mental wellbeing – areas often discounted by society (Raitt and Zeedyk, 2020). Due to cuts, HV services have faced reduced workforces and capacity (Royal College of Nursing (RCN), 2016; Vijayshankar, 2020), marginalising support for the mother-infant relationship as a result.

It is unclear how HVs support this critical relationship. This study aimed to explore HVs’ perceptions of their role in supporting mother-infant relationships, including challenges and potential practice improvements.

Methods

NHS ethical approval was granted by the relevant research ethics committee. The HVs volunteered to take part in two focus groups, offering an opportunity to share their experiences and perspectives on interventions and practice. The participants were British-White female HVs and had from six to 25 years’ experience. Those in focus group 1 (F1) worked in a highly deprived area, while focus group 2 (F2) included HVs from the same area and a more affluent one. There were six HVs in each group, with both sessions lasting 90 minutes. Their names were anonymised in the transcripts, and here.

The data was analysed using reflexive thematic analysis (RTA) (Braun and Clarke, 2006), following an iterative process that included:

• Immersion within the data.
• Generating initial codes.
• Educing themes.
• Reviewing themes.
• Defining and naming themes.
• Producing a report that tells a convincing story of the data.

RTA was used to interpret the data at semantic (descriptive) and latent (interpretive) levels (Braun and Clarke, 2019). The analysis was conducted inductively, elucidating data-driven themes.

Results

Two themes were identified:

1. ‘Our many hats and the intersubjective alchemy’. This theme’s central organising concept was the multiple co-existing roles expected of HVs, which affect their support for the mother-infant relationship.
2. ‘Moving in close and stepping away from the mother-infant relationship’. This theme’s central organising concept highlighted the shifting positions HVs adopt in their practice, alternating between strong identification and emotional distance from the mother-infant relationship.

See the diagram illustrating these themes and subthemes.

Key themes identified from the HV focus groups

Theme 1

HVs described the HV-mother and mother-infant relationships as paramount. The HV-mother relationship was vital for identifying health needs. This bond facilitated trust and openness, enabling healthcare provision and promoted effective communication. HVs identified that their caring relationships made them more effective in modelling relationships, disseminating information and increasing the likelihood of being confided in by mothers.

HVs saw themselves as ‘sisters and liberators,’ providing practical and emotional support to mothers and recognised that sharing infant information could be transformative. Sharing information that enhanced understanding and improved the mother-baby relationship was liberating and the HVs’ responses revealed the pleasure of intersubjective engagement in practice.

At times, HVs withheld infant information from mothers. The word ‘unsettled’ may minimise the infant’s experience. Although the participants discussed that understanding the infant’s behaviour may reduce maternal feelings of failure, they shared concerns it may exacerbate guilt. In the HVs’ narratives, they were the ‘sheepdogs to their managers’ and commissioners’ shepherds’, however, their priorities differed. Their shepherds prioritised imparting information to women: immunisation, dental hygiene, safety, etc. These demands compromised the relationship, and consequently HVs’ effectiveness. The expectations were overwhelming and under-resourced. HV F2, 131 said: ‘I think we have to wear a lot of hats don’t we in health visiting … but actually we haven’t got the financial back up to wear all those hats.’ The lack of capacity forced HVs into a crisis management role.

The HVs longed for a larger emphasis on the mother-infant relationship and felt that cuts had led to loss of capacity, continuity, and a reliance on clinics over home visits. The ‘shepherds’ were criticised for prioritising targets and failing to grasp the significance of relationships.’ The HVs felt trapped in a system driven by non-relational priorities, unable to steer their practice towards meaningful connections.

Theme 2

Mothers’ vulnerabilities resonated with HVs, often recalling their own experiences, and they recognised the stress of being under HVs’ surveillance. Though HVs resonated with mothers’ experience of intensive domesticity, no reference was made to discussing the division of labour or domestic chores.

The HVs appeared more distanced from mothers living in deprivation, particularly young mothers who were described as being ‘task orientated. HVs described young mothers as ‘lacking’, perceiving this to be something rooted in their childhood experiences.

HVs indicated the power of the ‘traditional baby’ narrative within mothers’ dispositions. The HVs appeared to individualise maternal lack of knowledge, rather than identifying it as a social issue. The HVs struggled to empathise with the intense arousal of maternal focus on the infant; it was perplexing for them. They disclosed a strong identification with the mothers’ preference for their maternal mother. However, some HVs were uncomfortable that the primary support was not the woman’s partner. The focus groups acknowledged the miraculous nature of pregnancy and birth. The HVs spoke passionately about this stage of a mother’s life and of the ‘gift’ of having a child.

Discussion

Despite challenges in articulating their role, the HVs portrayed it as relational care. Care, though essential, often goes unnoticed (Paul et al, 2023). Care demonstrates the interdependency of humans, challenging the values of individualism and autonomy (Barnes, 2012). The HVs described themselves as resisting a quantitatively measured, task-orientated, tick-box service delivery model that relied on individual responsibility.

HVs emphasised that their relationship with mothers was crucial (Frost, 1999). They felt they provided emotional support and expertise. However, the focus on the mother might marginalise the mother-infant relationship. For example, the fear of triggering guilt and blame could result in avoiding considering the infant’s birth experience. The tendency to blame aligns with societal discourses of individual responsibility and control (Barnes, 2012).

While HVs saw supporting the mother-infant relationship as being fundamental, they described few direct interventions and lacked a cohesive strategy. Their efforts often involved encouraging mothers to look at and speak to their infants, highlighting mutual gaze and mirroring. Without shifting the narrative to one in which the infant is a relational being with a range of capacities, behavioural changes would have been in dissonance with the embedded ‘traditional baby’ narrative and less likely to be adopted. HVs reported frustration at mothers’ lack of knowledge, focusing on individual deficiencies (Bourdieu, 1977). They often referred to needing more time with families to provide the personalised care that has been described by mothers as valuable (Donetto et al, 2013; Brook and Salmon, 2017). However, the cuts to health visiting-services, and the subsequent poor retention rates had reduced personalised care (RCN, 2016). The HVs described a systemised approach marginalising women, young children, and mental health, thus perpetuating inequalities (Barnes, 2012; Raitt and Zeedyk, 2020).

Supporting mother-infant relationships was not explicitly referred to in HV contracts. While there is discourse regarding its importance, supporting the mother-infant relationship does not appear to be valued (Douglas and Klar 2019; Gillies et al, 2017; Phoenix, 1996). Rather, the mother is given individual responsibility for her infant, in accordance with neoliberal values (Barnes, 2012; Gillies et al, 2017). HVs exposed the practice paradox: effective information sharing and surveillance required a relationship of care. Sharing information would only have impact under the condition of epistemic trust, surveillance would only be effective with a positive relationship with the mother (Fonagy and Allison, 2014; Peckover, 2002).

HVs often ‘othered’ young mothers of low socio-economic status, viewing their deficits as familial ones rather than being located in social structures of inequality and hardship (Gillies et al, 2017). This process aligned HVs with normative, middleclass mothers, potentially masking real differences and reinforcing class structures (Gillies, 2007). When the mother is ‘other’, the ‘sheepdog’ role may be prioritised over ‘sister and liberator’, making the potent care-relationship an illusion. This study supports DeSouza’s (2013) call for practitioners to examine how mothers have been historically, culturally and socially produced, in order to avoid complicity.

Using Waring and Latif’s (2018) hierarchy to examine power, the HVs adopted the ‘sheepdogs’ role to the ‘shepherd’ one played by managers and commissioners. However, HVs identified with gendered life stories (Pritchard, 2005). This identification appeared to feed the resistance to the shepherds – rather than obedient sheepdogs, they appeared to be snapping at their shepherd’s heels. As sisters, HVs were strong supporters and advocates of the mothers, while as liberators they challenged the oppressive expectations of motherhood. However, they did not engage in challenging social expectations or intensive domesticity, (Eagleton and Bourdieu, 1992). Pritchard (2005) describes that when subjective experience-based knowledge intersects with objective knowledge, it creates a transformation in knowledge. However, to achieve this HVs need to reflexively challenge the expectations. Without this, they may offer comfort but not transformation; commonality of experience may mask and distract from curiosity towards both differences and different approaches.

HVs did not resonate with mothers’ detailed focus on infants, perhaps due to the transient nature of maternal preoccupation (Winnicott, 1987; Milne, 2025). As the conversation deepened, some HVs spoke touchingly of the ‘gift’ of the infant. The extraordinariness of new life and a human infant still held power. This appeared to be celebrated tentatively and acknowledging the maternal matrix seemed almost controversial. This hesitation may support Lerner’s (1986) argument that patriarchy’s strategy is to undermine reproductive power, and thus women and infants. This may also add to the understanding of the lack of support for the mother-infant relationship.

Implications for practice

• The mother-infant relationship is undervalued in health visiting-practice due to systemic constraints, conflicting priorities and limited resources.
• HVs recognise the relational nature of their work but lack structured interventions to support mother-infant bonds effectively.
• Traditional narratives of motherhood and infant care persist, limiting opportunities for transformative change.
• Young mothers and those from deprived backgrounds may face implicit biases, affecting equitable support.

Recommendations

Policy
Direct investment to support HVs in meaningfully supporting mother-infant relationships and maternal adjustment. Prioritise the mother-infant relationship in commissioning contracts.

Practice
Equip HVs with intervention tools to challenge outdated infant narratives and promote an understanding of the relational infant.

Family engagement
Involve maternal mothers/primary attachment figures in contacts to systemically support understanding of infants.

Supervision
Implement reflective supervision that encourages HVs to recognise societal pressures and use an appreciative eye when supporting mothers with less privilege.

Conclusion

HVs are expected to play a crucial role in supporting the mother-infant relationship, but face challenges such as conflicting roles, resource constraints, and societal pressures. Despite its importance, neoliberal values and cuts to HV services marginalise this relationship in practice. HVs struggle to challenge traditional narratives of motherhood and infant care, hindering a more relational approach. Greater recognition and support for HVs, adequate resources, intervention tools and policy changes are essential for prioritising the mother-infant bond for optimal child and maternal wellbeing.

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