Ab Initio International | At Home with the NBO

by Lee MacKinnon, Ed.M.
Director, Family Education and Support, Hilltown Community Health Centers
Doctoral student, School of Education, University of Massachusetts, Amherst

As a practitioner, I walk a fine line between two very different worlds. On the one hand, in the academic world, I study research that seeks to be replicable, cumulative and true in as broad a context as possible. On the other, I work with real families, whose lives, like all of ours, are quirky, messy and unpredictable. Occasionally these worlds meet. For me, nowhere was this more striking than in my integration of the Newborn Behavioral Observations (NBO) Systems in to newborn home visits this past year.

Based at a community health center in western Massachusetts, I work with families in this rural region who face challenges that many would not expect in such a populous state. The area is characterized by great natural beauty, but also geographic isolation, few services, and complete absence of public transportation. The lack of universal broadband Internet services contributes to an almost anachronistic lifestyle. Rather than rely on slow dial-up connection, many eschew regular Internet use and the many on-line links that connect their peers in more populated areas. Several towns in the region have little more than a post office and a general store, and secondary, winding roads (including many dirt roads) make travel difficult, especially in the winter. With houses located miles apart and no social centers, new parents, who know no other local families with infants, can become isolated and feel alone. Parents, particularly mothers, who often stay home with their infants due to a shortage of jobs and childcare, may spend long days seeing no other adults. Depression and loneliness grow.

For some time, in my role as a parent educator, I had been looking for the right intervention around which to structure contact with parents of newborns. With no funds for an ongoing home visitation program, our services included seeing families prenatally for childbirth education and breastfeeding support, helping them plan for the arrival of their baby, and then, with luck, talking with them by phone after the birth. The follow up phone calls, however, were not fruitful. Parents, struggling with lack of time and sleep, usually did not answer the phone. When they did return calls, they rarely shared details of how things were going. The staunch independence that sustains people in the region no doubt played a role in their reluctance to reveal concerns or problems. By the time they were bringing their babies out in the world, their roles as parents were no longer new and many weeks of isolation had passed. When asked, they often described their early days and weeks after the birth as chaotic, overwhelming, and best left to the miasma of postpartum amnesia.

In designing follow up services for after birth, I found that the NBO provided the hook I was looking for and opened doors, both literally and figuratively, again and again. One key was introducing the concept of the NBO prenatally when parents were not only curious about who their baby was, they were highly motivated to gain new skills and information. Getting them excited beforehand made the follow up call after birth brief and do-able. The reason for the visit was already clear, the excitement high, and the logistics quick. There was no need to get into conversation at that point, we just needed to schedule a time for the visit.

Anita (not her real name) called me when her premature daughter (34 weeks GA) came home from the hospital. Anita’s husband was deployed and would not be home for another 8 weeks. Instead of the 2 weeks on her own that they had planned for, she now faced 2 months on her own with a premature baby. Her mother had just returned to her other obligations in the Midwest after spending the prior 2 weeks helping Anita get back and forth to the NICU, a 45-minute drive away. As a recent transplant to the area, Anita had not yet made friends close by. Now in the first few days home alone with her baby, Daphne, Anita remembered our prenatal discussion about the NBO and my availability to come to her home. Armed with my NBO kit, I set out to fulfill one of my documented visits required for NBO certification.

I have little experience with preterm infants and wondered how well I would be able to read Daphne’s behavior, much less interpret it to her mother. Full of doubt whether this tool was even appropriate for non-medical personnel, especially with high-risk infants, I wondered if I could judge muscle tone appropriately, what I should expect her soothability to be, how I would assess her orientation responses. Not sure how to begin, I explained to Anita that I thought we should just start by watching Daphne together. We sat on the floor with the baby swaddled in a blanket in front of us, and there the story unfolded.

Anita shared with me what she had already learned about Daphne. She was a good nurser. She settled down easily when swaddled and held. She had gained weight quickly. As she talked, I watched Anita relax. She smiled. It was an opportunity for her to reflect on how much she had already learned and to recognize her own insights as a mother. The NBO had just met the first goal of parent education: to help parents recognize that they truly are the experts on their own children- no one knows their child as well as they do. Together we went through parts of the observation system: hand grasp, response to face and voice, orientation to sound and visual tracking. We saw how much Daphne was already capable of and together we talked about what to expect in the days ahead. Taking a break to nurse, Anita shared Daphne’s birth story, which she had not yet been able to tell to many people. Two weeks earlier, upon realizing she was in premature labor, Anita had called her mother and mother-in-law, both hours away, and then driven herself to the hospital, 35 minutes from home. After describing the birth, she laughed. “I wouldn’t have thought I could do it on my own like that, but I did,” she said.

Through the NBO, Anita had learned some new information about her baby, and through the exploratory process she had been able to share her questions, anxieties, and accomplishments in the security of her own home. The visit gave me the opportunity to answer her questions about breastfeeding and to share information about community resources, such as early intervention services and a local family center where she could meet other parents. Yet perhaps most important to her situation was the fact that the NBO allowed me to became a familiar person, there during a huge transition in her life, not only a helping professional who gave advice and information about her baby. The NBO had been the vehicle that brought us together. We continued to talk by phone in the weeks that followed, and when her husband returned, she called to let me know.

In subsequent visits with other families, the NBO proved to be a natural fit for home visiting. As any home visitor can attest, the initial visit with a family can be awkward and unfamiliar, to visitor and family alike. Particularly for families living in a rural area with few nearby neighbors, opening their homes to visitors is not a frequent occurrence. Furthermore, with no funding for ongoing visits, this single postpartum visit was a “one-shot” opportunity for me to make a connection with a family. The NBO, by its very nature is a positive-adaptive, rather than pathological approach, and provided a purpose and a structure to the visits, with no stigma attached. Without the NBO as my raison d’etre, I might have encountered parental suspicion or concern about my coming to their home with a hidden agenda of “checking up on them.” With the NBO, I was not there because the family had been labeled “high risk” or because of concern about infant or parental welfare. I was there for the very basic reason of helping new parents get to know this new person in their lives. I found parents were eager to have me come and we had a structure for engagement. Our roles were clearly defined, and together we embarked in the discovery process that the parents in fact had already started.

With its focus on the individual characteristics of the baby, the NBO leveled the playing field in the visits. As the parent educator, I may have had information about infant development and general expectations for the days ahead, but the parents were the true experts on this baby. Giving them an opportunity to reflect on what they had already learned about themselves and their child in their transition to parenthood was key. Even when one parent felt less confident or experienced than the other, participation in the NBO gave information about their infant that was new to both of them and helped each recognize how to forge a unique relationship with the baby. Ben, a young father, met me at the door and led me to the living room where his wife sat in a rocking chair, holding their infant son. Ben was reserved and barely looked at the baby, as he sat on the periphery of the room, letting his wife do all the talking. He deferred questions to her and reported that he really didn’t know anything about babies. Yet when we started the observations, Ben showed interest, and as the visit went on and I asked for his reflections, he became increasingly engaged. His face lit up when the baby oriented to his voice. As we talked about soothing he described his role as “master burper.” Through the NBO he was able to learn the unique competencies and characteristics of his infant, recognize his growing competency as a father, and see his role in their developing relationship.

During the visits, I learned that, beyond allowing parents to share interpretations they have already made about their baby, the NBO supports parents to share their point of view. The more I was able to acknowledge the parents’ view of their baby and to use that as the starting point in the visit, the more they shared about themselves, their needs, their hopes. The more I was able to validate that point of view, the more I was able to guide observations that led to a greater understanding of the baby. Monica, a 42-year-old mom, who had lost several pregnancies before getting to a healthy full-term delivery, sat on her couch with the baby, and, with a catch in her voice, described how things were going. I heard her anxiety about how the baby was doing, her fear that maybe these early days were not on track, and her worry about the future. Allowing her view of the baby to guide our discussion, I was able to fill in some gaps, suggest some alternatives, and normalize behaviors as together we went through the observations. The NBO allowed us to form a partnership that both honored her point of view and allowed us to forge a new, shared vision of what the baby was telling us.

Using the NBO in home visits is a natural fit. At its core, the NBO is a relational tool that supports the relationship between the practitioner and the family and the parents and the baby. Home visiting, too, is all about relationship, with the visitor given the honor of being in families’ homes and witnessing first hand their interactions with each other in their most intimate surroundings. The NBO is also not prescriptive, which is essential of any intervention that takes place in the home environment. Just as each family and baby are different, especially in the privacy of their own homes, the NBO can be tailored to fit the particularities facing the home visitor each time she crosses the threshold.

As my clinical skills with newborns deepened over the course of the year, I also learned to appreciate just how differently each visit may unfold. The baby may sleep the entire time. The visit may be consumed more with the interaction between the parents themselves or between the mother and grandmother than between the parents and their baby. The mother may have many more questions about nursing than interest in the behaviors of the baby in that moment. In each situation, however, the NBO provided a valuable way for me to follow the parent’s lead, share information to guide the parent–child interaction, and to build rapport with the family. But in every case I left the visit with a deeper relationship with the family that I could follow up on in the weeks ahead. And the parents appeared to have renewed vigor and confidence in their new roles and increased appreciation of the amazing capabilities of their baby.