At inclusion, data were obtained based on medical records and self-administered questionnaires. The investigator however could help the participant on request. We recorded the following variables.
Motor impairment and disability
The name of the disease affecting the patient was recorded based on the participant’s declaration and on the specifications of her medical record. The Barthel index (BI) was used as a measure of independence in activities of daily living (1). Briefly participants declared if they felt independent, or needed help, for performing the following activities: feeding, bathing, dressing, bowels, bladder, toilet use, transfers (bed to chair and back), and mobility. This resulted in a score ranging from zero (completely dependent) to 100 (completely independent). We did not modify scoring based on our own observation.
We also asked participants if they felt they were independent, or needed help for each of the following parenting activities: changing or bathing, feeding, outing, dressing, playing, cuddling, and calming down a crying baby. For each activity, participants declared if they were independent (with or without an adapted environment), could do the activity with help, or were unable to do it. Eventually this enabled us to identify two groups of participants: those who considered they were independent for all baby-care activities and those who declared they needed help for at least one activity. We included a detailed description of the number of body parts with motor impairment and additional non-motor impairment.
Child development and mother-infant interaction
The postnatal visit took place between 3 and 13 months after delivery. One of the authors (LB, a clinical psychologist) made an appointment with the mother either at home (21 cases) or at the parenting support center (one case). She assessed child development using the Brunet Lézine scale. The Brunet-Lézine Scale evaluates the psychomotor development of infants aged 2 to 30 months. It analyses motor or postural development, eye-hand coordination, vocalization, and sociability. Combining these items, results in a global developmental score (12, 13).
Infant withdrawal was assessed by LB using the Guedeney and Fermanian Modified Alarm Distress Baby Scale, M-ADBB (14–16). Briefly, m-ADBB is a screening tool including only five areas: (a) facial expression, (b) eye contact, (c) vocalization, (d) activity level, and (e) relationship. In addition, the scoring is changed to three global levels: “Satisfactory,” “Possible problem,” or “Definite problem” for each area. “Definite problem” or two “Possible problems” on the m-ADBB indicates that the infant required further assessment.
Mother infant relationship was assessed by LB based on clinical evaluation using the parent-infant relationship global assessment scale (PIR-GAS) (17). The PIR-GAS allows for a global rating of the quality of a parent-infant (or parent–child) relationship on a numerical scale, with higher scores indicating higher relationship quality. We used the original score, which classifies the quality of relationship as follows. 90: well adapted, 80: adapted, 70: perturbed, 60 significantly perturbed, 50: distressed, 40: disturbed, 30: disordered, 20: severely disordered, and 10: grossly impaired (18).
When parents gave consent, we made a video of mother infant interaction. Mothers freely fed or played with their child either at home or at the parenting support center. Videos were analyzed offline by a trained child psychiatrist (SVS) blinded to the perinatal history, using the Coding Interactive Behavior (CIB) New-born and Feeding Scale (19, 20) using a validated French version (21). The CIB is a global rating system of parent-child interaction that contains micro-level codes and global rating scales. Each code is rated from 1 (a little) to 5 (a lot). Forty-two different codes are grouped into several interactive composites. Six composites were used in the current study focusing on the mother (N = 2), the infant (N = 2) and the dyad (N = 2). (1) Maternal sensitivity was the average of maternal acknowledgment of infant interactive signals, imitation and elaboration of the infant’s behavior, gaze directed to the infant or joint activity, appropriate tone of voice/motherese, expression of appropriate range of affect, resourcefulness in dealing with infant negative states, affectionate touch, supportive presence, and infant-led interaction, i.e. mother focusing on the child’s needs and state. (2) Maternal intrusiveness was the average of maternal inappropriate physical manipulation, mother overriding behavior (i.e. mother disregarding the infant’s signals and interrupting the infant’s ongoing behavior), maternal anxiety, maternal negative affect/anger toward the baby, maternal criticizing of infant’s behavior, and mother-led interaction (i.e. interactions being led by the mother’s needs rather than infant’s needs, pace, and agenda). (3) Dyadic reciprocity was the average of the mother’s elaboration of the infant’s vocalizations and movements, maternal gaze directed to the infant, child gaze directed to mother or joint activity, verbal praise of the infant’s behavior, affectionate touch and enthusiasm, infant vocalization, warm and positive affect for both parent and child, dyadic adaptation – regulation, and fluency of the interaction. (4) Negative dyadic status was the average of maternal negative affect/anger, mother’s hostility behavior, child’s negative or labile affect, withdrawal of the infant from the environment, dyad constriction, and expression of tension. (5) Infant avoidance was the average of the child’s avoidance behavior toward the mother, child’s negative and labile affect, and withdrawal from the environment. (6) Infant social engagement was the average of joint attention, child positive affect, affection to parent, alertness, low fatigue, vocalizations/verbal output, initiation, competent use of the environment, and infant-led interaction.
During the post-partum visit, we also recorded somatic and psychological events that occurred before pregnancy, during pregnancy, and post-partum. We recorded the needs expressed by women regarding medical care, psychological, social, and environmental support (self-administered questionnaire). We recorded child protection legal decisions if applicable.