Interpretation & Application
While the BIMF is often used in research studies as a continuous variable ranging from 0 to 120, it was also envisioned for use in clinical settings. Unlike depression, which may be treated pharmacologically or through therapy, there is no established and corresponding clinical “treatment” or intervention for suboptimal postpartum maternal functioning (to the authors knowledge). As a relatively new area of clinical assessment, evaluation of postpartum functional status may lend itself best to skill-building interventions; in this scenario, improved performance across the domains of maternal functioning is the goal. For example, if the mother endorsed “Strongly Disagree” on self-care items such as “I am getting enough adult interaction” or “I take a little time each week to do something for myself” counseling might be focused on supporting the mother in recognizing opportunities to bolster self-care in the context of parenthood. Additional suggestions for functional skill-building are included below. Another key distinction from depression evaluation is that functional assessment does not contain items related to thoughts of self-harm/suicidal ideation, which, if endorsed positively, should trigger immediate action on the part of the provider. Because thoughts of self-harm are not included in the BIMF, the provider has the flexibility to approach the results in an exploratory manner and from a perspective of skill-building.
What number means what?
In order for functional assessment via the BIMF to have clinical relevance, a target or goal range of maternal functioning is ideal. This process of identifying a target range or “clinical threshold” is relatively straightforward when there are multiple tools which were designed to access the same construct (e.g., depression). In this case, there is only one other measure that is purported to measure postpartum functional status. The Inventory of Functional Status after Childbirth (IFSAC; Fawcett, Tulman & Myers, 1988) was developed in 1988 and does not account for the natural reprioritization that occurs after childbirth. Additionally, while there is some overlap, the IFSAC and the BIMF differ significantly in content, scoring, and approach. As it stands, the IFSAC does not allow us to readily map onto it in order to derive a target range of functioning for the BIMF.
Due to the lack of a comparable measure, results from existing studies (where the BIMF was used to assess maternal functioning) were reviewed and synthesized in order to provide preliminary guidance regarding BIMF scoring interpretation. Design elements such as composition of the study population across socioeconomic and clinical parameters, depression status at baseline, and type of intervention were considered when reviewing the available data. It is important to note that “target range” is aspirational – women may be functioning adequately enough to care for their children, but may not be functioning “optimally”. Longitudinal studies focused on the relationship between postpartum BIMF scores and child development outcomes have not yet been conducted. The guidance provided below represents what we know (and can infer) right now; as additional data becomes available, the guidelines regarding interpretation may be adjusted. Some preliminary guidelines based on the current, available data can be found below.
What do we know right now about how to interpret BIMF scores?
Three published reports of results from the Screening Study (R01 MH071825, K Wisner, PI) indicate that at baseline, women who were screen-positive for depression scored between 79.6 and 81.4 on the BIMF (Barkin et al. 2010, 2014, 2016). Depression and maternal functioning are established correlates with a significant, indirect relationship (as depression increases, maternal functioning decreases) (Barkin et al., 2014). Therefore, it is a reasonable assumption that a BIMF score of approximately 80 amongst depressed women (who have been flagged for treatment) is not optimal or even approaching optimal functioning; this would make it likely that the ideal score (or lower bound for the ideal range) is to the right of 80 on the number line.
There is one published report including BIMF scores before and after intervention (Geller et al., 2018), and one preliminary analysis currently under review. The Mother Baby Connections (MBC) program is the only intensive outpatient program specializing in perinatal mental health that is situated in an academic setting. Specifically, “Clinical programming is directed towards pregnant and postpartum women in the Philadelphia region experiencing significant perinatal mental health symptoms (primarily mood and anxiety disorder (PMAD) symptoms) and/or demonstrating impaired maternal-infant interaction styles.” Early reports from the MBC program describe a mean baseline BIMF score of 70, whereas the BIMF score at discharge was 19 points higher at 89. While a post-intervention BIMF score of 89 may not represent ideal functioning for a healthier population, it represents a large(and statistically significant) improvement in functional score, and may provide a benchmark for interventions in which all participants were experiencing significant perinatal mental health symptoms at baseline. Larger studies with similar populations should be conducted.
The other longitudinal analysis of note was conducted with a population of women participating the Lauren & Mark Rubin Visiting Moms® program of Jewish Family & Children Service in Waltham, Massachusetts. The article associated with this study is now in available here: https://journals.sagepub.com/doi/abs/10.1177/1078390319877444 The client population for Visiting Moms® is considerably different from MBC as the women are, on average, mentally healthier at baseline. Visiting Moms® is not a clinical program, but, rather, a home-visiting program in which trained volunteers offer new mothers tailored support through weekly home visits for the first year of a baby’s life. Where patients in MBC are experiencing “significant” PMAD symptoms at the outset, the women who enroll in Visiting Moms® enter the program through a variety of referral paths and are not necessarily experiencing significant PMAD symptoms at program entry – although some may be. Due to the historical success of the Visiting Moms® program (Paris & Bronson, 2006), and its client base – who more closely mirror the general population of new mothers – the average BIMF score at program completion is considered to be a more reliable guidepost for “ideal” maternal functioning. The average BIMF score at program intake was 81.5; at program completion, the average BIMF score was 97.4. This represents a statistically significant (p<.0001), 16 point increase in functioning. The Visiting Moms® clientele represents a population of women that may be seeking additional support in the postpartum, but are not necessarily depressed. As the developer, I would consider this a success and conclude that the women were functioning adequately at program completion. Why? The mean at completion is in the high 90s and is at a considerable distance from the average BIMF score at program intake (81.5). Further, the score at program completion is also at a considerable distance from where depressed women have clocked in pre-intervention.
If you have questions related to any of this information related to interpretation of scores, please email Jennifer L. Barkin at firstname.lastname@example.org.
Additional Information Regarding Available Data
Depressed women, one timepoint. Three published reports of results from the Screening Study (R01 MH071825, K Wisner, PI) indicate that at baseline, women who were screen-positive for depression scored between 79.6 and 81.4 on the BIMF (Barkin et al. 2010, 2014, 2016). Specifically, all participants had scored ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden & Sagovsky, 1987) prior to completing the BIMF. Depression and maternal functioning are established correlates with a significant, indirect relationship (as depression increases, maternal functioning decreases) (Barkin et al., 2014). Therefore it is a reasonable assumption that a BIMF score of approximately 80 amongst depressed women (who have been flagged for treatment) is not optimal or approaching optimal; this would also mean that the ideal score is to the right of 80 on the number line.
One timepoint, low-income OB/GYN population. Functional status was ascertained at the standard 6-week postpartum follow-up visit in a group of 128 low-income women who received obstetrical care in Macon, GA (Barkin et al., 2017). The average BIMF score at 6 weeks postpartum was 104, a number that falls in the ideal functioning range stated above. Though the women were of low socioeconomic status (84.4% were Medicaid subscribers), they were not, on average, depressed when queried at the 6-week visit, nor were they seeking mental health treatment, to our knowledge. With a mean EPDS score of 7, the group fell well below the EPDS threshold for screen-positive (EPDS total score of 10 or more) (Barkin et al., 2017). Due to the general nature of the clinic visit (a standard work-up for all postpartum women), and the group’s average EPDS score, there is no reason to believe that functioning was impaired in a way that would necessitate intervention.
One timepoint, mothers with infants within 1-3 days of discharge from the Neonatal Intensive Care Unit (NICU). The average total BIMF score for a population of mothers whose infants were soon to be discharged from the NICU was 99.7 (Barkin et al., 2019) which does not appear to indicate “in need of functional intervention” for several reasons. This same group of mothers had an average EPDS score of 7.4 at that same timepoint, which is also well below the threshold for screen-positive status for depression. While this valuation regarding the BIMF score may seem counterintuitive, given the emotional challenges of having an infant in the NICU, there are several aspects of the NICU environment that may actually support a mother’s functioning. For example, the clinical staff’s attention to the majority of the infant’s physical needs may actually open up pockets of time for maternal self-care (such as sleep hygiene and adult interaction), a key domain of functioning. At this point, while having a child in the NICU may create emotional distress and unexpected travel, the physical burden of childcare rests primarily with the clinical team. For example, the difficulties that sometimes accompany breastfeeding are not an issue at this point. Additionally, it is important to remember that these are mothers whose infants were well enough to be discharged and taken home. Maternal functioning after discharge should be studied in the future, with special attention given to the complexity of the discharge care plan which has the potential to significantly impact daily family functioning.
One timepoint, healthy Iranian mothers with healthy infants Mirghafourvand et al. (2019) interviewed 530 new mothers recruited from healthcare centers in Tabriz, Iran. The study population was comprised of women who were primiparous, had vaginal deliveries, self-declared physical health, no recent stressful life events and healthy infants. Eligible women also had no history of depression and an absence of mental health disorders during the pre-pregnancy, prepartum, and postpartum periods. In essence, they were physically and mentally healthy, had healthy offspring, and relatively stable life conditions (absence of recent trauma). The women completed the BIMF and a sociodemographic survey once, between 6 and 10 weeks postpartum. The mean (s.d.) BIMF score for this group of women was 95.2 (12.1). This average total score in the early postpartum is consistent with the characteristics of the population under study.
Suggestions/approaches for functional skill-building:
As with depression assessment, functional assessment (for clinical purposes) will be most effective where supports are in place to treat women with suboptimal scores (Wisner et al., 2013). On-site counseling services with a licensed therapist(s) will be most beneficial and provide the opportunity to both digest and review the results in a relaxed and thorough manner. Though review with a mental health counselor is ideal, primary care physicians can also discuss the results with the patient. Please note that the approaches listed below are suggestions; each healthcare provider may have her/his own approach based on BIMF results.
Approach #1: Review all item scores regardless of total BIMF score.
In this scenario, the BIMF could be reviewed in its entirety for items with low scores and a plan of action developed based on the review. For example, if a patient responds to item 17, “I am able to take care of my baby and my other responsibilities,” with “strongly disagree,” “disagree,” “somewhat disagree,” or even “neutral” the counselor may take this as an opportunity to discuss management strategies with the mother that support greater ability to balance or “juggle” the complex task of motherhood in the context of competing role demands.
Approach #2: Administer the BIMF as two separate scales, and review items within those two conceptual areas.
A comprehensive psychometric analysis (Barkin et al., 2014) indicated that the BIMF can also be administered as two separate scales: the Mom’s Competency Scale and Mom’s Needs Scale (Maternal Self-Care Scale) (see Scoring and Usage tab). While thresholds are not currently available for each of these two sub-scales, items may be reviewed within scale. This would organize treatment around the two core concepts of 1) the mother’s performance in the maternal role (maternal competency) and 2) her care of herself (maternal self-care).
Approach #3: Review item scores for women scoring less than desired threshold.
Here, you would employ the same strategy as detailed in Approach #1, but only for women whose BIMF total score fell outside of the ideal range. For example, if working with a group of women who were experiencing significant PMAD symptoms at baseline, you might use the Gellar et al. study to guide your ideal range; in this case, anyone scoring under 89 would have their entire 20 items reviewed in order to identify priority areas. Though at the provider’s discretion, this approach may be more appropriate once a target range has been firmly established for the BIMF.