A Research Program Testing the Effectiveness of a Preventive Intervention for Couples with a Newborn

Abstract

Noxious family environments are associated with a wide range of adverse child outcomes. In order to prevent couple and parent-child relationship problems, a number of programs have been developed for couples with newborns. The current paper describes a program of research evaluating the American version of Couple CARE for Parents of Newborns (CCP; Halford, Heyman, Slep, Petch, & Creedy, 2009). This version of CCP was administered to low-income, unmarried couples with a new baby in an uncontrolled demonstration project (Study 1), compared with a waitlist control condition in a randomized controlled trial (Study 2), and evaluated with low-income parents recruited from urban hospitals in two major metropolitan areas of the United States (Study 3 & Study 4). Despite participant satisfaction with CCP, preventive effects of the program were limited and there was one potential iatrogenic effect. Results were likely impacted by major challenges with recruiting participants and maintaining their engagement in CCP for the duration of the program. We discuss methodological differences between this series of studies and previous trials of prevention programs and make recommendations for improving service delivery to at-risk new parents. These results have implications for public policies that aim to benefit children and families.

Healthy, stable couple and parent-child relationships are widely touted as the bedrock of societies (e.g., Peterson & Bush, 2013). However, reality often falls short of aspirations for such relationships given the high prevalences of divorce (Teachman, Tedrow, & Kim, 2013), intimate partner violence (IPV; Heyman, Slep, & Foran, 2015), and child maltreatment (Slep, Heyman, & Foran, 2015). These noxious home environments are a public health concern of substantial magnitude for both children and their parents. A meta-analysis of 118 studies found that children in noxious environments, compared with controls, fared significantly worse on a host of outcomes (Kitzmann, Gaylord, Holt, & Kenny, 2003). Such environments may be more the rule than the exception, with nearly two-thirds of young children living in homes with parental emotional or physical IPV (Slep & O’Leary, 2005).

Around the turn of the century, stakeholders in high-income countries — politicians, policy makers, researchers, religious leaders, social service agencies, advocates — joined to try to turn the tide and avoid raising yet another generation in noxious homes (see Cowan & Cowan, 2014). Given antipathy in the U.S. toward European-style social services for young parents and U.S. norms emphasizing individual responsibility for behavior, momentum built toward investing in relationship education programs (Giele, 2013). Support for programs promoting respectful, nonviolent intimate partner and parent-child relationships reached its apex in the mid-2000s with the massive federal funding of the Building Strong Families (BSF) study (Wood, McConnell, Moore, Clarkwest, & Hsueh, 2010) and Healthy Marriage Initiatives (HMI; see Cowan & Cowan, 2014).

The U.S. has spent nearly $1 billion in the last decade to propagate and evaluate prevention programs for couples and parents, frequently targeting couples with newborns. The logic behind prevention programs held that if healthy, stable relationships are due to partners’/parents’ behavior, then prevention programs at key developmental milestones that teach and/or bolster skills could reduce the emotional and financial cost of problems, improve public health and, more broadly, the commonwealth.

The birth of a child is a propitious prevention crossroad that was explicitly targeted by both U.S. policymakers (Cowan & Cowan, 2014; Johnson, 2012) and preventionists (Feinberg, 2002). First, new parents recognize the challenges facing them, providing a critical period for optimal openness to learning/improving relationship and parenting skills (Halford et al., 2003). Second, high-risk couples agree to participate in prevention prior to the birth of a child at rates higher than do such couples prior to marriage (Petch, Halford, Creedy, & Gamble, 2012). Third, the perinatal period is an important one for prevention, as partners are at slightly elevated risk for IPV (Charles & Perreira, 2007) and substantial relationship satisfaction decline (see meta-analysis by Mitnick, Heyman, & Slep, 2009). Yet, effectiveness studies of such programs have been decidedly mixed (e.g., Moore, Avellar, Patnaik, Covington, &Wu, 2018; Pinquart & Teubert, 2010; Wood et al., 2010) and, of greater concern, there have been indications of iatrogenic effects, especially around IPV (e.g., Moore et al., 2012). Thus, despite some promising results and the possible openness of parents to prevention during the perinatal period, further research is needed to test both effectiveness and iatrogenic effects.

In summary, noxious home environments are endemic and are especially harmful to public health, with direct and lasting effects on childhood well-being while modeling harmful behaviors for children to repeat in their own adult homes. Programs that could effectively instill respectful, nonviolent behavior between parents and from parents toward children would likely improve adult and child health and well-being now and provide a large down payment toward future generations’ safety, stability, and satisfaction in their homes.

This paper will describe a program of research testing a prevention intervention — Couple CARE for Parents (CCP), originally developed in Australia — that targets both couple and parent behaviors during the perinatal period. We first describe the theoretical and empirical justification for CCP and the development of the U.S. adaptation. We then summarize four trials: (Study 1) an uncontrolled trial with exurban low-income, unmarried parents of a newborn; (Study 2) a randomized controlled trial (RCT) with exurban parents of a newborn as a primary prevention agent for clinically-significant IPV; (Studies 3 and 4) small trials with mostly minority, low-income urban parents of a newborns.

Theoretical and Empirical Justification for Couple CARE for Parents

CCP targets interpersonal processes within relationships and promotes skills-based changes in behavior among couples with a newborn. It bears some resemblance to other cognitive-behavioral dyadic skills-based approaches to prevention with two important exceptions. First, it has greater emphasis on flexibility in mode of delivery (e.g., video-based content and participant personalization via workbook exercises combined with coaching face-to-face, via telephone/video, or via the Internet). Despite the social support that a group delivery model affords, there were strong countervailing reasons to deliver CCP separately to each couple. Groups impose invariant, inflexible scheduling demands that fit poorly with the ever-changing and challenging work and home demands of the target population. CCP allows partners to build skills in their home at a time of their choosing (with no work time missed). Given that perception of barriers (e.g., time, travel) is the strongest predictor non-participation in family skills education (e.g., Sullivan, Pasch, Cornelius, & Cirigliano, 2004), this seemed like a critical consideration. Second, CCP has a greater emphasis on self-directed goal setting and self-targeted behavior change. Halford, Sanders, and Behrens (1994) argued that most skills-based couple prevention and treatment adopt the same problematic approach that produces couple distress: individuals try to change their partners. In a self-regulation approach, prevention involves moving participants toward a self-focused, positive change orientation. This approach is empowering because individuals have no direct control over their partners’ behavior but do have control over their own behavior.

CCP targets four major domains. First, it focuses on coping and stress. Perceived parenting stress among new parents is one of the best predictors of couple relationship problems following the birth of a child (Wallace & Gotlib, 1990), and conflicts over childrearing are the most likely to escalate to physical IPV (Straus, Gelles, & Steinmetz, 1980). CCP topics in this domain include life with a newborn, partners supporting one another, and stress/time management. Second, CCP targets couple communication and conflict management. Heyman’s (2001) review of more than 200 observational studies of couples noted numerous communication differences between distressed partners and nondistressed partners, as well as between couples with and without physical IPV. Third, CCP focuses on negative, or blaming, attributions that are a risk factor for relationship distress (Fincham & Bradbury, 1988) and IPV (e.g., Holtzworth-Munroe & Hutchinson, 1993). Fourth, CCP targets expectations for both the couple relationship and for the parent-child relationship that affect parents’ adjustment generally and relationship functioning (including IPV) more specifically (Foran & Slep, 2007; Harwood, McLean, & Durkin, 2007). Finally, CCP targets mastery of self-directed change (self-regulation), which is associated with both relationship satisfaction (Halford, Moore, Wilson, Farrugia, & Dyer, 2004) and aggression (Anderson & Bushman, 2002).

The original Couple CARE (designed for all couples, not just parents) was shown to be efficacious (e.g., Halford et al., 2004). CCP, which adapted and expanded Couple CARE for use with expecting couples, has been evaluated in two Australian RCTs. The first trial compared CCP with a mothers-only treatment control and found less decline in relationship satisfaction for women who received CCP, but no difference between conditions for men (Halford et al., 2010). A subsequent RCT found moderated effects on relationship adjustment: high-risk women who received CCP evidenced less decline in satisfaction compared with those in the control group, with a similar trend for men (Petch et al., 2012b). These CCP trials focused on couples expecting their first child and were provided in concert with birthing classes and home-visitation. Three-quarters of CCP hours were delivered in weekend workshops during the final trimester, with two home visits after the child’s birth. Participants were almost entirely middle-class couples in established, long-term relationships.

American CCP Adaptation

The American version of CCP (Halford, Heyman, Slep, Petch, & Creedy, 2009) was developed initially as part of a project delivering services to low-income, unmarried parents, which necessitated several changes to the Australian version of CCP. First, our partners in obstetrics departments indicated that only postnatal recruitment on maternity units would provide access to most in the target population. Second, this change in recruitment necessitated vast rearrangement and reworking of the material to transform a largely prenatal program into a postnatal one. Third, the college-level language and coverage of concepts would have to be simplified. Fourth, based on pilot testing, the highly didactic style of the relationship education videos was a poor fit to our couples. Therefore, American CCP videos were professionally produced by a New York-based film company in a documentary style using American couples (with diverse race/ethnicity backgrounds, socioeconomic statuses, living situations, and relationship statuses) who had participated in CCP pilot testing.

The American version of CCP comprised eight sessions during the baby’s first eight months. Similar to the Australian version, a coach assisted each couple through the program. Coaches were master’s- or doctoral-level clinicians supervised by licensed clinical psychologists. Sessions 1 and 4 were home visits; the others were typically conducted via telephone. Sessions began when newborns were ≤ 3 months old and were scheduled 1–3 weeks apart, with early sessions being more closely spaced. Home visits were approximately 1 hr, and phone sessions were 30–60 min. Sessions 1–7 comprised 2–3 segments, with each segment including a 5–7 min video that introduced key relationship or parenting skills. Videos included didactic content and demonstrations of the skills targeted in that session (e.g., communication, playing with a young baby, asking for support). Couples watched the videos and completed activities from their workbooks prior to the session. Session 8 aimed to solidify prior gains and plan for maintaining them into the future. In each session, the coach (a) clarified concepts with which the couple was struggling, (b) helped the couple identify and implement self-change objectives, and (c) was a source of support and knowledge.

Study 1: Uncontrolled Demonstration Project: Low-Income, Unmarried New Parents (Heyman, Baucom, Slep, Mitnick, & Halford, 2020)

Despite valuing marriage equally, people from low-income circumstances are at higher risk for divorce, not marrying, and having children out-of-wedlock (e.g., Karney & Bradbury, 2005). Children from low-income homes are at higher risk for myriad problems, ranging from cognitive and academic problems to delinquency and psychological disorders (e.g., Roy & Raver, 2014). Economic stress, which is substantial in low-income families, affects parental discord and parent-child relationships; this is a key pathway to children’s later poor adjustment, the risk for which extends into early adulthood (Sobolewski & Amato, 2005). Thus, as required by a Healthy Marriage Initiative funding opportunity, Study 1 (see Heyman et al., 2018 for full details) enrolled low-income, unmarried couples with the goal of improving both couple and parent-child outcomes.

Study 1 Method

Trained research assistants recruited participants at the maternity units of a university hospital and a private community hospital in Suffolk County, NY, the exurbs of the New York metropolitan area. Recruiters visited each maternity unit daily beginning mid-morning (after doctors completed rounds, breakfast trays have been collected, etc., but before visiting hours began). Recruiters knocked on the door of rooms that were not marked requesting privacy. The recruiter introduced the program and asked if the mother would like to determine if she and her partner might be eligible. If interested, the mother was asked the screening questions. If the couple appeared to be eligible, the recruiter showed a professionally produced several minute promotional video describing the program and left an informational flier. Fathers were screened subsequently but before baseline assessment. A total of 9,456 couples were screened for eligibility. (See Online Figure 1 for participant flow diagram.) To meet inclusion criteria for Study 1, couples had to (a) be unmarried, (b) be able to participate in English, and (c) earn less money than the county’s “self-sufficiency standard.” Couples were excluded if either partner reported male-to-female IPV with injury or significant fear during a private assessment. Overall, n = 1,847 couples met the inclusion criteria and were allocated to Study 1 (19.5% yield from screening) and n = 491 couples agreed to participate (26.6% of eligible and assigned couples; 5.2% of those screened). Of the eligible couples, 249 were randomly allocated to participate in Study 2 instead of Study 1 (they met eligibility criteria for both studies). On average, partners were in their mid-to-late 20s and had been together for just under 4 years. Less than half of participants were White, non-Hispanic (43.4%).

In addition to demographic information, participant questionnaire packets included scales measuring IPV (both psychological and physical) and relationship satisfaction. Additional assessments were included but are not the focus of this paper. Couples were assessed before CCP (pre-program), following session 4 (mid-program), at the end of the intervention period (post-program; approximately 8 months post-birth), and approximately 6 months after CCP (follow-up; approximately 15 months post-birth).

Study 1 Results

The ns per session can be found in Online Figure 1. Bulling et al. (2018) investigated a vast array of individual, family, child, and program engagement factors related to program retention in the Study 1 sample. The only predictor of total session attendance was younger age of both mothers and fathers (Bulling et al., 2018). Several variables predicted dropping out after only one session: mother’s lower engagement during session 1, worse alliance between the coach and both partners, and surprisingly, higher relationship commitment.

Heyman, Baucom, et al. (2020) examined trajectories of change in relationship outcomes and examined potential moderators (i.e., gender, racial/ethnic minority status, intervention dosage, and relationship commitment) of baseline levels and of change in outcome variables. There was no significant change across the four time points in severe psychological, moderate physical, or severe physical IPV (ps > .05). There was significant linear decline in moderate psychological IPV over time (p = .008) that did not depend on examined variables. There was significant linear and quadratic change in relationship satisfaction that depended on partners’ commitment to the relationship (p = .012 and .018, respectively). There was not significant linear or quadratic change in relationship satisfaction for participants with the same or higher levels of relationship commitment relative to their partners’ (i.e., at the mean or +1 SD; ps > .05). In contrast, participants with lower levels, relative to their partners’, of relationship commitment (+1 SD) had an initial increase in relationship satisfaction (i.e., positive linear change component; p = .006) and concave downward curvature (inverted U-shape) across time (i.e., negative quadratic change component; p = .004). Post hoc tests showed that participants with lower levels of relationship commitment relative to their partners’ reported relationship satisfaction levels at post-program and follow-up that were not significantly different from baseline (ps > .05). Thus, although initial gains from baseline to mid-program were not maintained, baseline levels of relationship satisfaction were (i.e., these partners did not show declines in relationship satisfaction commonly seen across the transition to parenthood).

Thus, couples on average demonstrated maintenance or improvement in key aspects of relationship functioning over the course of the study. Because this study did not include a control condition, it is unclear if significant changes were due to CCP or to natural change. Study 2 included such a control group.

Study 2: RCT of Primary Prevention of Clinically-Significant IPV (Heyman et al., 2020)

Using a much broader participant pool (i.e., not restricted to low-income couples), we conducted an RCT of CCP as primary prevention for clinically significant physical IPV (CS-IPV; acts that resulted in injury, high potential for injury, or significant fear; see Heyman, Slep, & Foran, 2015). CCP was an appealing intervention because increased perinatal risk for physical IPV (e.g., Charles & Perreira, 2007) and perinatal parents often have two particularly robust demographic and psychosocial risk factors for physical IPV: youth — particularly under 30 years of age — and psychological IPV (Capaldi, Knoble, Shortt, & Kim, 2012). Thus, we recruited couples during the perinatal period who were young and reported psychological, but not physical, IPV. Couples who qualified for both Study 1 and Study 2 were placed in Study 2 for random assignment; those assigned to CCP were also included in the treated group for Study 1’s results.

Study 2 Method

We recruited new parents (N = 368 couples;) at risk for CS-IPV from the same hospitals as Study 1 as part of a unified screening; Study 2 was added while Study 1 had been underway for one year. Screening for both continued until the conclusion of recruitment. Whereas Study 1 couples were low-income and unmarried, Study 2 did not restrict inclusion on those factors.

To meet inclusion criteria, (a) couples had to report at least one act of verbal aggression in the last year, (b) at least one partner had to be under 30 years of age, and (c) both partners had to be able to participate in English. On average, partners were in their late 20s and over half of partners identified as White, non-Hispanic. The median annual household income of the sample was close to the national median but substantially lower than that of the high-cost counties of residence. Couples completed a battery of self-report measures before CCP (pre-program), at the end of the intervention period (post-program; approximately 8 months after the birth of the child) and approximately 15 and 24 months after birth.

We examined intervention process (fidelity, alliance, engagement) as well as the effect of CCP on a wide range of couple relationship outcomes (Heyman et al., 2020; incidence of clinically significant IPV, frequency of IPV, relationship satisfaction, dysfunctional relationship attributions, self-regulation in relationships, couple conflict behaviors). These constructs included the four domains targeted in CCP. Given that an index of risk moderated women’s CCP outcome in the Australian trial (Petch et al., 2012b), we examined whether cumulative risk for IPV (low education, low income, unplanned pregnancy, poor bonding, and physical IPV) moderated intervention effects in the current study.

Consistent with recommendations for the study of family-based prevention programs (Huang et al., 2014), intervention effects were modeled using Complier Average Causal Effect (CACE) models, which take into account participant noncompliance with treatment (Jo, Ginexi, & Ialongo, 2010). Below we summarize only the statistically significant findings (p < .05).

Study 2 Results

Coaches and clinical supervisors reported that CCP was delivered as intended (i.e., coaches had good fidelity to intervention session content), and participants, coaches, and supervisors all rated the participant-coach alliance as generally high. Participants were generally rated as engaged in the CCP content by both coaches and supervisors. Similar to Study 1, there were minimal preventive effects of CCP-treated couples, compared with controls, in the RCT; the only significant main effect of CCP was on conflict behaviors. Couples’ collaboration was lower at 15 months post-birth in CCP men (p = .006) and women (p = .021), and at 24 months post-birth in men only (p = .021). Further, there was a significant Intervention × Cumulative Risk interaction on male-to-female physical IPV at post-program (p = .027); CCP participation reduced male-to-female physical IPV acts in couples with lower levels of cumulative risk but increased physical IPV in those with higher levels of cumulative risk. When analyzed individually, the only cumulative risk factor with a significant association was unplanned pregnancy (p = .005).

Study 3: Extending CCP to Health Outcomes: Targeting Physical and Oral Health in NYC

Noxious family environments are related to poor child physical health, including oral health (U.S. Department of Health & Human Services, 2000). In Study 3, we added oral health content and a brief motivational interviewing (MI; Miller & Rollnick, 2012) component to CCP. MI is “a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence” and enhancing intrinsic motivation for change (Miller & Rollnick, 2012). MI has accrued a substantial evidence base supportive of its efficacy across disciplinary lines (e.g., Rubak, Sandbaek, Lauritzen, & Christensen, 2005). To increase accessibility of the program, couples had the option of completing the intervention through telephone or video (e.g., Skype). The goal of this 10-session extended CCP intervention was to add targets to those described for CCP above: daily oral health behaviors, regular child dental check-ups, and noxious family environments in low-SES children at risk for poor oral health.

Study 3 Method

We recruited couples from maternity units at two public hospitals serving predominantly Latino, low-income families in New York City. To qualify for the study, families were required to (a) communicate in English, and (b) report at least two to the following risk factors for ECC (Fontana et al., 2011): (1) family income below 200% of the Federal Poverty Line (FPL; a stringent criterion in the New York metropolitan region), (2) both parents with no more than a high school education, or (3) at least one non-European-American parent. Most participants had a high school education or less (men: 64%; women: 61%) and identified as Latina/o (68%).

First, we conducted a study of recruitment viability (N = 132). Subsequently, we conducted a pilot trial (N = 27), in which couples were randomized to either 10-session CCP with MI and oral health content (n = 9), 2-sessions of MI only (n = 10), or treatment-as-usual (TAU; oral health psychoeducation; n = 8).

Study 3 Results

In the recruitment viability study, after hearing descriptions of CCP, two-thirds of new mothers said they’d be willing to participate and most thought that their partner would also be likely to participate; interest was similar to that of the MI and psychoeducational programs (Supplemental Tables S3.1–3.3). Video delivery was viable: 74% had Internet access at home; of the 26% who did not have Internet at home, 45% were capable of finding a private place with Internet access. Three-quarters of those assessed said that the main thing that would discourage them from participating was lack of time.

In the trial, only 4 of 9 couples (44%) randomized to the CCP intervention completed the first session; of these, 2 couples (22%) completed 2 sessions and 1 couple (11%) completed 3. Thus, despite flexible delivery, no couples completed even half of the 10-session CCP intervention. In contrast, 100% of the couples randomized to MI completed session 1 and 80% completed session 2; 100% of the couples randomized to TAU completed both sessions. There were significant differences between CCP and the other conditions in Fisher’s exact tests of both intervention initiation (i.e., attendance at session 1; p = .002) and completion of the first 2 sessions (p = .029). This could be explained by lower interest in CCP, by the higher time burden of CCP, or as an artifact of fewer first-time mothers being randomized to CCP (27%) compared with MI (50%) and TAU (67%) conditions.

Study 4: First-Time Parents Trial in Los Angeles County (Baucom et al., 2018)

The American version of CCP was developed to target a wide range of couples, including those who had multiple children. However, much of the basic relationship research on challenges surrounding the birth of a child are focused on the transition period following the birth of a first child (Mitnick et al., 2009). The overwhelming majority of participants in published trials of couple-based prevention programs delivered around the birth of a first child are White and of middle or high SES (e.g., Pinquart & Teubert, 2010). Given the unique challenges that low-SES and ethnic minority families face, and the possibility that intervention around the birth of a first child would set the stage for a positive family context for subsequent births, we tested CCP in first-time, low-income parents in Study 4.

Study 4 Method

We recruited 21 couples expecting their first child together (Baucom et al., 2018) from prenatal appointments at a state-funded practice. Eligibility for the practice required an annual household income of less than 200% of the FPL. Couples were eligible for the study if (a) both partners were 18 years or older, (b) fluent in English or Spanish, (c) living together most of the time, (d) expecting their first child together, and (e) in the first 32 weeks of the woman’s pregnancy. Study 4 couples met with their coach once during pregnancy (focused on expectations for parenthood) and then completed the American CCP’s postnatal Sessions 1–7.

Most couples were unmarried and cohabitating. Partners were, on average, in their 20s. The majority of participants identified as Latina/o and four couples participated in all aspects of the study in Spanish. Eligible and interested couples enrolled in the study during the third trimester of the woman’s pregnancy (weeks 28–32). Couples were randomized to either CCP (n = 11) or TAU (n = 10). TAU services, to which all enrolled couples had access, included educational materials and classes on topics including health behavior, depression, childbirth, breastfeeding, and infant care. Outcome measures focused primarily on relationship functioning. However, given the high dropout rate, we focus only on participation results.

Study 4 Results

Of the 192 women who spoke with a member of our study team in person, 156 (81.3%) provided us with their contact information. Following initial contact, we were able to reach 95 women by phone and screen a total of 45 couples. As 21 couples were randomized to conditions and enrolled in the study, 10.9% of the women approached and 46.7% of those formally screened ultimately enrolled in the study. Only four couples in the CCP condition (36.4%) completed the entire 8-session intervention. The remaining couples completed only one (n = 3; 27.3%), two (n = 1; 9.1%), or three (n = 3; 27.3%) of the 8 CCP sessions. As TAU did not include a set number of sessions, we cannot compare participation rates. Yet, fewer CCP, relative to TAU, couples completed the post assessment (p = .01).

Summary of Results of Studies 1–4

Across these four studies, support for preventive effects of the American version of CCP was limited. Although there was improvement in some outcomes (e.g., psychological IPV) targeted by CCP in the uncontrolled trial (Study 1), the majority of outcomes did not change. Because the study was uncontrolled, it was unclear whether the CCP was iatrogenic or the results simply reflected natural postnatal trajectories (Mitnick et al., 2009) exacerbated by the multitude of psychological, social, and economic stressors low-income, unmarried parents face. However, results from a large RCT (Study 2) with much broader inclusion criteria that compared CCP with a waitlist control were similar in that there were no significant main effects of CCP on relationship outcomes. There was also an iatrogenic effect in the RCT. Taken together, these findings raise concern about the lack of effectiveness of prevention programs for new parents and their potential to benefit some couples while possibly doing harm to others (e.g., fathers of unplanned newborns). Results from Study 3 and Study 4 highlight another potential problem with prevention programs for new parents: challenges with keeping couples engaged, especially when the intervention is delivered after the birth of a child.

Discussion

Given the wide-ranging adverse outcomes of noxious home environments on children and parents (Kitzman et al., 2003), extensive resources have been devoted to prevention programs in the last 15 years in hopes of optimizing family relationships — especially for at-risk new parents. This was sensible given the generally supportive evidence of the effectiveness of relationship education for low-income couples (see meta-analysis by Hawkins & Erickson, 2015). Yet, many funding opportunities specifically targeted perinatal couples, for whom the empirical support of effectiveness is more equivocal (Pinquart & Tuebert, 2010). Further, there were some hints of iatrogenic effects of such programs (e.g., more instances of severe physical IPV in intervention, compared with control couples; Moore et al., 2012).

The current series of studies tested the American version of CCP (Halford et al., 2009), a flexibly-delivered, skills-based prevention program for new parents. CCP targets both couple and parent-child relationships and was delivered near the birth of a child, a time when couples are open to intervention (Feinberg, 2002; Halford et al., 2003). Although the Australian CCP program was effective in lessening relationship satisfaction declines across the transition to parenthood in high-risk women (Petch et al., 2012b), our studies found that the American version did not consistently prevent couple relationship problems. In fact, Study 2 results suggested there may have been an iatrogenic effect on IPV in men with more risk factors. Whereas Study 1 found that partners, on average, maintained levels of relationship satisfaction across time, as this was an uncontrolled study, it is unknown whether CCP caused this iatrogenic effect.

Although rarely dwelled on in couples prevention (for exceptions, see Dixon, Gordon, Frousakis, & Schumm, 2012, and Rogge, Cobb, Lawrence, Johnson, & Bradbury, 2013), equivocal prevention effects, and even iatrogenic effects, would be unsurprising given one of the oldest theories that behavioral psychoeducational prevention programming has drawn on — Thibaut and Kelly’s (1959) Social Exchange Theory. Social Exchange Theory posits three key cognitive/affective estimates relevant to relationship satisfaction and stability: the net rewards received; the Comparison Level (CL) of the rewards individuals expect in relationships based on past experience (lived and vicarious); and the Comparison Level of Alternatives (CL_alt), or the rewards individual believe they could receive in alternative relationships (including being in no relationship). Thibaut and Kelly (1959) posited that satisfaction was due both to CL and CL_alt (i.e., “Am I getting what I deserve?” and “Could I do better?”). Prevention interventions both explicitly and implicitly lead individuals to focus on all three estimates, with enrollment in the programming most likely leading to a rise in both CLs. (See Dixon et al., 2012 for an empirical exploration of CL-related disappointment in couples’ prevention interventions.) Relationships with disparate interest in the intervention or in creating change, or with more relationship ambivalence seem at most risk for CL/CL_alt related disappointment.

Further, in a handful of evaluations of prevention programs in nonexpectant newlyweds, increases in positive behavior and decreases in negative behavior in women have been linked with declines in satisfaction (see review by Bradbury & Lavner, 2012). It is possible that CCP’s focus on communication and attributions — common in behaviorally-based prevention programs — may not be helpful for some couples during this uniquely stressful time. McNulty’s (2010) review of data from four longitudinal studies of newlywed couples demonstrated relationship satisfaction declines in couples with more frequent and severe problems who had fewer positive cognitions and more negative behavior. Although it is unlikely that these aspects of the intervention are to blame for the null effects in the current studies, it is possible these components of the intervention do not meet the needs of at least some of the targeted couples at this stage of their relationship.

Bradbury and Lavner’s (2012) brilliant review extracts six key lessons/directions for the causes of the disappointing results of relationship education programs. One suggests shifting from prescribing communication-specific behaviors to conveying the principles underlying them. Although we wholeheartedly agree with Bradbury and Lavner, our findings did not support this point. Our version of CCP boiled down the nine communication skills covered (some for speakers, some for listeners) into two principles: “be clear” and “be considerate.” Furthermore, CCP’s self-regulation approach emphasized individuals choosing what would be most valuable to implement (i.e., was explicitly non-prescriptive). Although we have not yet tested CCP’s impact on observed behavior, its impact on self- and partner-reported communication behaviors was not significant nor was its impact on satisfaction.

Contrasts between CCP-America and Other Prevention Programming for New Parents

The first implementation of CCP in America (Study 1) was funded via the U.S. Healthy Marriage Initiative; the award required that participants be unmarried, low-income couples who were pregnant or within 3 months of delivery. Further, only couples for whom both partners agreed to participate together could be enrolled. The obstetricians at the hospital with whom we partnered strongly dissuaded us from recruiting prenatally, since a large proportion of couples delivering there made sporadic, if any, contact with medical doctors or birthing classes during pregnancy. They presumed that this would make recruitment difficult, if not impossible, and would result in a highly skewed sample for those recruited. Because Study 2 — an RCT with far broader inclusion criteria — piggy-backed off of Study 1’s recruitment activities, it too recruited couples on maternity units, and Study 3 followed their lead. The post-natal timing of recruitment; the low-income status in Studies 1, 3, and 4 (but not the RCT, Study 2); the inclusion of parents who may have previously had children; and the inclusion of many couples who, despite becoming parents together, were not life-partners, makes our research different not only from the Australian CCP trials but also from much of the transition-to-parenthood trials, yet similar to many of the studies emanating from the Healthy Marriage Initiative. In essence, the benefits of reaching couples on the maternity unit seem to be substantially undermined by the disadvantages of delivering an intervention that requires energy and engagement at a time when these resources are at their nadir, especially for society’s most resource-strained new parents.

Despite recruiting a readily available, hospital-bound audience, our recruitment challenges raise questions about the acceptability of CCP in the couples we targeted at the time we recruited them. In Studies 1 and 2, only 6% of couples who were screened enrolled in the study, an exceptionally low recruitment rate compared with previous studies. A review of RCTs of prevention programs for couples at the transition to parenthood demonstrated substantially higher rates of recruitment: between 23% (Feinberg & Kan, 2008) and 83.8% (Midmer, Wilson, & Cummings, 1995) of couples screened ultimately enrolled in these studies (Baucom et al., 2018). Lower recruitment rates in the current research could be accounted for by Baucom et al.’s focus on RCTs of programs for first-time parents, as was the case in Study 4, which had a higher recruitment rate (46.7%). Our struggles in this area are consistent with those from previous studies targeting disadvantaged families. In the large-scale BSF study almost half of the couples in the intervention condition did not attend any of the intervention, and only 17% completed more than 80% of the intervention (Dion, Avellar, & Clary, 2010). Whether this is due to the timing of recruitment, number of other children, financial poverty, time poverty, bandwidth poverty (Mullainathan & Shafir, 2013), cultural mismatch between programs and participants, or a combination of these factors is an area in need of research. Regardless of the reasons, it is possible that couples who would have benefited from CCP did not enroll in the study.

Before discussing implications of the program of research reviewed here, it would be useful to highlight the differences between the Australian CCP RCTs (Halford et al., 2010; Petch et al., 2012b) and the American trial (Study 2). The Australian RCTs found participation in CCP, versus control, resulted in less decline in relationship satisfaction in women in one study (Halford et al., 2010) and high-risk women in the other (Petch et al., 2012b). Although our findings are at odds with these results, there are a number of methodological differences between the Australian trials and ours that may explain the divergent findings. The Australian trials included predominantly White middle-class couples who were fairly established and satisfied in their relationships (e.g., Petch et al., 2012b) and were expecting their first child. Our RCT (Study 2) sample was racially diverse (with minority representation higher than the American average) and younger (inclusion criteria required at least one parent to be under 30 years of age). Additionally, about half of the American pregnancies were unplanned. Further, Study 2 did not require couples to be first time parents (M = 1.74 children). Finally, as the American couples reported incomes equivalent to the national average, the median income would have been around the threshold to be considered self-sufficient in the high-cost exurban county in which they lived.

As alluded to earlier, the timing of CCP was also considerably different. Almost the entirety of Australian CCP was delivered in a prenatal workshop, with one home visit following the birth of the child. This (a) ensures high dosage, (b) makes dropout nearly impossible, and (c) occurs at a considerably less harried time (especially because first-time parents have no other children at home). In large part due to the recruitment of couples after the birth of a child, our timing of outcome assessments was quite different compared with Australian trials. Research on trajectories of change in relationship outcomes across the transition to parenthood has typically conducted assessments during pregnancy and again when the baby is 4–5 months old (Mitnick et al., 2009); Petch et al.’s (2012b) trial employed an equivalent time period. In contrast, couples began CCP in the current studies around when the post-intervention assessments have occurred in this previous work. It is possible that we did not find an effect of CCP in our RCT because the primary changes in outcomes had already occurred. Consistent with this, there was little change in outcome in couples in the control condition.

This recruitment timing issue was a symptom of an even larger problem — the vast differences in the societal and health system ecology in which these studies were embedded. Australia, like all high-income countries except the U.S., has universal health care and extended paid family leave. There is very short (and often a complete lack of) paid family leave in the U.S., adding to the stress of the postnatal time generally and the perceived time poverty more specifically for a postnatal program that requires the participation of both couples. Australian CCP involved collaboration with midwives, who delivered some of the program (Petch et al., 2012b); there was a natural fit with a trusted medical provider that made a more seamless connection between obstetric and psychological prevention services. Health care in the U.S. is a commonly identified source of financial stress (APA, 2017) and is more challenging to access and navigate compared with other high-income countries (Ridic, Gleason, & Ridic, 2012). These factors contribute to the issues on which our colleagues based their recruitment timing advice. Further, although CCP recruiters were permitted to go into families’ rooms on the maternity units, the program was seen as adjunctive; many couples likely volunteered because they could be paid for the research (but not the program) participation. Undoubtedly, American CCP’s (a) placement external to the medical ecology and (b) postnatal timing worked against recruitment and retention in all four studies, given the paltry American financial, logistical, and social support for new parents. Participation barriers in American CCP were likely greater than those in countries with universal healthcare.

Suggestions for Improving Service Delivery

Program developers face a bit of a Catch-22: on the one hand, relationship behavior is notoriously difficult to change, thus leading to multi-component, multi-session prevention programs that are considered brief by treatment standards; on the other hand, couples (especially those in a high stress/high time-poverty period) are voting with their feet that the programs require more than they have to give. Flexible delivery did not, as we had hoped, notably lower this hurdle. Couples in Studies 1, 3, and 4 had the most financial strain; the majority did not get the full program and a large minority dropped out after the first 1–2 sessions. The Australian approach of delivering nearly the entire program in one day mitigated dropout, but involves the highest sight-unseen time commitment and is the least-flexible way to deliver a flexible program. There is a broader movement toward shorter, even single-session interventions (albeit, sometimes with several-hour sessions, as in Australian CCP), especially for anxiety (e.g., Davis, Ollendick, & Öst, 2012). A flexibly-delivered program including all key content within no more than 2 hrs would likely be easier to recruit for and have less drop out. The better retention of Study 3’s 2-hr MI intervention — combined with the number of couples who attend only one or two CCP sessions — is consistent with the idea that a very brief intervention (a “Minimum Intervention Needed to Produce Change”, MINC; Glasgow et al., 2014) that could be followed by just-in-time, on-demand extended content may be the best way to engage new parents. An evidence-guided program of this sort would extend CCP’s flexible approach to its natural ends.

Relationship enhancement approaches may benefit by expanding beyond the typical psychoeducational offerings. Examples in the literature include brief, motivational assessment and feedback (e.g., Cordova et al., 2014); easy computerized tasks that could be programmed to reduce angry responses (e.g., Stoddard et al., 2016); watching and discussing couple-themed movies (Rogge et al., 2013); reappraising conflicts (Finkel, Slotter, Luchies, Walton, & Gross, 2013); or applying gamification strategies (e.g., Johnson et al., 2016) to relationships.

Bradbury and Lavner (2012, p. 112), summarizing the general relationship education field, wrote that “[e]ven a generous reading of the literature indicates that our understanding of how relationships change is incomplete and that our ability to teach couples how to preserve and protect their intimate bonds is not adequate to the task.” Likewise, this synthesis and the accumulating body of results on similar programs (see Cowan & Cowan, 2014) indicates that innovations are still required to improve the lives and trajectories of couples with newborns.