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VJ 31¢! :k ‘ I’ll >1}! .9 A 'a .I..)\> i591... 1‘s! I’lc‘llo. ..rl.!!4;7..}.l ligill’all .A {1.7 1| .Q, I. .l .0‘5 '45!“ ). ‘XAZ.§¥{ . i).l0lz.¢.\. iii-Ix 1.0.1.11.- |a|.|\t. A: 1§q091cll r ..‘...Po.ls:(». Art; I” «als‘ .1...‘ 3.9%}? ‘. iv...v ”Bu... :13 ‘ng ‘7’ 7 26 m LIL@ngflllgflllllglzllllllll LIBRARY ‘ Michigan State University This is to certify that the dissertation entitled THE RELATIONSHIP OF MOTHERS' OWN REARING AND METHOD OF DELIVERY TO MATERNAL BEHAVIOR WITH FIRST - BORN INFANTS presented by JOYCE ANN FRENCH has been accepted towards fulfillment of the requirements for Ph.D. degree in Fam11y Ecology Major professor L Date FEb. 6, 1990 MS U is an Affirmative Action/Equal Opportunity Institution 0-12771 PLACE IN RETURN BOX to remove this checkout from your record. To AVOID FINES return on or before date due. DATE DUE DATE DUE DATE DUE W I?! Z; g l 3% . % Ely-v» ‘ I . - . a—b- ' ‘ I ' J , l l l Ifififu MSU Is An Affirmative Action/Equal Opportunity Institution THE RELATIONSHIP OF NOTHERS’ ONN REARINO AND METHOD OF DELIVERY TO HATERNAL BEHAVIOR NITH FIRST-BORN INFANTS BY Joyce Ann French A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Family and Child Ecology 1990 6054298 ABSTRACT THE RELATIONSHIP OF HOTHERS’ ONN REARINO AND METHOD OF DELIVERY TO HATERNAL BEHAVIOR NITH FIRST-BORN INFANTS W Joyce Ann French Previous research implies that socially deprived upbringing and cesarean delivery could have a deleterious effect on maternal behavior with the newborn. The purpose of this study was to examine the relationship between rearing, method of delivery, and maternal behavior with first-born infants. A prospective, descriptive, longitudinal, repeated measures design was used. Maternal behavior was measured prenatally with Cranley’s Maternal/Fetal Attachment Scale and postnatally (at both 2 days and 4 months) with Bernard’s Nursing Child Assessment Feeding Scale (NCAF). Recollection of rearing by mother and recollection of rearing by father were measured by the Acceptance/Rejection portion of Epstein’s Hother/Father/Peer Scale. The sample consisted of 217 mothers, 161 of whom were selected prenatally and 51 who delivered by cesarean and were added postnatally. ANOVA and HANOVA procedures were performed to ascertain the effect of rearing, and/or method of delivery on maternal behavior at the three time periods. No significant effect of rearing or delivery was found on maternal behavior at Time 1 (prenatally). Recollection of rearing by mother showed no effect statistically on maternal behavior at Time 2 or Tine 3. Recollection of rearing by father showed a statistically significant (P=.007) effect on maternal behavior with those reporting rearing above the median having higher scores on the NCAF scale at Time 2. This effect was not seen with Time 3 observations. The method of delivery showed statistically significant effects (P=.031 and P=.04) on RGAF scores at both Time 2 and Time 3; however, this was in an unexpected direction. The mothers who delivered by cesarean consistently reported significantly higher scores on the NCAF observations than did these mothers who delivered vaginally. A step- wise multiple regression analysis revealed the best predictors of maternal behavior postnatally to be marital status, socio-economic status, and education. When controlling for these factors, method of delivery continued to have an effect on the maternal behavior scores and accounted for 5 to 14s of the variance. The scores for cesarean- delivered mothers remained higher than the scores for the vaginally- delivered mothers. The results of this investigation were not consistent with what was expected. Further research is recommended. Copyright by JOYCE ANN FRENCH i990 TO NY PANILY Gene, Pam, Darcy, and Jeff 1 11 ACKNOWLEDGMENTS Many people contributed in a variety of ways to this research. My colleagues encouraged me throughout the process by sharing their experiences, reviewing my work, serving as resources, and cheering me on as I pursued this study. The families that allowed me to enter their lives and their homes taught me much about parent/infant interaction and the value of the varieties of ways to achieve fordinary good mothering“ (Ninnicott, 1987). Dr. Earladeen Badger piqued my interest in early parent/infant interactions, acquainted me with methods to help parents achieve positive relationships, and encouraged me to to pursue advanced education. Dr. Ray Helfer helped me focus the problem by suggesting I review the article by Dr. Dilbert Meier and enthusiastically shared my curiosity about the effect of rearing and method of delivery on maternal behavior. The physicians, Doctors Corwin VanderVeer, Glenn VanDommelen, Jerry Mittingen, Kenneth VanderKolk, James Irwin, Earl Nilliams, Joseph Moore, Thomas Klein, Thomas Marks, Stephen Rechner, David Kreuze, and Jack Romance gave me permission to contact their patients. The nurses and receptionists in the physicians’ offices were particularly helpful. Mithout their assistance and support, this research would not have been possible. The personnel on the postpartum units at Butterworth Hospital facilitated my efforts in data collection. Their personal warmth, enthusiasm for the project, gracious hospitality, and assistance made my visits to their units enjoyable and productive. The Butterworth Hospital and Salvation Army Clinic staffs assisted me by providing the 111 names of patients as potential participants, the times of the scheduled appointments, and even verbal recognition of the value of the research to their patients. I appreciated the extra effort and time each of the staff members gave to support this research project. I want to extend a very special thank you to my committee. I am eternally grateful to them for their guidance throughout my entire doctoral program. They helped me build a program that progressively provided the information and experiences that I needed to get to the point of being able to accomplish this research. Dr. Robert Boger, the chairman, shared my excitement from the very beginning. His expression of confidence in my ability never wavered, and that confidence was the secure base from which I was able to venture toward what sometimes seemed like impossible goals. He shared his vast knowledge about parenting in a way that was empowering to me. His insightful suggestions and probing questions added much to the quality and breadth of this work. I particularly appreciated his willing accommodation of my commuting schedule and his shared concern about time and miles. Dr. Tom Luster’s concrete assistance with references, statistics, instruments, and timely questions and answers will never be forgotten. He, like the other committee members, was generous with his time, energy, and.knowledge. I appreciated his uncanny understanding of my insecurities as I approached the “tests“ of the doctoral program. Dr. Dennis Keefe opened my mind to a much broader concept of family management and development of human capital. His unique method of consultation led me through difficult areas to a clarity of thought that seemed inconceivable. I thank him specially iv for the suggestion of augmenting the sample with additional mothers who delivered by cesarean. Dr. Marshall Klaus guided me through my first research project and introduced me to Dr. Jack Pascoe, with whom I’ve been privileged to present and publish. That first study was an important preparatory step to the development of this dissertation. He generously shared information, gave me tips on writing, and always encouraged me to “keep looking.” His ability to lead me through the maze of an abstract idea to final concrete expression was most helpful; particularly as we dealt with issues of love and attachment. It has been a distinct privilege to study with these four men. I treasure their mentorship. The people who have supported and assisted me in this project are too numerous to list in this paper, but to all of them I extend my appreciation. Among those are some which must be acknowledged personally. Pat Krause, R.P.T., my friend and colleague of many years hand scored every questionaire in preparation for computer entry. My sister, Charlotte Nenham, Ed.D., who proceeded me in the achievement of a doctoral degree, edited this manuscript. I have learned a great deal about writing and the use of language from Charlotte and for this I’m grateful. But most of all, I have appreciated her humorous interjections and very real support throughout this entire process. Judy Pfaff, Nick Filanow, and Joe O’Brien provided the skills that gave meaning and expression to the raw data. Judy did the statistical analyses and never lost patience as she tried to translate my questions into procedures that could provide answers. Nick converted the data into graphic displays that facilitate the reading of this V paper. Joe, along with Judy and Nick, patiently and humorously taught me to use my computer and brought me almost to literacy in use of the manuals. » In conclusion, I want to thank my family. My parents, Robert and Louise McConnell, for instilling in me an insatiable curiosity, desire for learning, and the persistence to achieve goals. My husband, Gone, for his unwavering confidence in my ability, his generous financial commitment, his enthusiastic support, and most of all his love and shared interests. Our daughters, Pam and Darcy, who allowed me to know the joys of parenting. They continue to critique my work and keep me in touch with reality. My heartfelt thanks to all who have enabled me, in one way or another, to study this important subject. vi TABLE OF CONTENTS Chapter Page No. I. INTRODUCTION Introduction and Statement of the Problem...............i Background of the Study.................................2 Purpose of the Study....................................4 Research Objectives.....................................5 Ecological Framework....................................5 Conceptual a Operational Definitions....................9 Limitations............................................12 Assumptions............................................13 II. REVIEW OF LITERATURE Rhesus Monkey Research.................................15 Influence of Rearing on Maternal Behavior..............19 Influence of Method of Delivery on Maternal Behavior...22 Fetal Attachment Behavior..............................26 Maternal Attachment Behaviors During Early Infancy.....26 Factors Influencing Maternal Attachment Behavior.......27 McCubbin’s Double ABCX Theory..........................29 Bronfonbrenner’s Theory of the Ecology of human Development..........................................34 Belsky’s Theory of Circular Influences.................37 smryeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee,eeee38 III. METHODOLOGY AND HYPOTHESIZED RELATIONSHIPS Research Questions.....................................40 Research Predictions...................................41 Research Hypotheses....................................41 Design of this Study...................................42 Analytical Chance/Probability Decision.................43 Research Procedure.....................................46 Sample Selection.......................................46 Sample Description.....................................50 Procedures and Measurements............................53 Data Analysis..........................................51 Time Line..............................................58 IV. RESULTS R.mrch F1m1n9s...OCOOOCOIOIOIOIOOOOOI0.000000000000059 vii V. DISCUSSION The Implications of the Results on the Ecological Framework of the Study................................123 The Effect of Rearing on Maternal Behavior............125 The Effect of Delivery on Maternal Behavior...........132 The Effect of Demographic a Status Variables on Naternal Behavior with the Newborn....................144 VI SUMMARY AND CONCLUSIONS Clinical Implications of this Research................148 L1.‘t‘t1M‘ Of tm sthOIOIOIIIOIOOOIIIOIII0.00.00.00150 Suggestions for Future Research.......................151 WDICESCOIIIOIOOCIIIIIOOIIIOIOI0.0.0.000...OOIOOIOOIOIOICIIO153 A. B. C. D. E. F. O. H. I. J. K. L. Consent Forms A-i Prenatal a Postnatal A-2 Postnatal Only Face Sheet Questionaire 91 Maternal/Fetal Attachment Scale Mother-Father-Peer Scale Maternal Social Support Index Center for Epidemiologic Studies Depression Scale Dyadic Adjustment Scale Ouestionaire 92 Infant Temperament Ouastionaire Nursing Child Assessment Feeding Scale Schedule of Observations and Measurements REFERmEs...I.O.I'D...0...-O...00.00.00.000.0.0000000000000000188 V111 Table 4. 5. 10. 11. 12. 13. LIST OF TABLES Pl“ NO. ”1. mm‘mntOIOIo.I.I.0...OIIOOIIOOOOI0.0.000000000049 Mean Scores (8.0.) from Maternal/Fetal Attachment Scale (MFA).eeeeeeeeeemeeeeeeeeeeeeeeeeeeeeeeeemeeeeeemeeeeeeeee65 Results of Analysis of Variance of Maternal/Fetal Attachment by Poorly-Reared and Nell-Reared Pregnant Subjects........69 Results of Multivariate Analysis of Maternal Behavior (NCAF Parent Subscale Scores) at Time 2 by Differences in Rearing w “t.“ Of m11v.ry00000000......OOOIIIOOOOOOIOIIII0.0.70 Results of Analysis of Variance of Maternal Behavior (NCAF Total Scale Scores) at Time 2 by Differences in Rearing and m mt.“ Of “I‘verYOII.OIOOOIOIIIIOOOOOOU00.0.00000000072 Results of Analysis of Variance of Maternal Behavior (NCAF Parent Subscale Scores) at Time 3 by Differences in Rearing m mtm Of m11v.ry..IIOOIIIIOOOICIOOIOIIOIOOOIOOIIIIII73 Results of Analysis of Variance of Maternal Behavior (NCAF Total Scale Scores) at Time 3 by Differences in Rearing w mt.“ 0f m]1V.ry..00....OOOOOIOIIOIOOIOI...0.0.0.00074 Pearson Product Moment Correlations Between Demographic m St‘tU‘ var‘ab].8000......0.0.0.0...00.0.0000000000000076 Pearson Product Moment Correlations Between Independent and “mat var‘w‘.s0DOOIIIIOIOOOIIOOOOO0.0.00.00000000000078 Results of Multivariate Analysis of Mothers’ Perception of Labor/Delivery Experience by Differences in Rearing and ht“ Of “‘1very.OII...DID-.0...OI.CID-OIOOIIOIOOOIIIIIIaa Results of Multivariate Analysis of Maternal Behavior (NCAF Parent Subscale Scores) at Time 2 and Time 3 by Sex of Baby m “M 0f m1‘v.ry00000000......IIOIOIIIOOOOIOOIOD0.0.85 Results of Repeated Measures Analysis of Differences Between Time 2 and Time 3 of Maternal Behavior (NCAF Parent Subscale Scores) by Sex of Baby, Method of Delivery, and Interaction of Sex and Delivery.......................................BC Results of Analysis of Variance of Maternal Behavior (NCAF Scores) at Time 2 by Recollection of Quality of Rearing by mtmr and by FatmrilOCl...-0.000000000000000...0.0.0....88 ix 14. 15. 16. 17. 1B. 19. 20. 21. 22. 23. 24. 25. 26. Results of Analysis of Variance of Maternal Behavior (NCAF Scores) at Time 3 by Recollection of Quality of Rearing by mmr am by FatmrIIOOOOIIOOI.0.0.0....IOIOIIOOOOOOOOOI.89 Results of Analysis of Variance of NCAF Scores at Time 2 by those Mothers who dropped out of the Study Prior to the 4th mt" m TM“ m cmtinMOOIOOIOOOOIOOIIOOIOOOOIIIIOOIOO Results of Chi Square Analysis of Differences in Percentages of Poorly-Reared and Nell-Reared Subjects in Group: “amt. am “cm1nu1ngu.lIIIDIOOIIOIOOIIOI0.92 Results of Analysis of Variance of Maternal Behavior Prenatally (MFAT Scores) by Method of Delivery............90 Results of Analysis of Variance of Maternal Behavior (NCAF Scores) at Time 2 by Method of Delivery...................94 Results of Analysis of Variance of Maternal Behavior (NCAF Scores) at Time 3 by Method of Delivery...................94 Results of Analysis of Variance of Maternal Behavior (NCAF Scores) at Time 2 by Method of Delivery Among Low SES, s1ngl.’ Tun mrsl.IO...0.0.0.0000...0.0.0.0000...I....95 Results of Analysis of Variance of Maternal Behavior (NCAF Scores) at Time 3 by Method of Delivery Among Low SES, 81n91., To." mtmr‘flI0.000.000.00.00...-0.0.0.0000000000095 Results of a Stepwise Multiple Regression Analysis Predicting Maternal Behavior During the Immediate Postpartum Period in the Hospital (Step 1, Rearing).......99 Results of a Stepwise Multiple Regression Analysis Predicting Maternal Behavior During the Immediate Post- partum Period in the Hospital (Step 1, Marital Status)...100 Mean Scores of Maternal Behavior by Categories of m1m1c sutu’OOIOIOODID-IOIIOIOOCIOIII0.0.0....-I101 Results of Analysis of Variance of Maternal Behavior (NCAF Parent Subscale Scores) Among a Subsample of Low SES, Teen Mothers at Time 2 by Quality of Rearing and Method of Delivery.................................................103 Results of Analysis of Variance of Maternal Behavior (NCAF Total Scale Scores) Among a Subsample of Low SES, Teen Mothers at Time 2 by Quality of Rearing and Method of Delivery.......................................104 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. Results of Analysis of Variance of Maternal Behavior (NCAF Parent Subscale Scores) Among a Subsample of Low SES, Teen Mothers at Time 3 by Quality of Rearing and Method of Delivery........ ....... ....................105 Results of Analysis of Variance of Maternal Behavior (NCAF Total Scale Scores) Among a Subsample of Low SES, Teen Mothers at Time 3 by Quality of Rearing and Method of Delivery.......................................ioo Results of a Stepwise Multiple Regression Analysis Predicting Maternal Behavior at Time 2 and Time 3 m9 mtmrs Of L" 858.000.0000....-OOOOIIOOIIIOOII0.0.101 Results of a Stepwise Multiple Regression Analysis Predicting Maternal Behavior at Times 2 and 3 Among a Subsample of Low SES, Single Mothers.....................109 Results of Repeated Measures Analysis of Maternal Behavior At Time 2 and Time 3 Among a Subsample of “Poorly-Reared by Mother” Subjects by Method of Delivery.112 Results of Repeated Measures Analysis of Maternal Behavior at Time 2 and Time 3 Among a Subsample of 'Poorly-Reared by Father“ Subjects by Method of Delivery.ii3 Results of Repeated Measures Analysis of Maternal Behavior (NCAF Parent Subscale Scores) at Time 2 and Time 3 by Quality of Rearing by Mother and Method of Delivery..............................................ii4 Results of Analysis of Variance of Maternal Behavior at Times 2 and 3 Among 'Poorly—Reared by Mother” Subjects by Method of Delivery...........................119 Results of Analysis of Variance of Maternal Behavior at Times 2 and 3 Among ’Poorly-Reared by Father“ Subjects by wt.“ Of “11"”.IOOOIIII...IIOODOIIOOOIIIIIIOI0.0.0120 NCAF Scores Selected to Confirm the Accuracy of the Data entryOIIOIOOOIIOICICII...0..IOOICIIIOCOIOICOIOIIIOO ...... ‘22 xi LIST OF FIGURES Figure Page No. 1. Projected Responses of Rhesus Monkeys............ ......... 7 2. Study Variables Applied to Double ABCX Model.............ii 3. Hill’s Model of Factor Interaction.......................30 4. The Double Ach Model....................................33 5. Jay Belsky’s Model of Circular Influences........ ........ 37 o. Split-plot, Multifactorial Layout........................44 7. Percentage Distribution of Mother/Father Acceptance/ mam‘m ”r...IOOIIOIOIOIOII000......OIOOOIIOIOIOIIIIIGO 8. Percentage Distribution of Perception of Labor/Delivery amr1m0000ICIOI.IIIIIIOOIIOIIIIIIOOOOIIC0.00.00.00.0063 9. Percentage Distribution of Retrospective Feelings About mm Exmr‘mc‘OOOIIOOIOIOOOOOOOIOOIOOIIOIIICOO-OOOOOO‘ 10. Percentage Distribution of Nursing Child Assessment Fud1n9 (WP) scam ‘t T1” 2000......0.0.0.0000000000067 11. Percentage Distribution of NCAF Scores at Time 3.........68 12. Mean Scores of Maternal Behavior for “Poorly-Reared by Father“ and 'Mell-Reared by Father” Groups, Time 2. (mu fr“ Tabla13)....IOOIOOOOOIOIOOIIIIIOIOOI0.00.0012? 13. Mean Scores of Maternal Behavior for “Poorly-Reared by Father” and “Nell-Reared by Father” Groups by Delivery, 11" 2. (D‘t‘ fr“ Tab].. ‘ w 5)....IOIIOII.0.0.0.0000128 14. Mean Scores of Maternal Behavior Among Subgroup of Low SES, Teen Subjects for 'Poorly—Reared and Nell-Reared by Father“ Groups by Delivery, Time 2. (Data from Tables 25 and 26)............................129 15. Mean Scores of Maternal Behavior by Delivery, Time 2. (Datg fm Tm].1a)IIIIOOIOIOOIIOOIOIOIIIOOOOIIOOIIOOOI‘ae xii 16. 17. 18. 10. 2D. 21. 22. Mean Scores of Maternal Behavior by Delivery, Time 3. (Data fr“ T‘b‘. 19)....IIIIIIIIOOOIOIOOCOIOIIIIIOOOOIII137 Mean Scores of Maternal Behavior by Delivery Among Low SES, Single, Teen Mothers, Time 2. (Data from Table 20).138 Mean Scores of Maternal Behavior by Delivery Among Low SES, Single, Teen Mothers, Time 3. (D‘t‘ fm Tab}. 21).ClI.I.00......0.0.0.000000000000000139 Mean Scores of Maternal Behavior by “Rearing by Mother“ and Delivery, Time 2. (Data from Tables 4 and 5).......141 Mean Scores of Maternal Behavior by “Rearing by Father” and Delivery, Time 2. (Data from Tables 4 and 5).......142 Mean Scores of Maternal Behavior by Rearing and Delivery, T1” 3. (0.“ fm Table 7)....0...0.0.0.00000000000000143 Mean Scores of Maternal Behavior Among “Poorly-Reared by Mother and by Father“ Groups by of Delivery, Time 3. (0.“ fm Tab‘.. 3‘ & 35)...OOOOIOOOIOIOOOOOOOOOOOI0.0.145 xiii CHAPTER I INTRODUCTION Mrs. A. said she felt as if she had lost a baby rather than had one. She had an emergency cesarean at 2:45 a.m. following a 40 hour unproductive labor and is now the mother of a healthy baby girl. Nhen she woke up she knew, cognitively, that she should greet her baby with joy, enthusiasm, and a hug; but emotionally, she felt empty. Mrs. A. behaved in a way that met her expectations of a "good“ mother, feeling “strong curiosity but no connection.” Although thankful that her husband had been able to spend time with their new baby, she felt jealous of their relationship and guilty for all her negative feelings. She was depressed over the birth and became increasingly so as the postpartum became more dismal. She did not feel like caring for her baby, did not enjoy it, and consequently did as little as possible with her baby. This is an extreme but true example of how a number of women having unanticipated cesarean births expressed their feelings after delivery. This type of perception of the birth experience could delay or even prevent initial bonding experience and transactional relationships, setting the stage for a negative response to the baby. The infant’s future well-being is dependent on the development of an attachment to at least one caring adult (Bronfonbrenner, 1979). A birthing experience that is perceived as disappointing and devastating to a woman’s selfbesteem and confidence is no way to enter motherhood. 1 Cesarean delivery is becoming increasingly more common, especially in primiparous women. An unanticipated cesarean delivery may be viewed as a welcome reprieve from a long, difficult labor; as a disappointing but acceptable alternative method of birth; or, as a blow to the self-esteem and capability of womanhood and as an infringement upon biological rights. Are there characteristics that make certain women more vulnerable than others to a negative response if their delivery is by cesarean and does this affect their maternal behavior? THIS DESCRIPTIVE STUDY INVESTIGATED POSSIBLE CONTRIBUTORS TO THIS VULNERABILITY BY EXAMINING MOTHERS’ RECOLLECTIONS OF THEIR OMN REARING AND THE RELATIONSHIP OF THOSE REOOLLECTIONS AND THE METHOD OF DELIVERY TO MATERNAL BEHAVIOR WITH FIRST-BORN INFANTS. BACKGROUND 9E IHE $190! The rate of cesarean delivery continues to escalate even as national governments (United States 1978 and 1984, Canada 1988, England 1986), consumers, medical professionals, and cost payers continue to abhor the trend, study the issue, and make recommendations to control the incidence. Expectant mothers today, across the nation, can expect a 1:4 or 1:5 chance of having a cesarean. If they are primigravidous, their chance may be even higher. More assessment of the fetus, more pregnancies at both extremes of the childbearing age range, a greater premium on each pregnancy, defensive medical practice, and more obstetric specialists are given as factors contributing to the continuously increasing trend. Improved physical health for both mother and baby is the desired outcome that justifies the choice of cesarean delivery. Improved psychological outcome for emother and baby has been addressed through attempts by hospital personnel to “normalize“ the surgical experience. These attempts include allowing fathers in the operating room, allowing both parents contact with the baby in the operating room and participation in the delivery, educating prenatally about cesarean birth, assisting with early breast feeding, and encouraging the mothers to remain awake by using regional anesthesia. As the rate increases there is increased acceptance and more societal support which improves peer and self- appraisal. This is cause for concern, however, for those desiring a more natural solution to problems. A technological world in which the body is valued as a machine is abhorred by many and feared by others. The normative transition of birth has its usual stressors, to complicate the process may cause rather then solve problems. Self-esteem and satisfaction are important components of mental health; mental health effects interpersonal relationships and productivity, both essential attributes of parenting. In 1985, Dr. Gilbert N. Meier investigated the differences in maternal behavior of feral-reared and laboratory-reared monkeys following the surgical delivery of their infants. The laboratory- reared monkeys were deprived of maternal love and affection. He found that none of the laboratory-reared monkeys responded appropriately to their offspring during a 3 day postpartum period. All their feral- reared counterparts responded appropriately by the second day. The parent/infant interaction following vaginal delivery of the laboratory-reared females was normal, although of lower intensity. Like Meier’s monkeys, Mrs. A., whose extreme reaction to cesarean was described earlier, is one of a number of mothers who, after cesarean, had difficulty responding appropriately to the newborn. Perhaps human maternal behavior with the newborn is also influenced by the mothers’ own rearing and method of delivery. EUBEQSE.QE IH£;§I!D! Discovering prenatally who is at risk for a negative emotional outcome of cesarean is an important component of the decision-making process that leads to choice of method of delivery and preparation for birth. The purpose of this study then, is to examine mothers’ recollection of their own rearing and the relationship of those recollections and the method of delivery to maternal behavior with first-born infants. If, in fact, there are psycho-social factors that affect perinatal morbidity, these must be known. If this study shows a relationship between rearing, method of delivery and behavior with the infants, interventions could be designed to dilute the negative relationship and/or steps could be taken to assure that cesarean is chosen only as a final option. Early maternal behavior sets the stage for later maternal/child relationships. It is important for mothers and babies to begin a positive relationship as early as possible. Maternal response to birth is one of the variables contributing to initial maternal ability to parent. Information gained in this study could be useful to prospective parents, physicians, nurses, hospitals, and expectant parent educators in planning care with their clients. If, in fact, the mothers’ rearing and method of delivery have no relationship to maternal behavior with the offspring, the knowledge would eliminate at least one question that is raised periodically by those interested in the issue. To accomplish the purpose of this study several specific objectives have been developed to guide the research. BESEABQH QfliEQIIYES The research objectives are as follows: 1. To assess each mother’s perception of the quality of her own childhood rearing. 2. To determine the method of delivery for each mother studied. 3. To assess each mother’s perception of her birthing experience. 4. To investigate the relationship between the quality of rearing and the method of delivery. 5. To assess prenatal and postnatal maternal behavior of the mother. 8. To investigate the relationship of quality of rearing and the method of delivery to the maternal behavior of the mother. ECOLOGICAL EBAHEHQBK An ecological approach is essential to any comprehensive, holistic study of the complexity of birth. In the search for answers as to why individuals respond differently to what seem to be similar situations, one must look at how a person and the environment have interacted and impacted each other over the continuum of time. Bronfonbrenner’s theory of the ecology of human development (1919), Belsky’s theory of family transaction and circular influences (1981), and McCubbin’s Double ABCX theory (1987) make up the theoretical framework for this study. These three theories provide the basis for looking for a relationship between the upbringing of a female human being, the method of delivering her own first child, and how she behaves with that child. Each of these theories implies a relation- ship between the three variables. If the relationship could be empirically supported, effective therapeutic interventions could be implemented that could alter the process in a positive way. Meier (1985) found that monkeys who were deprived of good mothering during their childhood and were delivered by cesarean did not mother their offspring. Among humans, dyadic relationships and second—order effects within a child’s microsystem have been shown to impact the developing person (Belsky, 1981). Therefore if mothers were abused, neglected, or had less than optimal rearing, the expectation would be for them to perform less than maximally with their own infants when they become mothers. McCubbin’s (1987) theory of the pile-up of stressor events occuring to an increasingly vulnerable person leads to the supposition that one more stressor could be the event that affects the way a person performs from that point on. A vulnerable person, confronted by the necessity of cesarean could, then, be affected in the way she performs as a mother. In Figure 1 the McCubbin Double ABCX model (McCubbin a Figley, 1983) is adapted to project Meier’s monkeys’ responses to deprived rearing and delivery by cesarean. Figure 1. Projected Responses oi Rhesus Monkeys I (researcee) lb Geeerei Beetle Case otter sugary Other caretakers t A (evemt) a (crisis) Am (6/9) “v n Deprived Delivery by 6/8 (naiodapioiiem) Pasemtimg \ assets is \ pasemi c (perceptiom) c " Alive bei eaieeiimg? 1’. met a mother .- —--— -5 o - This model, although not intended as a model of animal response to stress, shows how the cesarean becomes another stressor event for the monkey and could act as a deterrent to mothering. Humans have far more resources and more potential for a variety of perceptions of the stressors in their lives. The Double ABCX theory accounts for those very human characteristics and attributes. As a developing person moves from one microsystem to another s/he carries with her the effects of the relationships in the original microsystem. As s/he builds relationships in the new microsystem, those new relationships affect behavior and continuing relationships. Each interaction with people, objects, and incidents in the environment has an impact, large or small, forgotten or remembered. Some are considered stressors in that they demand change; some are not, depending on constitutional strength, resources, and perceptions. As stressors pile up, any one event can tip the balance into maladaptation. Buffers to stress are the resources, both internal and external. The choices one makes in life (e.g. marriage partner) are potential resources or stressers as are the temperament of additional members of the new microsystem (e.g. newborn). The origin of one’s perception lies in one’s personal experiences. Thus the three models proposed by McCubbin, Bronfonbrenner, and Belsky determined the variables included in this study of the effect of the independent variables (mothers’ rearing and method of delivery) on the dependent variable (maternal behavior). The possible confounding or biasing variables are looked at as McCubbin’s resources and perceptions, are derived from Bronfonbrenner’s propositions of human development, and/or are found in Belsky’s circular family relations. Much research has been done on mothers’ perception of cesarean birth, and some on their behavior with their newborn. Research has made connections between mothers’ own rearing and their maternal care and feelings; but, no research has investigated the possible triadic link between rearing, method of delivery, and maternal behavior. In addition, most of the research on the impact of cesarean was done at the time of the original increase in incidence of cesarean which was from 1978 to 1986. As cesarean becomes more common, there is more acceptance. During the past few years efforts to normalize the experience seem to have exceeded efforts to understand its socio-emotional effects. QQNQEEIUAL AND QEEBAIIQNAL.DEE1NIIIQN§ Maternal behavior toward the infant: CONCEPTUAL: The mother’s responsive style during prenatal and postnatal interactions with her fetus/infant. OPERATIONAL: The mother’s score on the Maternal/Fetal ' Attachment Scale (MFAT) (Cranley, 1981) and on the Nursing Child Assessment Feeding Scale (NCAF) (Bernard, 1987) . Quality of mothers’ rearing: CONCEPTUAL: The mother’s recollection of the quality of her own up-bringing by her mother and by her father. OPERATIONAL: The mother’s score on the "Acceptance VS Rejection“ portion of the Mother/Father/Peer Scale (MFP) (Epstein, 1988). Mothers’ perception of marital satisfaction: CONCEPTUAL: The mother’s contentment with her spouse and their relationship. OPERATIONAL: The mother’s score on the Dyadic Adjustment Scale (OAS) (Spanier, i978). Mothers’ Social Support: CONCEPTUAL: The number of people on whom the mother can count for friend-ship, information, aid, and shared caring. OPERATIONAL: The mother’s score on the Maternal Social Support Index (MSSI) (Pascoe, 1982). Mothers’ depressive symptomatology: CONCEPTUAL: The mother’s mood level at any one point in time. OPERATIONAL: The mother’s score on the Center for Epidemiologic Depression Scale (CESD) (Radloff, i977). Mothers’ perception of labor/delivery experience: CONCEPTUAL: The mother’s retrospective view of her labor/ delivery experience. 10 OPERATIONAL: The mother’s responses to three questions: “How would you describe your labor experience: pleasant, mainly pleasant, mainly unpleasant, unpleasant?" “Describe the degree of pain: no no pain, little pain, pain, but no worse than expected, pain worse than expected, severe pain.“ “Thinking of your labor experience, would you: happily repeat the experience, repeat the experience, not repeat the experience?“ (Robson, 1970). These questions were part of Questionaire s2. Indication for cesarean section: CONCEPTUAL: The medical reason given for the surgical delivery. OPERATIONAL: Information was categorized as follows: “failure to progress,“ “breech presentation,“ “fetal distress,“ “bleeding disorders,“ - “maternal disease,“ and “post-date.“ This information is reported in Questionaire 92 by the subject. Infant temperament: CONCEPTUAL: The infant’s style of behavior as perceived by the mother. OPERATIONAL: The fourbmonth-eld infant’s behavior profile as calculated from the mother’s responses to the 97 item Infant Temperament Ouestionaire (ITO) (Carey, 1978). Time of initial contact: CONCEPTUAL: Time, in relationship to delivery, that the mother recalls having had a meaningful interaction with the baby for the first time. OPERATIONAL: The mother’s response to the question, “When did you first see, touch, and/or hold your baby for more than what you recall as a fleeting moment?" This question is part of Guestionaire 92. The Double ABCX model (McCubbin a Figley, 1983) provided the framework for the choice of variables considered in this study. This model is described in Figure 2. 11 Figure 2. Study Variables Applied to Double ABC! Model Resources (Family) A ."g‘.' — fl “0'“, fl - c].— Dmreeelved biliiy) Iiariial states (Vulnera- 1 Pereepiiem (Ad eq,eaie/imadeqaaie) Adieu-eel fill. Iariial aaiiaiastiem Social Support lecioecomo-ic States Imiami Te-pera-emt leiami Des leibera‘ age. edeoaiiom. race. amd relig iem Presemce oi co-pamiom .1. _. :12: l - .333... Pereepiiem oi birtb Plasmed/emplameed preg. type at amesibeeia Comiaci viib baby Ieibed oi ieedimg. Adaptatioa 12 LIEIIAIIQNS The quality of mothers’ own rearing can only be assessed retrospectively through the mothers’ recollections and perceptions. A standardized, acceptably reliable instrument was used (Epstein, 1988). In addition, the other primary independent variable, method of delivery, could not be controlled or predetermined. The sample of 161 women, selected prenatally, was large enough to support the assumption that 15 to 25: of the cases would result in cesarean. Actually, 15.5: of the mothers sampled delivered by cesarean section. To assure adequate numbers for analysis, an additional sample of 57 women delivered by cesarean was selected and observed beginning with the first postpartum time period. This omission of prenatal date is a compromising but acceptable strategy when predicted numbers in a given category are known to be small. The known problem of biases resulting from the naturalistic selection of respondents in each of the comparison groups is acknowledged. The assessment of maternal behavior was limited to three isolated tests. The first, during pregnancy, through the self-report questionaire assessing maternal/fetal attachment behavior, was followed by two postpartum observations of feeding episodes. The Nursing Child Assessment Feeding Scale, appropriate for newborns and infants, has been used in many research projects and has been shown to have acceptable predictive validity (Hammond, 1983). The investigator for this research was trained in the use of the instrument at the University of Meshington and demonstrated reliability in the required observations. Reliability was reaffirmed by a joint visit with another observer at the midpoint of data collection in this study. The sample of healthy, 13 pregnant woman came from three private obstetric medical practice offices, one hospital clinic, and a prenatal clinic run by the Salvation Army. All mothers delivered at an acute care, private, net- for-profit community hospital. The hospital has 500 beds and approximately 5,000 deliveries per year. The selection of healthy, primiparous women from one community limits the generalizability of the results of the study. Since the data collected on each mother occurred over a four to six-month period, as assumed, there was some subject attrition. “Multiple treatment interference“ (Campbell and Stanley, 1963, p.6) was minimized by multifactorial analysis of the known biasing and confounding variables. A§§HHEIIQN§ 1. Primiparous women in a midwestern community have characteristics in common with healthy, primiparous women across the country. 2. Medical and hospital obstetric practices in the midwestern community reflect standards that are similar nationwide. 3. Mothers’ adult recollections of their quality of rearing reflect the actual quality of parenting delivered to them by their mothers and by their fathers. 4. These women who choose not to participate in the study are not significantly different from those who do. 5. Positive, responsive, maternal behavior (bonding) is essential for attachment to occur. 6. Attachment is the infant’s developmental task during the first year of life. 14 7. Participation in this study during the prenatal period will have no effect on the outcome measures postnatally. CHAPTER 11 REVIEW OF LITERATURE BHESUS HOUSE! BESEABQH This study was designed to discover if quality of rearing and method of delivery in human females influences maternal behavior. Such influences were discovered for Rhesus monkeys in a 1965 study by Dr. Gilbert N. Meier at the University of Nisconsin (Meier, 1965). Meier observed the behavior of 13 female monkeys. Seven were feral- reared and as adults were captured and introduced into the laboratory colony. Six were born and reared in the laboratory in individual wire cages with only life maintenance attention; limited auditory and visual stimulation was provided by other monkeys. Meier found that neither maternal experience nor age was related to maternal behavior with offspring. All of the 13 monkeys were delivered surgically under local anesthetic and returned to their home cage to recover. All exhibited some depressed behavior in the immediate pest-operative period. The newborns were taken from the operating room to the nursery, placed in cloth boxes and had their vital signs assessed. Mithin a short time each one was taken in its box to it’s mother. The infant was first presented for maternal visual inspection, then the investigator removed the infant from the box and placed it on the floor of the mother’s cage, where it remained for two hours. The investigator observed. If the mother picked up the infant and clutched it to her breast, her behavior was judged appropriate. If 15 16 the mother did not touch the infant, the investigator would, near the end of the two hour period, position the infant so to achieve tactile contact with the mother and then continue to observe for reaction. This observation scheme was repeated on each of three consecutive days. The six laboratory-reared monkeys responded with indifference or even active avoidance to contact with their infants. The feral- reared monkeys responded acceptably to their infants on the first or second day. Other studies (Harlow, i971) consistently have shown that laboratory-reared, socially-deprived monkeys display less intense maternal behavior with their young than do their non-deprived counterparts. They eventually behave appropriately especially when encouragement is provided. Meier concluded, therefore, that had these laboratory-reared monkeys delivered vaginally they would have been capable of adequate maternal behaviors. Harry F. Harlow (1971) studied Rhesus monkeys extensively at the University of Wisconsin to learn and describe the process of the development of the affectional system. In his book “Learning to Love“ (1971) he suggests that his research has correlaries with that done on human mother/infant pairs. Harlow says there are at least five basic kinds of interactive, interpersonal love which he defines as affectional feelings for others. The first affectional system is maternal love, the love of the mother for the child; the second is infant love, the love of the infant for the mother; the third is poor, or age-mate love; the fourth is heterosexual love; and, the fifth is paternal love of the adult male for his family or members of his social group. According to Marlow, each love system prepares the individUal for the one that follows and the failure of any system deprives him of the proper 17 foundation for increasingly complex relations. This established Harlow’s contention of the absolute necessity for monkeys’ of the existence of initial maternal love. Although monkey data does not translate directly to an explanation of human experience; it does give a clearer picture of the basic love system of all primates and provides a factual framework for the collection of relatively rich human data. Harlow described three stages of maternal love: care and comfort, ambivalence, and relative separation. During the stage of care and comfort which, in monkeys, lasts approximately five months, the primary function is to provide the infant with intimate bodily contact, nutrition, and protection. These are the mechanisms which elicit reciprocal love from the neonate. Generally the appearance of the infant monkey releases maternal love behaviors, as does body contact and nursing. Harlow observed that any infant could cause this maternal behavior release during the first week. Robson and Moss (1970) found a similar developmental process in human mothers. They found that mothers exhibited impersonal feelings of affection until they could view their infant as a person; this occurred when the baby responded with smiles, coos, and signs of recognition. At that time the affectional tie was sufficiently strong that the imagined loss of the infant became an intolerable prospect. Passes and French (1989) found, however, in a study of 100 healthy, human, primigravidous women that the maternal love was directed to their specific baby during the first 72 hours and the threat of loss became an intolerable prospect at that time. 18 The second stage of ambivalence begins when the infant has developed competent locomotor skills. Maternal behavior involves protection, retrieving, and restraining. The ambivalence results as the mother/infant pair begin to separate. Margaret Mahler (Fitzgerald, 1982) describes a similar evolution in humans, calling the first stage, symbiosis, and the second stage, hatching. Harlow’s third stage of relative separation, he says, is characterized by stress, fear, and frustration but eventually results in the independence needed to progress through life. Harlow found long-term effects of maternal love deprivation in primates, with trust in others being rooted in transactional maternal relationships. Male primates were shown to be more vulnerable to problems involving romantic sex when they were deprived of early love (Harlow, 1971). He refers to social crippling and affectionless lives being the result of early and continued deprivation. Affiliation begins at birth in primates in the arms of the mother and becomes strengthened through gradual learned associations with others. This statement is consistent with the writings of Ninnicott (1987) regarding human affiliative behavior. Although man is an extremely complex animal and intrinsically more variable than monkeys, this research on monkeys, particularly those reared in wire cages and deprived of maternal love, serves as a basis for the study of humans who suffer deficit maternal love. Much human social behavior makes sense when studied in terms of man’s biological heritage. A healthy appreciation for the comparative perspective found through primate research may assist, at least in part, in gaining an understanding of human nature. 19 IflE INELUENQE QE.BEABIN§ QB HAIEBNAL BEHAXIQB There is little doubt that a person’s childhood rearing continues to influence behavior over a lifetime. (Rutter, i985; Quinton a Rutter, 1984; Bowlby, 1979; Tizard a Hodges, 1978; Garbarino, 1980; Crockenberg, i981; Crnic, 1983; Hunter, 1979; Helfer, 1976; Klaus, 1982; Klein, 1971; Cochran, i979; Ricks, 1985) Comprehensive research into this linkage began with Rene Spitz’ study on institutionalized children (Bronfonbrenner a Mahoney,1975). This was followed by Harold M. Skeel’s reports in the late 40’s and his subsequent research 20 years later (Bronfonbrenner a Mahoney, 1975). The definitive empirical evidence, however, may be found in the tendency for the cycle of abusive and neglectful parenting to be transmitted across generations. Hunter (1979) found that in a study of 255 abuse cases, at least one of the parents had themselves been abused. In a study by Klein (1971) 10 of 12 abusive mothers had suffered maternal and environmental deprivation in their own childhood. Rutter (1985), in his London study of groups of children from varied environments, showed that those who experienced severe adversities in their own childhood were most likely to exhibit marked problems in parenting. He found support for his findings in those of Kruk and Molkind (1982) who found that people’s experiences of rearing when they were young were important determinants of their own qualities as parents. This search for antecedence of ineffective or harmful parenting is crucial, according to Rutter. He suggests that if a multiplicity of antecedent variables is found, it would be possible to predict deficits in maternal behavior prior to birth and to develop interventions to prevent recurrences. The continuity of development 20 implies meaningful links over the course of time. Each link is capable of being remediated or exacerbated by an environmental event that could change the direction of behavior. Therefore, the effects of early neglect, discord, and deprivation are not necessarily enduring and likewise, good early experience does not necessarily prevent damage from later developmental stress. The factors that determine persistence of behavior patterns are only partially known. In the case of parenting, Quinton and Rutter (1984) found that a stable, harmonious marriage to a non-deviant spouse served to nullify the ill-effects of even seriously adverse experience in childhood. However, deprived people were more likely to choose a deviant spouse. A compensatory balance of pleasant and unpleasant experiences or the catalytic effect of social support have been shown to make a difference in the chain of events. Rutter (i985), like McCubbin (1987), found that adversities in childhood, especially when they pile-up, tend to make the individual less resistant in the presence of stressers in later life. According to Rutter (i985) developmental theories that postulate a structure of personality which is established during the developmental process does not fit the empirical findings. Equally, however, behaviorist theories that conceptualize effects entirely in terms of present observed behaviors without the need to invoke developmental considerations are also inconsistent with the evidence. Rutter reports consistent data which show patterns of upbringing that involve serious discord, discontinuities in parenting, and parental deviance carry a high risk that children will show socio-emotional problems in adulthood. He suggests that ability to predict the level 21 of risk is dependent on three variables: first, being the family of origin; second, being the child; and the third variable, environmental event or multiplicity of events that interact with the first and/or the second to protect from or predispose toward further disorder. In summary, it is clear that, although there is a relationship between childhood upbringing and adult behavior, the methods by which that relationship can be enhanced or interrupted are still essentially unknown. In this project a cesarean birth was viewed as Rutter’s third variable. Klaus and Kennel’s (i982) diagram of the major influences on parent-infant attachment shows parental background as a key variable. They have evidence that a sensitive period may actually exist during the early postpartum period when maternal transaction is especially important. They refer to this intense transactional reality as ”bonding.“ Bateson (1983) and Rutter (1985) agree that the concept of sensitive periods has some validity. Rutter (1985) defines this as a period during which environmental influences have a particularly marked effect and cites the newborn period as the time for initial formation of selective attachments. Bowlby (1979) suggests that these first bonds must develop during the first two years if normal social relationships are to be possible at later stages. Tizard and Hedges (i978) and Bronfonbrenner (1979) indicate that fully normal social development may be dependent on a solid, primary, dyadic relationship early in life. An interesting finding was reported at a recent conference by Mary Main of the University of California, Berkley (1987). She reported a 76: match was found between the mother’s recollections of the quality of the relationship with her own mother and the 22 performance of her child on the Ainsworth Strange Situation Test which measures parent/infant attachment (Main, 1987; Ricks, i985). IHETIBELQEHQE QE,NHHHBI.QE.QELI!EBI.QN.HAIEBNAL BEHAYIQB Separation of mother and infant may be prolonged and the acquaintance process may be delayed by cesarean birth. (Cranley, 1983; Lipson, 1980). If the mother is anesthetized or heavily medicated, she may not participate in the birth and also not see her child or even realize she has given birth until several hours later. If she feels removed from the situation, she indeed may feel like an onlooker and consequently have difficulty claiming the baby as her own.. Lack of enthusiasm is a natural accompaniment to lack of ownership or maternal linkage to the infant. The detachment from the labor and birth carries over to the postpartum period, according to Lipson (1980). Mercer (1983) found, in her comparison of women who had cesareans with those who had vaginal births, that the cesarean mothers were more hesitant to name their babies. This could be related to the anxiety that the baby was not really their own (Oakley, i983). Oakley (1983) says that the cesarean may signify to the woman an inner weakness in her ability to function as a woman and she may translate this weakness into a feeling of inability to mother. This could increase in complexity if the mother’s cultural value tells her that motherhood should be a state of bliss but she finds it is confusing, negative, painful, and empty. The negative feelings that1 may result from an unanticipated cesarean birth can be directed toward the baby and affect parenting behavior. In fact, Oakley (1983), in her report of the English study of i6 cesarean mothers, says that the 23 cesarean mothers described motherhood in more negative terms at one year post delivery than did vaginally-delivered mothers. She reports, too, that the cesarean mothers were more likely to delay their response to their year-old child’s crying and that they reported a later age at which they felt their child responded to them as a person. Donovan (1986) found that a large number of cesarean mothers reported feeling hostile to their babies for weeks after birth and some related that each time they looked at their infant, they were reminded of what their baby had put them through (Donovan, 1986). The English study reported by Oakley (1983) found similar angry reactions from mothers toward their babies, with doubts about their capacity to care for their babies. when birth achievements fail to match expectations, concern for the health of mother and/or child becomes paramount, and severe stress results from pain, disappointment, and forced separation; the climate is right for the development of hostile feelings which can affect the quality of parenting (Rubin, 1984; Cox, 1982; Klaus a Kennell, 1982). Lamb (1982) supports this statement with his observation that even brief depression can have long-term consequences. Peterson (1979) states that the birth experience acts as a powerful catalyst for nurturing behavior. This, if true in humans, could be viewed as showing parallels with the conclusions of Meier (1965) from his study of monkeys. A disproportionately high number of abused children are born by cesarean section (Cox, 1982). The occurrence of initial separation of the woman from her infant, complicated by the physical effects of surgery and anesthesia, has been implicated in long-term negative 24 effects on child development (Cranley and Hedahl, 1983). A disappointing birth experience can include disturbed patterns of parent/child interactions and ineffective communication within the entire family system (Leach a Sproule, i984). Goth-Owens and Stollak (1982) as well as Boger and Smith (1986) support this thesis of long- term impact in their statements that severe stresses in personal, marital, or family life may disrupt the mother and infant relationship. Ainsworth, Stern, and Siegle (Klaus a Robertson, 1982) report more positive developmental characteristics in children up to five years of age where early contact and good parent/infant bonding has occurred. Trowell (1983) found the most profound effects in her three-year longitudinal study of 16 mothers who delivered by cesarean. She found significant differences in their attitudes and behaviors from those who had delivered vaginally. Trowell became interested in cesarean when she discovered that 158 of the patients in the psychiatric hospital in which she worked had delivered by cesarean. On further investigation she discovered that a nearby unit for autistic children reported that the children they failed to help consisted predominantly of children delivered by cesarean section. In her study she found the cesarean mothers had less eye-to-eye contact with their infants, initiated play less often, and exhibited a delayed response to their infant’s crying. The evidence of the influence of method of birth on maternal behavior is not unequivocal but it does indicate the need for more research. 25 EEIAL.AIIAQHHENITEEHAYIQB- Mecca S. Cranley (1981) reports that the attachment process begins long before birth and cites three previous studies that demonstrated this to be true. Cranley did her maternal-fetal attachment stUdy at the University of Wisconsin. She studied 30 expectant mother volunteers by interviewing them between 35 and 40 weeks gestation and again on the third postpartum day. She defined maternal-fetal attachment as “the extent to which women engage in behaviors which represent an affiliation and interaction with their unborn child” (Cranley, 1981, p. 65) and operationalized the definition by designing the Maternal-Fetal Attachment (PAS) scale (Cranley, 1981). She found that women did, as previously reported, demonstrate attachment to the fetus during gestation. (See Appendix D for the scale) I Several of Cranley’s areas of inquiry are pertinent to this research. She examined three categories of independent variables for their relationship to fetal attachment. She found no differences due to antecedent or demographic variables, nor to personality factors of self-esteem and anxiety trait. She did find differences due to what she called ”situational variables,“ social support and perception of stress during pregnancy. Pertinent to this study is the finding that several of the women reported their social support as being supplied by their mother. Stress during pregnancy showed a negative relationship to fetal attachment. An increased perception of stress related to a decrease in roletaking, interaction with the fetus, and differentiation of self. Cranley found no significant correlations between fetal attachment and scores on the Neonatal Perception 26 Inventory. However, mothers who were more attached to their fetuses did show more positive attitudes toward crying, spitting-up, and bowel movements of their newborn. Five of Cranley’s subjects delivered by cesarean. The mean fetal attachment score for these women was significantly lower than the scores for women who delivered vaginally. Cranley suggested that this finding should be further investigated. In a rebuttal to Cranley’s paper, Niles Newton says, ”The high cesarean section rate in the sample and a tendency for these mothers to score lower on maternal- fetal attachment are intriguing. Maybe a larger, more normal sample would confirm the finding that nonmal labor and positive attitudes toward the fetus go together“ (Cranley, 1981, p.77). HAIEBNAL AIIAQHHENI.EEHA¥IQB§.DURING EARLI.IHEANQI Securely attached children have mothers who, early-on, were responsive to the infant’s cues, held their babies more tenderly, paced their interactions appropriately, used face-to-face contact, and showed sensitivity in initiating and terminating feedings according to Vaughn, Egeland, and Sroufe (i980). Belsky (1984) stated that cognitively motivated, socially and emotionally adjusted children have parents who were attentive, warm, stimulating, responsive, and nonrestricting during their infancy. He further defines parenting competence as including three important factors: recognition of the malleability of children, an appreciation for individual differences, and knowledge of child-rearing techniques. Klaus and Kennell (1982) view eye-to-eye contact, on face positioning, holding, touching, vocalizing, and smiling as maternal bonding behaviors. These are the interactions originating in the mother that affect the infant. These 27 interactions are measurable signs in human mothers that are similar to those described by Harlow in his first affectional system, maternal love. Bernard (1987) looks at sensitivity to infant cues, responsiveness to infant distress, attentiveness to infant, and verbalization as categories of attachment behaviors and measures in her feeding and teaching scales. (See Appendix K for this scale) Bowlby (1982) terms maternal attachment behavior “caregiving behavior.“ Retrieval, reducing the distance between mother and her infant, is the caregiving behavior and is seen in both animals and humans. This goal, according to Bowlby, drives maternal actions. An instinctual need to maintain proximity motivates touching, talking, feeding, and protecting. These behaviors than reinforce the infant’s attachment behaviors and reciprocity occurs. Winnicott (i987) taught that mothers needed privacy and freedom to develop their “good enough“ mothering feelings and behavior. EAQIQBS.INELUEBQINQTHAIEBHAL AIIAQHHEHI.E§HA!IQB Genevie and Margolies (1987), in a survey of 1100 mothers between the ages of 18 and 80, asked what factors determined how women felt about motherhood. They found that mothers who felt less accepted by their own mothers were more able to provide love for their children. This was an unexpected finding that only further research will be able to explain. The second finding was that women who had a supportive spouse or were reasonably content with single status were loving toward their children. Winnicott, (1987) the English pediatric psychiatrist, believed that mothers quite naturally provide a facilitating environment for 28 their newborn. He indicated that mentally healthy women who have experienced ordinary good mothering themselves begin to experience these protective, loving feelings during pregnancy and have strong desires to hold and care for their newborns. He suggests that inappropriate professional attention and teaching can interfere with the process. A study done at the University of British Columbia (Williams, Joy, 1987) revealed that feelings of attachment are related to women’s psychological well-being. Feelings of confidence and competence correlated with both attachment feelings and behavior in mothers of one-month olds and two-year olds. This study supported Belsky’s hypothesis that the mother’s own developmental history is an important determinant of her personality, which in turn is a factor that contributes to her childrearing behavior. Zeanah and Anders (1987) suggest that caregivers’ feelings and behaviors are influenced by their perceptions of past relationships, current relationships, current life stresses, and actual experience with their infant. This fits with the model described by Klaus and Kennell (1982) showing the major influences to be the parents, the infant, the care practices, and the parents’ background. Effective or ineffective caregiving is dependent on these broad variables. Klaus and Kennell suggest that these determinants are not fixed and that all can be changed. They list other influencing factors as attitudes and practices of the physicians and nurses in the hospital, the mother’s support in labor, the amount of contact with the baby, and the nature of the infant. Claudia Panuthos (1984) states that surgical deliveries have ”profound psychological effects on all women." (Panuthos, 1984, p. 142) Expression of anger and hurt are common. A grieving period, 29 which in addition to the usual grief due to loss of pregnancy and fantasy baby, includes the loss of the vaginal delivery experience, control, and possibly contact with baby, may be extended long into the postpartum period. If grieving is extreme, depression may occur which affects the mother’s behavior with her infant. The degree of pain and recovery process from surgery may be barriers to infant care and contact, therefore potential inhibitors of at least the initial bonding process. Panuthos (1984) quotes Marieskind’s (i979) statistical report showing that cesareans are more common in college educated women, women with the most prenatal education, those who have lost babies or have had infertility problems, and those having their first babies. Panuthos believes these findings point to the possibility that cesarean women place greater inner demand on themselves to be informed, well-prepared, in control, and perfect. These women tend to be hard on themselves when their goals are not achieved. One has to wonder how these women rate in the confidence and competence that Williams (1987) found correlated with attachment behavior. The factors that influence maternal attachment are numerous and not clearly defined. Like most other human behaviors, they are multifactorial in origin and expression. HOOOOOINLO OOOOLE ADO! IHEOB! The original ABCX Theory was developed by Reubin Hill (1948) in an attempt to explain why different families respond differently to what appear to be similar stressful situations. In this model, A is the stressor event; 8 is the family’s resources for meeting the demands caused by the stressor event; C is the family’s own definition 30 of the stressor event; and, x is the resultant change or crisis. The A, B, and C factors interact with each other and may produce a crisis; defined by Hill as disruption, disorganization, or incapacity of the family that results from the demands that the stressor event places on the family. This model is shown in Figure 3. Figure 3. Hill’s Model oi Factor interaction Hill’s mpdel was initially used to study 216 families which had a husband/father held captive or unaccounted for in the Vietnam War. In the course of that longitudinal study four additional factors were found which appeared to influence reaction to the stressor event. They were the pile-up of previous stressors and strains, the family’s efforts to acquire new resources, modifications in the definition of the event by the family resulting in a different meaning of the 31 situation, and the family’s coping strategies used to make changes in an attempt to achieve positive adaptation. (McCubbin, Sussman, a Patterson, 1983) These revelations led to revision of the theory and the development of the Double ABCX Model by Hill’s colleagues at the University of Minnesota (McCubbin, Sussman, a Patterson, 1983). The Double ABCX Model takes into account the fact that families and individuals within families deal with stressor events or demands continually throughout their lives. Normative transitions are part of everyone’s growth and development. Change is inevitable as one passes from one stage to the next. Any event that interrupts the status quo places demands (hardships) on families. These demands require change. If the required change is minor, it may occur with little disruption; if the stressor event is major or if it is perceived as undesirable, harmful, or negative, it has the potential of being extremely disruptive to the person or family. Stressor events may actually be initiated by family members as an opportunity for change and growth. It is characteristic of living systems to evolve toward greater complexity and this occurs through taking advantage of opportunities for change. (McCubbin, Sussman, 1983) Stressor events, strains, and hardships are interpreted, responses are formulated, the family adjusts, and they move on, hopefully in a positive direction. If the stresses come too fast or are too extreme, they may be precipitous to the family member having difficulty adjusting to the crisis, finding him/herself short on coping skills and resources to handle the changes, and finally not being able to make the adaptations necessary for growth. This model describes the process components used in response to stressor events as occur in normal, everyday living. 32 These stressor events may lead to adjustment and adaptation that are pathological and dysfunctional or they may lead to adjustment and adaptation that improve the family’s functioning capability. The Double ABCX model, outlined in Figure 4, describes adaptation as the outcome of post-crisis adjustment, therefore implying a two-stage response, one temporary and one more lasting on the time continuum (McCubbin, Sussman, a Patterson, 1983, p.12). 33 ‘ Figure 4. The Double ABC! Model 4., ~ :/..I.. __. ,, \ ‘ \1 late: aA-Accuimelatioa oi stressers pier tbe current stressor event. bI-Old and new resources. cc-Original and revised deiimitiom oi evemir. zx-Diareptivemese amd 34 The pile-up concept makes intuitive sense in describing why some families make better adjustments to stressor events than others and why they seem to make appropriate long-term adaptations to life events. This theory is useful in explaining the way in which background variables can play an important part in determining how a person might react to another stressor event and why the response can vary from maladaptation to adaptation. OBONEOHOBEEHEBLO IHEOB! OE IflE1EOOLOO!.OE HOHAH OEMELOEHENI Urie Bronfonbrenner (1979) presents a conceptualization of the environment as a nested structure consisting of the macrosystem, exosystem, mesosystem, and the microsystem. The macrosystem is the most distant, outermost area consisting of the societal institutions, cultural and subcultural ideologies. It is the framework within which all other components exist. It influences actions, relations and roles of people indirectly by virtue of its rules, regulations, policies, and customs. The innermost structure is the microsystem which consists of the setting for the developing person. The developing person has face-to-face contact with all the people within that setting. Bronfonbrenner’s conceptualization of the setting is a place where relationships, roles, and activities are carried out by and with the developing person. A person has many microsystems (e.g. home, school, church, and work.); the links that exist between these microsystems make up the mesosystem. The exosystem is a setting that indirectly effects the developing person but is a setting in which the developing person does not participate, for instance, the child’s mother’s workplace. Each of these systems exerts influence on and is influenced by the developing person. 35 According to Bronfonbrenner the primary dyadic relationship is the essential building block for all other relationships. How the primary dyad interact in their activities, view their roles with each other, and feel about their relationship is either growth producing or stifling. The ecology of human development consists of the transactions that occur between the developing person, other people, the settings, and all aspects of the environment. The theory is a dynamic theory in that it views people, places, and objects as changing. Activities, roles, and relationships may be quite different, depending on the point in time and the situation. Development is conceptualized as having lasting meaning. The developing person has increasing control over the environment which means an increasing ability to adapt, to negotiate, and to manage factors both within and outside of the self. Bronfonbrenner’s work is based on Lewinian Theory, which defines environment phenomenologically as the person’s perceptions of his/her surroundings. Like the ethologists, Bronfonbrenner believes a primary positive relationship with one person provides the base for future relationships. He suggests that caring is learned by contact and responsibility. He further suggests that social development can only take place within a social environment. Neighborhoods, communities, and intergenerational families provide the milieu necessary for a developing person to practice communication, activities, roles, and relationships. The opportunity to evaluate these interactions within the context of a warm, supportive dyadic relationship in a setting that models positive, productive human behavior leads to competence in dealing with one’s later environment. 38 Melson (McCubbin, Figley, i983) molds the McCubbin theory with Bonfonbrenner’s by describing a framework for understanding how environmental events are stressful to families using the concepts of "demand“ and “fit.“ Each of the environmental settings makes demands (expectations) on the family members and conversely, the family members have expectations of their environment. The greater the number and variety of microsystems involved, the greater the demands and the more the diversity of expectations. Stress is defined by Nelson in terms of the interaction between people and their settings. Identification of the stressers depends on the family’s perceptions. Individual differences contribute to within-family stress; a misfit between expectations and environmental reality contributes to external family stress. The process of adaptation is the method used to achieve a “good fit” with the environment. Since nearly constant change in both family and environmental demands is a fact of life, the family, in its dynamic, reciprocal relationship to its environment, is constantly adjusting, coping, and adapting (McCubbin a Figley, 1983). This study is concerned with how well the mother adapts to the stressor event of unanticipated cesarean, particularly if she has experienced a pile-up of stress within her primary microsystem, her home of origin. The unanticipated cesarean occurs within another microsystem, the hospital, which exists within a medical subculture, a component of the person's macrosystem. 3T OELOISL’O mm OE OIBOOLAB IHELOENOE The circular scheme of the three-person family proposed by Belsky (i981) depicts family relationships and functions as an interconnected system. The marriage relationship affects parenting, parenting affects the behavior and development of the infant, and the infant impacts the marital relationship. Belsky’sdiagram of this process is shown in Figure 5 (Belsky, 1981, p.6). Figure 6. Jay Belsky's Model oi Circular lniluences .\ 1t 38 The infant’s temperament and ability to emit cues and elicit responses from caretakers has been well-documented (Stern, 1977). According to Belsky (1981), the impact of parenting on the marital relationship and the marital relationship on the behavior and development of the infant have not, to date, been adequately studied. This interdisciplinary approach to the study of the linkages, impact, and influence that each component has on the other conceptualizes the family in an ecological framework. In 1984 Belsky took his model a step further and included the forces emanating from within each individual as contributors to the marital relationship, parenting, and behavior and development of the infant. These forces from within, in part, represent the environmental interactions that have occurred to the individual in development, thus, the connection with Bronfonbrenner and McCubbin’s theories. OOHHABI Bronfonbrenner describes the interrelatedness of the person, their setting, their personal history, and their activities. Belsky puts the developing person within the context of a family and offers a framework for analyzing family relationship and function. McCubbin explains why different people react to similar events in very different ways, depending on their past experiences, resources, perceptions, and skills. This review of the three theories supports the conceptual framework of this study. The literature reviewed in this research included what previous investigators have suggested about the relationships between rearing, delivery, and maternal behavior. To date however, there have been no actual studies done on the relationships proposed in this paper. The interactive effect of 39 human mothers’ own rearing and method of delivery on how they behave with their newborns is new, investigative territory. Current literature includes some contradictions but implies that there may be some connections. This literature review predicates the questions, predictions, and hypotheses that have been proposed for this study. CHAPTER III METHODOLOGY AND HYPOTHESIZED RELATIONSHIPS RESEARCH OOESIIONE The objectives of this descriptive research were met by addressing the following questions. i. What is the quality of each mother’s own rearing? 2. How was each mother delivered, vaginally or abdominally? 3. What is each mother’s perception of her birthing experience? 4. How do mothers behave toward their infants during pregnancy and during two feeding episodes,one when baby is less than 72 hours old and in the hospital, and one when baby is 4 months old and at home? 5. Is the score on the fetal attachment scale lower among mothers who report lower quality rearing? 6. Is maternal behavior during the two feeding episodes of lesser quality among mothers who report lower quality rearing when they experience a cesarean rather than a vaginal birth? 7. What relationship do the following factors have with each of the primary variables of quality of rearing, method of delivery, and maternal behavior? . mother’s age . mother’s marital status . mother’s race . mothers’ perception of marital satisfaction . mother’s religious preference . mother’s social support . mother’s education . mother’s socioeconomic status . mother’s depressive symptomatology 40 41 . mother’s pregnancy, planned or unplanned . mother’s perception of labor/delivery experience . indication for cesarean section . presence or absence of companion at birth . type of anesthesia . baby’s sex . baby’s temperament . method of feeding . initial contact time BESEABOH,EBEOIOIION§ The following relationships were predicted: 1. Those mothers who report positive childhood rearing will score significantly higher on maternal behavior than those who report negative childhood rearing. 2. Those mothers having a vaginal delivery will score higher on maternal behavior than these mothers having a cesarean delivery. 3. The difference in maternal behavior between mothers who deliver vaginally or by cesarean will depend on the mother’s childhood rearing. 4. The difference in maternal behavior between the three observation periods will be greater in mothers who are poorly- reared and deliver vaginally than in those who are poorly-reared and deliver by cesarean. BEEEABQH HIEOIHESES Based on the research questions and predicted results the following hypotheses were tested in this research study. Ho 1: There is no significant difference in maternal behavior between well-reared mothers and poorly-reared mothers. He 1: Well-reared mothers score significantly higher on maternal behavior than do poorly-reared mothers. Supported by: Rutter (i985). Quinton a Rutter (1984), Bowlby (1979), Tizard A Hodges (1978), Garbarino (i980), Helfer (1978), Klaus (i982). 42 Ho 2: There is no significant difference in maternal behavior between mothers who give birth by cesarean and those who give birth vaginally. He 2: Mothers who deliver vaginally score significantly higher on maternal behavior than do mothers who deliver by cesarean. Supported by: Cranley (1983), Lipson (1980), Oakley (1983), Donovan (1986), Rubin (1984), Mercer (1983), Trowell (1983). Ho 3: There is no significant difference in maternal behavior between poorly-reared mothers who give birth by cesarean and those who give birth vaginally. Na 3: Poorly-reared mothers who deliver vaginally score significantly higher on maternal behavior than do poorly- reared mothers who deliver by cesarean. Ho 4: There is no significant difference between maternal behavior at Time 2 and maternal behavior at Time 3 among poorly-reared mothers who deliver by cesarean and those who deliver vaginally. He 4: The maternal behavior score for poorly-reared mothers who deliver vaginally shows a significant increase from Time 2 to Time 3 which is higher than the increase among poorly- reared mothers who deliver by cesarean. Supported by: Cranley (1983). DESIGN OE IliE 311191 A prospective descriptive, longitudinal, repeated measures design was used to achieve the objectives of this study. The unit of analysis was the individual, healthy, primigravidous woman. Because the study was conducted in a natural setting, random assignment to equivalent groups was impossible. Comparison of groups was accomplished through analysis of variance. The variables believed to have some relationship with each of the independent and dependent variables were: mother’s age, marital status, race, perception of marital satisfaction, religious preference, social support, education, socio-economic status, depressive symptomatology, pregnancy plan, 43 perception of labor/delivery experience, and time of initial mother- infant contact. Correlations between these variables and the primary variables were done. In addition, the indication for cesarean; presence or absence of companion at birth; type of anesthesia; baby’s sex, temperament, and method of eating were also tested for correlation with rearing, delivery, and maternal behavior. The main effects of quality of rearing on maternal behavior with newborns and the method of delivery on maternal behavior with newborns was assessed. The interactive effect of quality of rearing and delivery was also assessed. Following the observations, each mother was assigned to one of four groups: poorly-reared vaginal delivery, well- reared vaginal delivery, poorly-reared cesarean delivery, or well- reared cesarean delivery. A third observation when the infant was four months of age provided a measure of consistency of maternal behavior. The layout of the fixed effects, split-plot, factorial with covariance design is provided in Figure 6. AHALIIIOAL OHANOEZEBOOAOILIII.OEOIOION A chance probability level of less than or equal to .05 was required to reject the four null hypotheses and to accept the research hypotheses. 44 Figure 6. Split-plot Multiiaciorial Layout ‘l'ilme Poorly-leased l-l CODING. l-l Vaginal 8-1 Cesarean s-r Vaginal 45 BESEABOH EBOOEOOBE The consenting participants were studied prenatally and postnatally. The settings of the observations, the community, hospital, physicians, and clinics, were selected by the researcher. Permission for the study was granted by the Michigan State University Human Subjects Review Committee, the hospital’s Institutional Review Committee, and verbally by the private physicians and the Salvation Army Clinic Director. The mothers’ consent was obtained by the investigator at the time of the initial contact. The physicians and the receptionists in the clinics provided, in confidence to the investigator, the names of the healthy, primiparous women who were due to deliver during the period, July, 1988 through January, 1989. The researcher was granted access to office/clinic schedule books to search for the date of each mother’s appointment. The researcher appeared at the office/clinic at the time the mother was expected for her regular appointment and approached the mother about participation in the study as she was waiting to see the physician. After hearing a description of the study and giving verbal and signed consent (see Appendix A), the expectant mother was given the packet of questionaires (s1, MFP, MFA, CESD, MSSI, OAS), including instructions for completion, and was requested to return the packet to the investigator at the conclusion of the office visit or to return them to the office at her next appointment. If the questionaire was not returned, the investigator followed up by telephone. The cesarean mothers who entered the study after delivery gave consent at the initial contact and were given the packet of questionaires after their initial 24 hours post delivery. Their packet included Questionaires i 46 and 2 plus the CES-D. Time 2 observation was completed by the researcher in the hospital. The method of delivery, mother’s perception of labor/delivery, the indication for cesarean (if done). presence or absence of companion at birth, type of anesthesia; baby’s sex, method of eating, and time of initial contact were questions on Questionaire 92. After re-introductory comments were made and confirmatory, continuing consent was obtained from the mothers who had agreed prenatally, the mother was given Questionaire i2 and the CES-D to complete. These were returned to the investigator while the mother was still in the hospital. The researcher arranged with the mother a mutually satisfactory time to do the feeding assessment. Time 3 observation was done by the researcher in the mother’s home. The time of the home visit was prearranged through telephone contact and confirmed by letter. Along with the confirming letter, (approximately one week before the scheduled visit) Questionaire 93 was mailed to the mothers. The mothers were asked to complete the questionaire during the week and have it ready for the researcher at the time of the four- month visit. The questionaire included the OAS, CEs-D, M881, and ITQ. All records were labeled by the assigned Identification Numbers and were filed in folders. Each folder included a Face Sheet which contained the participant’s name, address, and other specific identifying information. This confidential information was stored in a locked cabinet in the researcher’s home office. OAHELE OELEOIIO! The subjects of this study came from three private obstetric medical practice offices, one hospital clinic, and a Salvation Army prenatal clinic. All subjects delivered at a private, not-for—profit 47 hospital in a Michigan community of approximately 400,000 population. Selection of pregnant subjects occurred during the period of July through December, 1988. To be selected for study the expectant mother needed to: 1. Be experiencing her first pregnancy with gestation lasting longer than 3 calendar months. 2. Have no complicating medical condition and be considered healthy. 3. Live within a thirty mile radius of the hospital. 4. Be able to read, write, and speak English. 5. Give written consent to participate. (See Appendix A for this consent) Post-delivery continuation in the study required a term baby not requiring special intensive care. One hundred, sixty-one expectant mothers were selected and tested during the prenatal period. One hundred, sixteen (72:) were studied at all three observation points: prenatal, at birth, and when the infant was four-months old. Fifty- eight subjects, chosen post-delivery were added to the sample; 57 delivered by cesarean and one delivered vaginally. These subjects who were reported to have delivered by cesarean were chosen at the researcher’s convenience from the hospital’s postpartum, cesarean- delivered population during the 109 day period of July 7, through October 23, 1988. The one vaginal birth was discovered after consent was obtained. The criteria for selection was the same as that used for the base sample. Explanation and consent occurred in the hospital after the initial 24 hours post delivery. This additional sample was to assure an adequate number of mothers who delivered by cesarean and particularly to assure an adequate number of mothers on whom the interactive effect of rearing and method of delivery could be tested. The recruitment of the sample is described in Table 1. Column 4 shows that 232 women agreed to participate in the study from a pool of approximately 370+ (column 1). As described earlier, an attempt was made to contact every accessable primiparous patient due to deliver between August 1, 1988 and January 1, 1989 in the Hospital Clinic and in Medical Practices A and 8. For the most part, this was achieved. However, in the hospital clinic this became an impossible task due to the researcher’s time constraints. To attempt a non-selective selection of subjects, the researcher invited all those eligible women present in the clinic on the days she was there to participate in the study. The Salvation Army Clinic was selected after a refusal was received from a previously selected hospital clinic. The researcher attended the Salvation Army Clinic on 8 occasions: August 10, 17, and 24; September 7, 14, 21, and 28; and October 5, 1988. All eligible women were invited to participate via a generalized, verbal, group invitation. Therefore, the number of missed contacts in column 2 is unknown and the number of refusals in column 3 is zero. Medical Practice 0 was added to increase the number of women getting their medical care from private doctors. The lead physician was contacted in September, permission was granted in October, and the names of eligible women due to deliver in November and December were provided to the researcher by the office manager. Although there were five physicians in the office, names of patients from only three of the physicians were provided. The known potential patient population from which the sample was drawn was 370+. The researcher was aware she I! mu 1 Ml! mm IccennnIIc linncI Iitlrcn Insufficient Ionrcc Itnlntton Contact binned land Imntnlly Intn I I I I I I Ionital Clinic 99+ 1“ 14 ll 1 0 Inlvntion In: Clinic 30+ 2 I 30 t 1 mm Practice I 55 I ll 34 0 0 Wm Irncticc I 31 l 2 21 I I OIMI Prncticn C :0 l i ll 1 I Imitnl Iontnnrtnn C]! III II II It - ' 4 m "5.7" T T 737' "T" "T" Intjcctn Iittdm Intjnctn Iittdm Inland Intjcctn Iou’cn Tilt l Pro/I01. Tile 2 hit/I01. at 4 Ion. line I I I I I l I Inuitnl Clinic 70 l I! I 25 41 Inlvntien In! Clinic 25 l I! I I ll (ll/III Practice I ll 0 It 3 0 31 CIICII Practice I l! I 1! 0 I 1! WI" kettles C 12 I ll 1 I ll Innitnl Mtpnrtu C/I - - II I I 51 MIL lIl I 211 ll II III 5O missed at least 88 of these potentials. Fifty-two women refused to participate; some because they were moving out of town, some because they did not want to answer the questions, some for unexpressed reasons, but the primary reason given was they did not want a stranger visiting their home during the postpartum period. Although 170 women agreed prenatally to participate in the study, only 181 actually contributed data at Time 1. Seven changed their minds and withdrew prenatally. Two failed to produce sufficient data to be included in the study. Two women withdrew between Time 1 and Time 2 but allowed their data to be included. One woman’s baby died in-utero and the other one did not give a reason. The number of subjects at Time 2 was 217. Fifty people were lost between delivery and four months postpartum. This was an attrition rate of 23:. fibflELE DE§£BIEIIQB The mean age of the 219 women sampled was 22.5 years with a 5.0. of 5.04. The range spanned 24 years with the youngest mother at 14 years and the oldest at 38 years. Most of the women were between 16 and 25 years of age. Forty-six percent of the women were single, 54x were married and living with their spouse. Thirteen percent of the single women lived with a male partner. Eighty-one percent of the sample were white, 15: were black, and 4: were of another race. Twenty-three percent were Catholic, 52: were Protestant, .05: were Jewish, and 24.95% had no preference. The community in which the research was done is known for its Dutch heritage, however, only 34s of the protestants indicated membership in the Reformed or Christian Reformed Church. Thirty-eight percent of the women reported their pregnancy was planned, 34s said it was not planned but they were doing 51 nothing to prevent a pregnancy, and 28: said it was definitely not planned. Approximately cox attended prenatal classes. Sixty-one percent of those who attended did so with their partner. The clinic clients received education during their visits, so although many did not report enrollment in formal classes, they did have some prenatal education. Twenty-five percent of the women had not graduated from high school, 34: graduated from high school, and 41: had at least one year of college. Twenty percent of the male partners had not graduated from high school, 38% had, and 17: had at least one year of college. The Hollingshead measure of socio-economic status showed 28% in the lowest category, 21s in the second lowest, 17: at the middle level, 27: at the next to highest, and as at the highest or professional level. Fourteen percent of the sample women reported that one of their parents were deceased. Five of the mothers reported their mother had died before they were 19 and seven reported their fathers had died prior to their reaching 19. Forty-four percent of the sample women had parents who were single, separated, or divorced.' Seventeen percent of the sample were raised by a single mother who had never married. Ninety-five percent of the parental divorces occurred prior to the sample women’s 19th birthday. Fifty-nine percent of the women in the sample were raised by their biological mother and father. Twenty-four percent were raised by their mother, is was raised by the father, 10s were raised in a step-family, and on were raised by relatives, friends, or by adoptive parents. Two percent were "only” children, 313 were the youngest child, so: were within the middle, and 363 were the oldest in their family. The mean number of siblings was three. 52 Vaginal deliveries accounted for 135 of those sampled. Eighty- two delivered by cesarean section. The cesareans were done for ”failure to progress“ (52:), “fetal distress“ (24$), “breech" (21x), ”bleeding” (it), "post dates“ (13), and “maternal disease“ (1:). The women gave birth to 115 boys and 102 girls. Eighty percent of the mothers had contact with their baby within the first hour of birth, 8.5x had contact between one and three hours, 10: did not see or hold their baby until between 3 and 12 hours, and 3.53 did not see or hold their baby for at least 12 hours. During the immediate postpartum period 51: were breast feeding; by four months the percentage had dropped to 19. Ninety-six percent of the mothers had a personal coach with them during labor and 958 had a coach with them during delivery. Ninety-nine percent found their coach helpful and supportive. Fifty- one percent reported their length of labor as eight hours or less, 183 experienced nine to 12 hours of labor, and 33: were in labor for over 12 hours. Analgesia and anesthesia were minimal. Twenty-three percent reportedly had none. Twenty-eight percent had a local or pudendal for the delivery and 4% had epidurals. Seventy-eight of the 82 women who had cesareans delivered under spinal; only three had general anesthesia. 8y four months postpartum so: had returned to work outside their homes, 558 of these had returned by the time their baby was 8 weeks old. Fifty-one percent of those who had returned to work were employed full-time; 49:, parttime. According to the mothers’ responses on the Infant Temperament Questionaire, (ITO) 22% of the infants were ”easy,“ 24: were difficult, 10: were ”slow to warm,“ and 44s had average temperaments. 53 WMW The dependent variable, maternal behavior was measured at three different times: first, during the last trimester of pregnancy; second, within 72 hours of birth; and third, when the baby was four months old. The prenatal measure was done using Cranley’s Maternal/ Fetal Attachment Scale (MFAT). (See Appendix D.) This is a 24 item scale divided into five subscales: roletaking, differentiation of self, interaction with the fetus, attributing characteristics to the fetus, and giving of self. Each statement was responded to on a five point scale from “Definitely No to Definitely Yes,” with five being the most positive response. Scores from the five subscales were summed and the total was divided by 24 (number of questions) and a mean score was reported. Normative means and standard deviations for each of the subscales were established in tests with 328 women. The reliability coefficient for the total score with 181 women with gestations greater than 20 weeks was 0.81, whereas in 145 women at a gestation of 20 weeks or less the reliability coefficient was 0.83. The research for this study used only the mean of the total score (MFAT). Kathryn Bernard’s Infant Feeding Scale (NCAF), (1978) was used to measure behavior postpartally. (See Appendix K) The researcher’s reliability was certified by the faculty of the University of Mashington Nursing Child Assessment training in May, 1988. This measure involved observing an entire feeding episode and recording discrete maternal behaviors in the categories of sensitivity to cues, response to distress, social-emotional growth fostering, and cognitive growth fostering; and infant behaviors in the categories of clarity of cues and responsiveness to parent. A subscore was obtained 54 for each category with a subtotal for the parent portion and a subtotal for the child portion. A total score was also obtained. Only the parent subtotal and the total scores were used for this study (NCFBPT and NCAFBT). The independent variable of rearing was measured by the Mother- Father-Peer Scale (MFP) developed by Seymour Epstein (1988) at'the University of Massachusetts in 1983. (See Appendix E) The quality of rearing for this study was operationally defined as the score achieved on the “Acceptance VS Rejection“ portion of the scale. Responses on a five point scale of agree to disagree to these ten statements (ten for mother and ten for father) indicated the degree to which the subject’s mother and father “communicated love, acceptance, and appreciation of the child, as opposed to viewing the child as undesirable, a burden, a nuisance, and a source of unhappiness or disappointment“ (Epstein, 1983). The Acceptance total was derived by reversing the numbers on the five negative items and then summing the ten ratings. Means and standard deviations were established by Epstein in tests of 175 women. The mean score for mothers reporting maternal acceptance behavior was 40.40 (8.0. 9.39), with a reliability coefficient of .91. The mean score for paternal acceptance behavior was 39.84 (8.0. 9.27) with a reliability coefficient of .91 also. Validity of the MFP was assessed by administering the questionaire along with other personality inventories to female college students and correlating the results. Epstein correlated scores of the MFP with those of his own Ego Strength Scale, Baron’s Ego Strength Scale, Eysenck’s Neuroticism/Extroversion Scale, the Ouilford-Zimmerman Temperament Survey, O’Brien and Epstein’s Self-Esteem Inventory, and the Primary 55 Emotions and Traits Inventory (Epstein, 1988). The “mother accepting“ scores showed mild correlations with the other inventories. The female age, marital status, race, religion, education, whether or not the pregnancy was planned, perception of labor, companion at birth, baby’s sex, method of feeding, and time of initial contact was measured by the mothers’ written, forced choice responses on the self- report questionaires. The type of anesthesia, indication for cesarean, and method of delivery was obtained from the mothers’ responses on Questionaire 92. Perception of marital satisfaction was measured using the "Dyadic Adjustment Scale“ (OAS) which was developed by O. B. Spanier. This is based on the Locke-Nallace self-report measure (Spanier, 1978). The mean of 114.8, standard deviation of 17.8 are the published norms - established in tests of 218 married people. The mean of 94 divorced persons was 70.7 (5.0. 23.8). This is a valid and acceptably reliable scale which tests dyadic concensus, satisfaction, cohesion, and affectional expression. It is accepted for use when only one member of a dyad responds. (See Appendix H) Social support was measured by the Maternal Social Support Index (MSSI) developed in 1981 by John Pascoe, Frank Loda, Valerie Jeffries, and Joanne Earp in Toledo, Ohio. The self-report questionaire has been used to relate maternal social support to the care and stimulation of small children in the home. Construct validity was established by comparable testing of a group of protective-service referred mothers and another group of non-protective-service referred mothers. The mean for the protective-service mothers was 7.4 and 56 for the non-protective-service mothers the mean was 10.5. These means were significantly different at alpha .001. Socio—economic status was determined using the Four Factor Index of Social Status developed by August 8. Hollingshead at Yale University in 1975. This index combines sex, marital status, occupation, and years of schooling to estimate the status position individuals and members of nuclear families occupy in American society. This index is a revision of one developed by the same author in 1958. It is recognized as a reliable and valid instrument. It is a frequently used measure. Depressive symptomatology was measured using the Center for Epidemiologic Studies Depression Scale (CES-D). This instrument was designed to measure current levels of symptomatology, the information needed for this study. A strength of this tool is its value in studying the relationship between depressive symptoms and other variables (Radloff, 1977). The instrument has been widely tested on people with different racial backgrounds, ages, and on both men and women. The scale is reported to have high internal consistency, acceptable test-retest stability, excellent concurrent validity, and substantial evidence of construct validity. (See Appendix 0) Babies’ temperament was calculated from the mothers’ responses to the 97 item Infant Temperament Questionaire (ITO) developed as a screening device to be used in clinical practice by Carey and McDevitt (1978). The instrument was originally developed in 1970 and revised in 1978 to improve its psychometric characteristics. The internal consistency for the total instrument was 0.83 and the test-retest 57 reliability was 0.85. This restandardization was done on a sample of 203 infants, age 4 to 8 months. (Carey a McDevitt, 1978, p. 737). DAIA.ANALI§1§ Frequencies and condescriptive statistics were calculated for each variable with the SL-Micro Computer program for the IBM-PC. Multiple analysis of variance, using SPSS-x, and SPSS-PC, were performed to determine the differences between the two groups in each plot (poorly-reared vaginal and poorly-reared cesarean vs well-reared vaginal and well-reared cesarean). A repeated measures procedure was used to determine differences in maternal behavior between Time 2 and Time 3. Since the Time 1 measure of maternal behavior was on a totally different scale than Time 2 and 3 the repeated measure procedure could not be used. Therefore the three scores were compared using Pearson Product Moment Correlations. Homogeneity of the groups was assessed by the Bartlett-Box procedure. Hhen homogeneity was not present, an orthonormalized transformation procedure was automatically performed by the computer prior to further analysis. Step-wise multiple regression analyses were employed to investigate the predictive significance of each of the independent variables on the dependent variable. Pearson Product Moment Correlations and Spearman Correlations were used to clarify relationships between factors previously assumed to be related to the primary variables of rearing, method of birth, and maternal behavior with the newborn. Findings were considered significant if the statistical tests showed a chance probability that was less than or equal to .05. Correlations were considered significant when the coefficient was greater than zero by a 58 chance probability that was less than or equal to .05. A chance probability of .05 was used to reject the null hypotheses. IIHE LINE 1987 1988 1989 1990 March April May June July June December February Literature reviewed Proposal written Proposal approved by the Advisory Committee Proposal submitted to MSU, and Butterworth Hospital Permission granted by Physicians, Butterworth Hospital, and MSU. Data collection begun T-i T-2 T-3 July Aug. Dec. Aug. Sept. Jan. Sept. Oct. Feb. Oct. Nov. March Nov. Dec. April Dec. Jan. May Jan. Feb. June Data collection completed Analyses completed Research reported CHAPTER IV RESULTS mm Due to the descriptive nature of this study the results of the data analyses will be presented in terms of responses to the research questions and predictions posed in Chapter III, as well as in terms of the specific research hypotheses. Question 1. What is the quality of each mother’s own rearing? Figure 7 shows that 203 women completed the “mother” portion of the MFP. The mean score of the subjects’ recollection of the quality of rearing by their mother was 41.98, S.D., 7.99, and median 44.89. Scores of less than two standard deviations (8.0.) below the mean accounted for five and four-tenths percent of the sample while 11.3: scored within the second 8.0. below the mean and 22.2: were within one 8.0. below the mean. Above mean scores included 81.1: within one s.D. and none were greater than one 8.0. above the mean. The median score was used as the dividing line between the arbitrarily assigned groups of poorly-reared and well-reared subjects. Multifactorial analyses of the groups are reported later in this chapter. Figure 7 also shows that 188 subjects completed the ”father” portion of the MFP scale. The subjects’ mean score of their recollections of the quality of rearing by their fathers was 40.24; 8.0., 8.87; and median, 42.81. Scores less than two S.D.’s below the mean accounted for 4.3x of the sample; 14.8x of the sample had scores within the second 8.0. below the mean of the study; and, 22.4: had scores within one 8.0. below the 59 60 :59. 3 .0533— .o mozerooem dd «4 6.. no 84-: .fld T .9. an 8.50 adv g 3 a p [.1 P {F .1 I G 3 o— 3 0.3 on a an a. «.3 3 a. on 333 3 ‘ uefiofl um beamed .o mozerooom .9.- no v9.3 .9.- 7 34-. .6.- .. dd «7 00.0. 09.3 50.3 L no on 1 .I-.. v6 0.: .. 1 ca «flu v on s .. i... i av ioo as 3338 3 I .203 monogeuxeomgmeog megahefio: no coca-5.2.3 eugooouem .5 e59.— 61 mean. Above the mean scores included 45.2% within one 8.0. and 13.3: scored within the second 8.0. above the mean. The median of 42.81 was used in the multifactorial analyses that follow. The subjects’ recollections of rearing by mothers and recollections of rearing by fathers were mildly correlated (.38, P=.OO). Question 2: How was each mother delivered, vaginally or abdominally: There were 217 subject responses to the question regarding method of delivery of which 135 delivered vaginally and 82 delivered by unanticipated cesarean section. Question 3: What was each mother’s perception of her birth experience? Perception of the birth experience was operationally defined by the subjects’ responses to the following three questions: “How would you describe your labor experience?“ ”How would you describe the degree of pain?“ and “Thinking of your labor experience, would you happily repeat, repeat, not repeat?“ Figure 8 contains the descriptive responses. Labor was described as pleasant by 29.2x of the sample while 70.8: said it was unpleasant. Thirty-four and seven—tenths percent said they would not repeat the labor experience, 47.48 said they would repeat it, and 17.8x said they would happily repeat the labor experience. Thirty-nine and six-tenths percent reported pain as expected or less while 80.4: described the pain as greater than expected or severe. In addition to the above three variables, 29 (35x) of the subjects who delivered by cesarean were asked by the researcher how they felt about having to deliver by cesarean and these comments were categorized as negative, neutral, and positive as shown in Figure 9. Analyses of these 29 subjects’ perception of the 62 cesarean experience as it related to other variables were done using the Chi Square test. No significant relationships were found between the character of the perception and other variables. Question 4: How do mothers behave toward their infants during ‘ pregnancy and during two feeding episodes, one when baby is less than 72 hours old and in the hospital, and one when baby is 4 months old and at home? Table 2 lists the mean scores of the 158 expectant mothers on the MFA scale. The mean of 4.488 for the 'Roletaking" subscale among this sample is higher than the standardized mean of 4.10 reported by Cranley (1987. On “Differentiation of self“ Cranley’s sample of 181 had a mean of 4.23, whereas this sample mean was 4.41. “Interaction with fetus” resulted in a mean of 3.49 for this sample compared to 2.98 in the Cranley sample. On the subscale “Attributing to fetus“ this sample scored higher with a mean of 3.758 than the Cranley mean of 3.13. In ”Giving of self“ the samples were comparable, this sample’s mean of 3.978 and Cranley’s mean of 3.98. The total mean scores were also comparable with this sample mean being 3.983 and Cranley’s mean, 3.97. The mean score for the Total MFA scale (MFAT) was the only score used for multifactorial analyses. 63 c2023.".— 2 vegans-8 3:3 mansion—mu none..— 85:... .o moan—comm 52 .8 ozone 992 992 . new . com Gomez .02 . . .3 $3 . - . m5. So Genoa base 05 Boson Bane: .83 .o .388". 8.388.“. «8.2 come—men: reszenhong no moaneuuem no mos—5:25 madame—em d 953..— 64 Figure 9. Percentage Distribution oi Retrospective Feelings About Cesarean Experience 65 TABLE 2 V mmmmmmmmmw Gestation >20 Mk Cranley’s Data (N=181) This Sample (N=158) Mean Score (Mean Score (8.0.) TOTAL SCORE ‘ 3.97 3.98 (.451) Roletaking 4.10 4.49 (.57) Differentiation of Self 4.23 4.41 (.05) Interaction with Fetus 2.98 3.49 (.85) Attributing to Fetus 3.13 3.78 (.882) Diving of Self 3.98 3.97 (.504) Observations during a feeding episode within the immediate postpartum period numbered 203 subjects and their babies. The Nursing Child Assessment Feeding Scale (NCAF) served as the measurement of maternal behavior. The Parent Subscale score and the Total score were used for all the analyses. Figure 10 shows the distribution of scores resulting from the observations at Time 2. The mean parent score for the entire sample was 39.4 (S.D. 3.94). Of the sample 31: scored within one standard deviation below the mean, 10x within the second 5.0. below, and as were in excess of two S.D.’s below the mean. Scoring more than one 5.0. above the mean was 11.5: and 44: were within the first S.D. above the mean. Scores greater than two S.D.’s above the mean were recorded for 5s of the sample. Figure 10 also shows the distribution of the NCAF Total Scale. Thirty-one and five-tenths percent of the sample scored within one 8.0. below the mean of 55.21. Thirteen and eight-tenths percent scored within the second 8.0. below and 2: scored more than two S.D.’s below. Forty-one and nine-tenths percent of the sample scored within one S.D. above the mean, 7.8: scored within the second 8.0. above and 3: scored beyond two S.D.’s above the mean. Figure 11 shows the descriptive results of the NCAF observations at four months. One hundred, fifty-five mother/baby pairs were observed. The mean score on the Parent Subscale was 40.92 and on the Total Scale, it was 59.44. Parent Subscale scores for 29: were within one S.D. below the mean, 20: were within the second S.D. below, and 2.8: were more than two S.D.’s below the mean. A total of 48.4: of the subjects scored above the mean, 34.9: within one 8.0. and 13.5: greater than one S.D. above. NCAF Total Scale scores were within one S.D. either side of the mean for 84.5:; 17.4: were more than one S.D. below and 18.1: were more than one S.D. above. Question 5: Is the score on the fetal attachment scale lower among mothers who report lower quality rearing? Table 3 shows the results of the analysis of variance on the total sample separated by the median score into poorly-and well-reared groups of expectant mothers. The mean scores on the total MFA are lower, but not significantly lower, for the subjects in the “poorly- reared by mother” group and the “poorly-reared by father” group. Question 8: Is maternal behavior during the two feeding episodes of lesser quality among mothers who report lower quality rearing when they experience a cesarean rather than a vaginal birth? ' According to the results of the multiple analysis of variance (MANOVA) printed in Table 4, maternal behavior during the immediate 67 L 395 ~28. m402 dine dd? 33 a? an- .33 .33 .3. 8.8 :3 P - P . _ a 2, 3» Se Sag-OI ego-nun «den—uh m402 dine dd? 38 dd? an- 8.3 g 0.3 3.8 «a av on 0338 3 I « 03:. .eeuoom 340,3 umgeem «mean-en: 330 unamz .o e33n§3o eoauoeouem .2 e30: 68 - 360m :58 $402 dd no .96 .4 8:: .3 T .9. an 3.: 3. no 3.90 avg _:_ av egg-oi gunman—m aneuam “—402 .3 a. .3 7 .2... d.- .- d.- a- 2.3 on: «0.9. 8.3 3.3 In . z... a... av 3538 3 8 a 08—h .QOuOom E‘Uz no flOueflQuuanuD .DbuflOOMOA .2 .uubuh -m--c— -O-s—d 1M3 mumumnwmum «WWW mmummum Poorly-lard 1| 3.93 .43 loll-loud 7‘ 4.01 .41 mm amp «.5: 15: mm mm .10 1 1.3: .14 mm» at m u m Pauly-lard u 3.95 .43 loll-laud SI 4.01 .41 mm Gum 23.4: m lotion Gum .12 l .58 J5 W Significance t P < or = to .05 “Hersh.“ "UHF-Wu“! 79 mu 4 mummummmmmm 94.xill.2.91.9142::!|:|I.in.IIIIIII.I|4.I!4|II.24.92112::1. I. III! 9.9. 8.9. 9.9. I. P. mumum Imir Mini 93 39.19 4.43 lard 0mm: 29 49.19 2.99 9911- Mini 39 39.39 3.93 loud canon 49 49.93 4.99 hi1 leuiu 1.... . 1 4 .ss .4: [fleets 90mm 29.99 1 9.14 .9298 19992999299 mm .99 l .99 .994 mumnm !oorlr Mini 92 39.94 4.29 lured 0mm: 22 49.99 3.22 9911- mm 91 49.94 3.59 [and Canon 39 41.29 3.34 Iain 2mm 99.29 1 4.11 .9314 meet: Minn 91.92 1 4.44 .9324 lucrative 944962 .19 l .91 .91 Immune. 4 9 < o: = to .99 “North." MHoHuMI 71 postpartum period in the hospital among subjects who reported lower quality rearing by both mother and father was of higher quality on the NCAF Parent Scale when they experienced a cesarean rather than a vaginal birth. Both of these differences were statistically significant (P:.025 and P=.037). There was also a significant difference between the ”poorly-reared and the well-reared by father" subjects. The poorly-reared scored significantly lower than the well- reared. This difference was not present between groups when rearing was defined as 'rearing by mother.” Table 5 shows the NCAF Total Scale score during the immediate postpartum period to be significantly higher between the subjects who delivered by cesarean and those who delivered vaginally (P=.032 and P=044). There was no significant difference between poorly-reared and well-reared in either group. There also was no interaction between rearing and delivery on maternal behavior. There was no significant difference between the vaginal and cesarean groups in NCAF Parent scores among poorly-reared by mother. and father subjects at the four-month postpartum time. The results are displayed in Table 6. Table 7 displays the results of the NCAF Total scores at Time 3. There was no difference between poorly-reared and well-reared subjects in either group. There was, however, a significant main effect for type of delivery. The cesarean-delivered mothers had higher scores than did the mothers who delivered vaginally. There was no interaction effect, meaning that the differences in maternal behavior do not depend on some combination of types of delivery and quality of rearing. 12 99999 9 mumumummmmmm nmzuummumumuunm I. lean 9.9. 9.9. 9.9. 9. I. mumumum Poorly- 9e¢1u1 93 54.51 5.93 lend Cessna 29 99.19 3.59 ~— lell- leeieal 99 54.95 4.19 lend 9mm: 49 59.13 5.41 lain 9min: 19.99 1 .491 .524 91191199 Niven 124.99 1 4.99 .9324 Interactive 9119“ .115 1 .991 .939 mumum Peerle- leeiul 92 54.93 9.23 leerel cesarean 22 59.59 3.91 lell- lean! 51 55.51 5.29 lead Ceeeme 39 51.99 5.94 1.1. 1mm I 11.11 1 .15: .111 211m: Delivery 195.149 1 4.19 .9444 Interactive 911999 2.93 1 .193 .19 111.111....» 4 9 i or 8 to .95 98 1 ( or = to .91 m1 ______‘Attended lecture series ______‘Attended Preparation for Labor series ______‘Attended Lamaze classes 9. Did your spouse/friend attend class with you? Yes NO 10. What is your occupation? Briefly describe your occupation 180 Appendix C 11. How much formal school have you completed? ____Less than 7th grade _______7-6-9 years _______JO-11 years. __;____High School graduate 1-3 1/2 years college College graduate Graduate degree 12. What is your husband/live-in friend’s occupation? Briefly describe his occupation 13. How much formal school has he completed? ._______Less than 7th grade ___7-6-9 Years _______10-11 years ,_______High School graduate __1-3 1/2 years college ___College graduate _______Oraduate degree 161 Appendix C 14. Are your parents living? _______Mother and father are living _______Both parents are deceased _______One parent is deceased Approximate date of: Mother’s death Father’s death 15. Are your parents separated/divorced/never married? NO Yes If yes, please go on: Never married Approximate date of divorce: How old were you at the time? 16. Who did you live with as a growing child? Biological mother and father Biological mother Biological father Biological mother s stepfather/mate/friend Biological father a stepmother/mate/friend ______Adoptive parents Grandparents Other 162 Appendix C 17. What was your placement in your original family? ______Youngest child ______Oldest child Between the oldest a youngest. 16. How many brothers and sisters do you have? None ‘ One Two Three Four FTVO Six _____JMore than six are expecting. There are no right or wrong answers. Your first iepression 1(13 MATERIAL-FETAL kllkChIEkl SCALE by hecce Cranley, 1979 Please respond to the following itees about yourself and the baby you is usually the best reflection of your feelings. ESL! ill! I!!.!!£L.!flll 9!!.!!§!!£ 2!£.§!£l!fl£! 1. 2. 3. 12. 13. 14. 15. ll. 17. 16. 19. 20. 21. 22. 23. 24. ‘60 Y =d-HW.O== I talk to ey unborn baby.... ........ . ...................... I feel ell the trouble of being pregnant is worth it I enjoy watching ey tussy jiggle es the baby kicks inside.. ................... . 1 picture eyeelf feeding the beby............. l’e reelly looking forward to seeing what the baby looks like.... ... ... ... .. ........ I wonder if the baby. feels crasped. in there 1 can elsost guess whet ey baby’s personality will be free the way s/he loves around 1 do things to try to stey healthy that I would not do if I were not pregnant...... ..... ... ....... ..... I wonder if the baby can heer inside of es........... . l have decided on a nose for a baby boy ....... ......... I wonder if the baby thinks end feels inside of ee..... 1 eat west end vegetables to be sure ey baby gets . 9°00 di.t0000.00000800.000..OOOOIIOOOOOOOOIIODOCOIIO. 1 seess ey beby kicks end eoves to tell so it's ..ting ti..ssssesssssssssssesssesseeeesssssesssssseses l poke the baby to get hie/her to poke beck............ 1 can hardly wait to hold the beby....... ....... 1 refer to sy baby by a nicknese. ..... ..... ............. l ieegine eyself taking care of the beby............... l have decided on a nose for e girl beby............... Appendix D 1 try to picture what the baby will look like.......... 1 stroke ey tuesy to quiet the baby when there is too .ucn kiCNingeeee eeeeee ssssssssessesesssssssssess es 1 can tell that the baby hes hiccoughs................. I f..] .y D09, i. U!".. eeeeeeeeeeee seesesesesssssesees _____ I give up doing certain things beceuse 1 went to ".‘p .’ b.hy00000600IOOIOIOOOOODIOIOOOI00.0.0000... O l grasp ey baby’s feet through sy tussy to love it .rounGOOOOOO9.6000009000000000...006.000.600.0000000 1154 MOTHER/FATHER/PEER SCALE Appendix E Please indicate the extent to which the following steteeents describe your childhood relationship with the people indicated by using the following scale and circling the appropriate nusber following each statesent. 1 2 3 4 STRONGLY SOMEIHAT UICERTAII SOIEIHAT DISABREE IITH DISAGREE IITH Aaoul AGREE IITH STATEkEkT STATEhEhT STATEMENT STATEMENT UREA I HAS A CHILD, 11,591ugg (or sother substitute): 1) encouraged as to sake sy own decisions. 1 2 2) helped we learn to be independent. 1 2 31 felt she had to fight sy battles for as when 1 had a disagreesent with a teacher or friend.i 2 4) was overprotective of as. 1 2 5) encouraged as to do things for eysalf. 1 2 d) encouraged as to try things ey way. 1 2 7) did not let we do things that other kids sy age were allowed to do. 1 2 l) aosetises disapproved of specific things 1 did, but never gave as the ispression that she dis- liked ee as a person. 1 2 i) enjoyed being with we. 1 2 101 was seasons 1 found very difficult to please. 1 2 111 usually supported as when I wanted to do new and exciting things. 1 2 l2) worried too such that I would hurt eysalf or get sick. 1 2 13) was often rude to se. 1 2 it) rarely did things with as. — 1 2 15) didn’t like to have as around the house. 1 2 it) would often do things for we that I could do for eysalf. 1 2 STRONGLY AGREE IITH STATEHENT 165 (REAIADER: 1:Strongly Disagree, 5=Strongly Agree) 11) let ea handle ey own aoney. 13) could always be depended upon when I really needed her help and trust. 13) did not want I to grow up. 20) tried to sake we feel better when l was unhappy. 21) encouraged as to express ay own opinion. 22) eade we feel that l was a burden to her. 23) gave so the feeling that she liked as as 1 was; she didn't feel she had to wake as over into soseone else. IiIEll 1 us A CHILD. u E11121). (on father substitute): 24) encouraged as to sake ey own decisions. 25) helped we learn to be independent. 26) felt he had to fight ey battles for we when 1 had a disagreeeent with a teacher or friend. 27) was overprotective of as. 23) encouraged as to do things for syself. 23) encouraged we to try things ey way. 30) did not let as do things that othr kids ey age were allowed to do. 31) sosetiees disapproved of specific things 1 did. but never gave as the iapression that he disliked as as a person. 32) enjoyed being with as. 33) was soseone 1 found very difficult to please. 34) usually supported as when I wanted to do new and exciting things. 35) worried too such that 1 would hurt eysalf or get sick. 1 1 1 1 1 1 1 2 3 ikpgneruiiot 13 1" Appendix E (AEIIAOER: 1:Strongly Disagree, 5:3trongly Agree) 35) was often rude to es. 1 2 3 4 5 37) rarely did things with as. 1 2 3 4 5 33) didn’t like to have as around the house. 1 2 3 4 5 33) would often do things for as that I could do for syself. l 2 3 4 5 40) let we handle sy own eoney. '1 2 3 4 5 41) could always be depended upon when I really needed his help and trust. 1 2 3 4 5 42) did not want as to grow up. 1 2 3 4 5 43) tried to sake so feel better when 1 was unhappy. l 2 3 4 5 44) encouraged as to express ey own opinion. 1 2 3 4 5 45) ends we feel 1 was a burden to his. 1 2 3 4 5 43) gave as the feeling that he liked as as 1 was; he didn't feel he had to sake so over into soseone else. 1 2 3 4 5 INEI I IAS A CHILD, QIfl§fl_§fl1Lflflfifl; 47) liked to play with as. 1 2 3 4 5 43) were always criticizing as. 1 2 3 4 5 43) often shared things with as. l 2 3 4 5 mimunmmuonmaMtuudm. i 2 3 4 5 51) were usually friendly to as. 1 2 3 4 5 52) would usually stick up for we. 1 2 3 4 5 53) liked to ask as to go along with thee. l 2 3 4 5 54) wouldn’t listen when I tried to say soaething.1 2 3 4 5 55) were often unfair to es. 1 2 3 4 5 53) would often try to hurt sy feelings. 1 2 3 4 5 167 4 Appendix F MATERIAL SOCIAL SUPPORT IIOEX Please share with us the things you do in your hose as a sother by answering the questions below. Check the answer you feel is true for you. , 1 Generally Soseone to one Generally Soseone Else Else and _ 11211... 299.111. 11111.1. 1. the fixes seals? 2. lho does the grocery shopping? 3. the lets your children know what is right and wrong? 4. the fixes things around the house or apartsent? 5. the does the inside cleaning? 5.1MwmnoufluammdmeMMem apartsent? 7. the pays the bills? 3. Iho takes your child to the Doctor if he/she is sick? 3. the seas to it that your children go to bed? m.mnmuanmemnm Mar notice (if appropriate)? 11. If no car, can you get one in a few hours if needed? Yes No For the resainder of the questionaire, please CIRCLE the answer that is true for you. 12. How eany relatives do you see once a week or sore often? ~ 0123455733100rsore 13. lould you like to see relatives: here often Lass often It’s about right 14. How eany people can you count on in tises of need? 0 1 2 3 4 5 5 7 5 3 10 or sore 15. How eany people would be able to take care of your children for several hours if needed? 0123453733100rsore 15 a.How eany of these people are fros your neighborhood? hone Sosa host All 16. 17. 18. 19. 2°. 21. .168 Appendix F Do you have a boyfriend or husband? Yes No If yes, how happy are you in the way your boyfriend or husband lets you know what he feels or thinks? Yery happy Happy Unhappy Yery unhappy Are there adults, not including your boyfriend or husband, with whoa you have regular talks? Y“ NO If yes, think about the person you talk with the scat. Are you happy with the talks that you have with this person? Yery happy Happy Unhappy Yery Unhappy How often do you attend seetings of the following groups? Don't belong Attend Attend Attend < 1x/so. 1x/so )lx/so. Religious leg. church) Educational (eg. school, parent groups) Social lag. bowling, scouting groups) Political (eg. work for local candidate) Other: Are you a sesber of any cossittee or do you have any other duties in any of your groups? YOS___________ NO 169 Appendix C FEELINGS SCALE Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way guzlng the pg§t_wggk, RARELY or none of the time (less than 1 day) SOME or a little of the time (1-2 days) OCCASIONALLY or a moderate amount of time (3-4 days) MOST OR ALL Of the time (5-7 days) son-so During the past week: 0 1 2 3 1. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. I was bothered by things that usually don’t bother me. I did not feel like eating; my appetite was poor. I felt that I could not shake off the blues even with help from my family or friends. I felt that I was just as good as other people. I had trouble keeping my mind on what I was doing. I felt depressed. I felt that everything I did was an effort. I felt hopeful about the future. I thought my life had been a failure. I felt fearful. My sleep was restless. I was happy. I talked less than usual. I felt lonely. People were unfriendly. I enjoyed life. I had crying spells. I felt sad. I felt that people dislike me. I could not get “going.“ 170 Appendix H DYADIC ADJUSTMENT SCALE Most persons have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner (mate, spouse, friend, etc.) for each item on the following list. Place a chechmark in the appropriate column to indicate your answer. Column 1- Always agree Column 2: Almost always agree Column 3: Occasionally disagree Column 4: Frequently disagree Column 5: Almost always disagree Column 6: Always disagree 1. Handling family finances 2. Matters of recreation 3. Religious matters 4. Demonstrations of affections 5. Friends 6. Sex relations 7. Conventionality (correct or improper behavior) 6. Philosophy of life 9. Ways of dealing with parents or in-laws 10. Aims, goals, and things believed important 11. Amount of time spent together 12. Making major decisions 13. Household tasks 14. Leisure time interests and activities 15. Career decisions 16. 17. 18. 19. 20. 21. 22. 23. 24. 171 Appendix H For questions 16 through 23 use the following definitions: Column 1: All the time Column 2: Most of the time Column 3: More often than not Column 4: Occasionally Column 5: Rarely Column 6: Never How often do you discuss or have you considered divorce, separation, or terminating your relationship? How often do you or your mate leave the house after a fight? In general, how often do you think that things between you and your partner are going well? Do you confide in your mate? Do you ever regret that you married (or lived together)? How often do you and your partner quarrel? How often do you and your mate “get on each others’ nerves?“ Do you kiss your mate? Do you and your mate engage in outside interests together: All Most Some Very few None of them Use the following definitions to describe how often the events in questions 25 through 26 occur between you and your mate. 25. 26. 27. 28. Column 1: Never Column 2: Less than once a month Column 3: Once or twice a month Column 4: Once or twice a week Column 5: Once a day Column 6: More often Have a stimulating exchange of ideas: Laugh together: Calmly discuss something: Work together on a project: ‘172 Appendix H There are some things about which couples sometimes agree and sometimes disagree. Indicate if either item below caused differences of opinions or were problems in your relationship during the past four weeks. (Check yes or no) Yes No 29. Being too tired for sex. 30. Not showing love. 31. The response choices in the next item represent different degrees of happiness in your relationship. The middle point, “happy,“ represents the degree of happiness of most relationships. Please check the response which best describes the degree of happiness, all things considered, of your relationship: Extremely unhappy Fairly unhappy A little unhappy Happy ...—V9 TY happy Extremely happy Perfect 32. Which of the following statements best describes how you feel abut the future of your relationship? ____I want desperately for my relationship to succeed and would go to almost any length to see that it does. ____I want very much for my relationship to succeed and will do all I can to see that it does. ____1 want very much for my relationship to succeed, and will do my fair share to see that it does. ____It would be nice if my relationship succeeded, but I can’t do much more than I am doing now to help it succeed. ____It would be nice if it succeeded, but I refuse to do anymore than I am doing now to keep the relationship going. ____My relationship can never succeed, and there is no more that I can do to keep the relationship going. 173 Appendix 1 STUDY OF MATERNAL BEHAVIOR WITH FIRST-BORN QUESTIONAIRE 82 i. What is your assigned identification No.2 2. When was your baby born? Time Date PLEASE PLACE A CHECKMARK ( ) PRECEEDING THE ONE (1) STATEMENT THAT BEST DESCRIBES YOUR SITUATION IN THE FOLLOWING QUESTIONS. 3. How was your baby born? Yaginally Cesarean 4. What is the sex of your baby? _Halo _____Female 5. What did your baby weigh at birth? Less than 5 pounds _____5 lbs. 1 oz to 6 pounds 6 lbs. 1 oz to 7 pounds _____7 lbs. 1 oz to 6 pounds More than 6 pounds 174 Appendix I 6. When did you first see, touch, and/or hold your baby for more than you recall as a fleeting moment? _____Immediately after birth _____Within the first hour after birth _____After the first hour but before baby was three hours old. When baby was between three a six hours old. When baby was six to twelve hours old. ,_____When baby was twelve to twenty-four hours old. After baby was twenty-four hours old. 7. How are you feeding your baby? Breast _Bott l e 6. How would you describe your labor experience: Pleasant Mainly pleasant Mainly unpleasant Unpleasant Did not experience labor 9. How would you describe the degree of pain you experienced in labor? NO DGTI'I _Little pain Pain, but no worse than expected _Pain worse than expected Severe Pain 175 Appendix I 10. Thinking of your labor experience would you: _____Happily repeat the experience? Repeat the experience? Not repeat the experience? 11. Did you have a coach/partner with you in labor? Yes NO Only part of the time. 12. Did you have a coach/partner with you in the delivery, birthing, or operating room? YGS NO 13. Was this coach partner: _____your spouse? _____your male friend? _your female friend? _____your parent, sister, brother, aunt? someone other than those listed above? 14. Was this coach/partner: _____helpful/supportive? not helpful/supportive? _____a hindrance to you? 15. 16. 17. 176 How long was labor? TYPO No labor Less than 4 hours _____4 to 6 hours ____;9-12 hours _____More than 12 hours of anesthesia? N000 Local _____Pudendal _Epidural __Spinal General Indication for Cesarean (if applicable) Failure to progress Breech Fetal distress _____Bleeding disorder Maternal disease Appendix I 177 Appendix J INPINT TEMPERAHEUT QUESTIONNAIRE (for 4 to 8 month old infants) revised, 1977 . by William 3. Carey, 11.0., and Sean C. licDevitt, Ph.D. 0"- Child's Name: ' Sex Date of Birth: Present Age Rater'e Name: Relationship to child Date of Rating: The purpose of this questionnaire is to determine the general pattern of your infant’s reactions to his/her envircnment. The questionnaire consists of several pages of statements about your infant. Please circle the number indicating the :requency with which you think the statement is true for ycur infant. Although some of the statements seen to be similar, they are not the same and should be rated independently. If any tam cannot be answered or does not apply to your infant, just draw a line through it. If your infant has changed with respect to any of the areas covered. use the response that best describes the recently established pattern. There are no good and bad or right and wrong answers, only descrip- tions of what your infant doesz when you have completed the questionnaire, which will take about 25-30 minutes. you may make any additional comments at the and. Copyright @ 1977 by 17.3.3. and m. McD. 178 Appendix J USING THE FOLLOWING SCALE, PLEASE CIRCLS THE NUMBER THAT INDICATES ROW OFTER THE IRFART'S RECERT AND CURRENT BEHAVIOR HAS BEEN LIKE THAT DESCRIBED BY BACR ITEM. 2. 3e 4. IO. 11. 12. 1’s 14. other child for the first t e. Variable Xarieble Almost R 1 usually usually heirer age y doea3not dogs The infant eats about the same almost amount of solid food (within 1 never on) from day to day. The infant is fussy on waking up almost and going to sleep (frowns, cries) never The infant plays with a toy for under a minute and than looks ::::;I- for another toy or activity. The infant site still while watch- almost ing TV or other nearby activity. never .The infant accepts right away any change in place or position of :::::t feeding or person giving it. The infant accepts nail cutting almost ' without protest. never The infant's hunger cry can be stopped for over a minute by :::::t picking up, pacifier, putting on bib, etc. The infant plays continuously for more than 10 min. at a time with ::::;t a favorite toy. . The infant accepts hie/her bath “1.0.: any time of the day without never resisting it. . The infant takes feedings quietly “1.0.3 with mild expression of likes never and dislikes. The infant indicates discomfort 1 o t (fussos or aquirms)when diaper is 3.3.; soiled with bowel movement. The infant lies quietly in the almost bath. never The infant wants and takes milk almost feedings at about the some times never (within one hourlfroe day to day. The infant is oh (turns away or an”. clings to mother on meotin ~an- never Infquontly 1 2 3 4 5 l 2 3 4 5 l 2 3 4 5 l 2 3 4 5 l 2 3 4 5 l 2 3 4 5 l 2 3 4 5 l 2 3 4 5 l. 2 3 4 5 l 2 3 4 5 l 2 3 4 9 2 3 4 5 Almost alwgys almost’ always almost always almost always almost always almost always almost always almost always - almost always almost always almost always almost always almost always almost always almost always 179 Appendix J Variable Variable Almost usually usually never Rarely does not does Frequently 1 2 3 4 5 lS.The infant continues to fuss during In t diaper change in spite of efforts a 08 l 2 3 4 to distract him/her with game, toy “°V°r or singing. etc. 16.The infant amuses self for hour lm t or more in crib or playpen looking a 0’ l 2 3 4 at mobile. playing with toy). “°V°’ 17.The infant moves about much (kicks. 1m grabs, squirms) during diapering a °3t 1 2 3 4 and dressing. never 18.The infant vigorously resists addi- In t tional food or milk when full (spits a 08 l 2 3 4 out. clamps mouth closed, hats at never spoon, etc.) ° 19.The infant resists changes in feeding schedule (1 hour or more) almost 1 2 3 4 even after two tries. “'V" 20.The infant's bowel movements come almost at different times from day to day we 1 2 3 4 (over one hour difference). no r 21.The infant stops play and watches almost 1 2 3 ‘ when soseone walks by. ' never 22.The infant ignores voices or other almost ordinary sounds when playing with a never 1 2 3 4 favorite toy. ‘ 23.The infant makes happy sounds (coos. almost smiles, laughs) when being diapered never 1 2 3 4 or dressed. 24.The infant accepts new foods right almost 1 2 3 4 away. swallowing them promptly. never 25.The infant watches other children almost ' playing for under a minute and never 1 2 3 4 then looks elsewhere. 26.The infant reacts mildly (Just blinks or startles brieflylto bright almost 1 2 3 4 light such as flash bulb or letting never sunlight in by pulling up shade. 27.The infant is pleasant (smiles laughs) when first arriving in unfamiliar :igggt l 2 3 4 places (friend's house. store). ° 28.The infant gets sleepy at about the almost 2 same time each evening (within § hr.) never 1 3 4 29.The infant'accepts regular procedures inost a (hair brushing, face washing, etc.) never - - 3 4 at any time without protest. Almost alzays almost always almost always almost always almost always almost always . almost always almost always. almost always almost always almost always almost always almost always almost always almost always almost always 180 Variable Variable Almost usually usually never Rarely does not does 1 . 2 4 30.The infant site still (little Alm t squirming)while traveling in car nevg: -seat or stroller. 31.The infant's initial reaction to a almost new baby sitter is rejection 0": (crying.clinging to mother.eto.) n almost 32.Ths infant keeps at it for many minutes when working on a new skill never (rolling overipicking up object,eto.) 33.The infant moves much (squirms. bounces. kicks)while lying awake in crib. 34.The infant objects to being bathed - in a different place or by a diff- erent person even after 2 or 3 tries. 35.The amount of milk the infant takes at feedin is quite unpre- dictable (over oz.difference) from feeding to feeding. 36.?or the first few minutes in a new place or situation (new store or home) the infant is fretful. 37.The infant notices(looks carefully at)changes in the appearance or dress of the mother. 38.The infant reacts strongly to foods, whether positively (smacks lips. laughs squeals) or negatively (cries . 39.The infant is pleasant (coos.smiles etc.)during procedures like hair brushing or face washing. 40.The infant continues to cry in spite of several minutes of soothing. 4l.The infant keeps trying to get a desired toy. which is out of reach,for 2 min. or more. 42.The infant greets a new toy with a loud voice and much expression of (hairdo. unfamiliar clothing) almost never almost never almost never_ almost never almost never almost never almost never almost never almost never almost never feeling(whether positive or negative) 43.The infant plays actively with arents-muoh movement of arms. egs. body. almost never Appendix Frequently 5 l 2 3 4 2 3 4 1 2 3 4 1 2 3 4 l 2 3 4 l 2 3 4 l 2 3 4 1 2 3 4 1 2 3 4 l 2 3 4 l 2 3 4 l 2 3 4 1 2 3 4 l 2 3 4 J 5 U! Almost algays almost always almost always almost always almost always almost always almost always almost always almost always almost always almost always almost always almost always almost always almost always 181 Variable Variable Almost usually usually never Rarely does not does 1 2 4 44.The infant watches another toy 31.0.: when offered even though already never holding one. . 45.Ths infant's initial reaction at 1 t home to approach by strangers is ' °°' acceptance. never 46.The infant wants daytime maps at ‘1 ‘ differing times (over 1 hour diff- ‘°' erence) from day to day. never 47.The infant continues eating solid ‘1' t foods without reacting to differ- °' ences in taste or consistency. never 48.The infant cries when left to almost play alone. never 49.The infant adjusts within 10 min. almost toOnew surroundings (home. store, ' play area). . “° er 50.The infant's daytime naps are about almost the same length from day to day over (under one half hour difference). “ Sl.The infant moves about much during almost feedings (squirms. kicks. grabs). never 52.The infant reacts (stares or startles) to sudden changes in lighting (flash bulbs. turning on light 53.The infant can be soothed by talking almost or games when sleepy. 54.The infant displays much feeling (vigorous laugh or cry) during diapering or dressing. 55.Ths infant lies still when asleep and wakes up in the same place. 56.The infant adjusts easily and sleeps well within 1 or 2 days with changes of time or place. 57.The infant reacts to changes in temperature or type of milk or sub- stitution of juice. 33.The infant watches television for more than 5 minutes at a time. 59.The infant can be calmed for a few minutes by being picked up. played with. T.'.. if fussing about soiled diaper. 60.The infant wants and takes solid food feedings at ahput the same' 009.? ROVOP almost never almost never almost never almost never almost never almost never almost never time (within 1 hour) from day to day. almost Appendix J Almost Trequently always 5 6 almost 1 2 3 4 5 6 always almost 1 2 3 3 5 6 always almost 1 2 3 4 S 6 always almost 1 2 3 3 5 6 always almost 1 2 3 3 5 6 always almost 1 2 3 3 5 6 always almost 1 2 3 4 5 6 always almost 1 2 3 3 5 6 always . almost 2 3 4 5 6 always almost 1 2 3 4 5 6 ~always almost 1 2 3. 4 5 6 always almost 1 2 3 4 5 6 always almost 1 2 3 4 5 6 always almost 1 2 3 4 5 6 always . almost 2 2 3 4 5 6 always 1 2 3 4 5 6 almost always almost 1 2 3 4 5 6 always 182 .Variable Variable Almost , usually usually “'I'r 225.1, doe; not does 61.The infant is content (smiles, once) during interruptions of milk or solid feeding. 62.The infant accepts within a few minutes a change in place of bath or person giving it. 63.The infant cries for less than one minute when given an injection. 64.The infant shows much bodily move- ' ment (kicks. waves arms) when crying. 65.The infant continues to react to a loud noise (hammering, barking dog, etc.) heard several times in the spme day. 66.The infant's initial reaction is withdrawal (turns head, spits out) when consistency. flavor or temp- erature of solid foods is changed. 67.The infant's time of waking in the morning varies greatly (by 1 hour or more) from day to day. 68.The infant continues to reject dis- liked food or medicine in s its of parents' efforts to distrac with games or tricks. 69.The infant reacts even to a gentle touch (startle. wriggle. laugh. cry). 70.?he infant reacts strongly to strangers: laughing or crying. 71.The infant actively grasps or touches objects within his/her reach (hair. spoon. glasses, etc.). 72.The infant will take any food offered without seeming to notice the difference. 73.The infant's period of greatest physical activity comes at same time of day. 74.The infant appears bothered (cries, equirms) when first put down in a different sleeping place. 75.The infant reacts mildly to meeting familiar people (quiet smiles or no response). Breguently almost 1 2 3 never almost never almost never almost never almost never almost never almost never almost never almost never ' almost “CV. 1' almost never almost never almost never almost never almost never Appendix J ’J Almost alzays 5 6 5 6 5 6 5 6 5 6 5 6 5 6 5 6 5 6 5 6 5 6 5 6 5 6 5 6 55 almost always almost always almost always almost . lways almost always almost always almost always almost always almost always almost always almost always almost always almost always almost always almost always 183 Appendix J Variable Variable Almost usually usually neIer .Ragely doe; not dods. Frequently 4 5 76.The infant is fussy or moody through- almost 1 2 3 out a cold or an intestinal virus. never 77.The infant wants an extra feeding at a different time each day (over ‘1'°'t 1 2 3 one hour difference). never 78.The infant is still wary or fright- almost 1 2 3 ened of strangers after 15 minutes. never 79.The infant lies still and moves almost 1 2 3 'little while playing with toys. never 80.The infant can be istraoted from fussing or squinning during a pro- cedure (nail cutting, hair brushing. etc.) by a game, singing, TV, etc. 81.The infant remains pleasant or calm with minor injuries (bumps. pinches). 82.The infant's initial reaction to seeing doctor is acceptance (smiles. ooos). 83.The infant reacts to a disliked food even if it is mixed with a. preferred one. 84.The infant plays quietly and calmly with toys (little vocalization or other noise). 55.The infantis fussy period occurs a ' at about the same time of day (morning. a afternoon or evening.) ‘ 86.2he infant lies still during pro- cedures like hair brushing or nail B7.The infant stops sucking and looks when he/she hears an unusual noise (telephone. door ball) when drinking milk. 88. The infant pays attention to game almost never 1 2 3 almost 1 2 3 never almost never 1 2 3 almost never .d N u almost 1 2 3 never lmost ever ... N U almost 1 2 3 never almost 1 2 3 never almost 1 2 3 with parent: for only a minute or so. neyer 89.The infant is calm in the bath. Like or dislike is mildly expressed :::::t 1 2 3 (smiles or frowns). 90.The infant requires introduction of a new food on 3 or more occasions before he/she will accept (swallow)it. almost never 1 2 3 221.3253 55 56 56 56 56 5'6 56 56 56 55 55 55 55 56 55 almost always almost always almost always almost always almost always Q almost always almost always almost always almost always almost always almost always almost always almost always almost always almost always 184 Variable Variable Almost usually usually never Rarely does not does 1 2 3 4 9l.The infant's first reaction to any new procedure (first haircut, new medicine. etc.) is objection. 92.The infant acts the same when the diaper is wet as when it is dry. (no reaction) 93.The infant is fussy or cries during the physical examination by the doctor. 94.The infant accepts changes in solid food feedings (type. amount, timing) within 1 or 2 tries. 95.The infant moves much and for several minutes or more when playing by self (kicking. waving arms and bouncing). dailllenll_223212l§. Appendix J Almost ‘Prequently always 5 6 almost never 1 2 3 4 5 almost 1 2 3 4 5 never almost 1 2 3 4 5 never almost 1 2 3 4 5 never almost never 2 3 3 5 almost always almost always almost always almost always almost always ““Nm " 'C 185 Appendix K W" U WW!“ semen-am . “wars-Ow worms» ”......” 0. q same—— "L "was .. uni-0“” '0'“ O. D.“ mm mm was mans em. . mse_ FEED'NG SCALE m to o. M e m e. .- 0 www.mewomuafl,‘ I wwmumeusmemm-ocm e warms-assessin- “or ulnar-swan mascara-evens:- omen-Mmmoevvmwmm em. .mematsfiefl-Ntnsmtflfl flee-amtuu-PmMu-snu QM M 0" mum PM“ stun-«“99“ ”’fl'fifi MO WWI'I'~'~"7N IF” noes flour-t4 or wen—en“ v M M. I 0e Gees-O ans “8 9 "m sense" ”a m 4040'! ens mes nan-'9“ use. "can. Menu-In «at», its cameo. Novo- u-v-e was he so m0. 0"! venue-n mm s! H Mm as was” "mm M Dawns-s Mm 04 a". N... «as. "4104!". t antenna-ovum ewes Neal-dos H's". mumvwven-eem ”'0'.“ W o“ Chums. nave "hams" "I 'W‘NWI'OVW'WNMMF MN “mammary-emu” “newemv'ooemeeuassun-e 0's own-mwu'euoeeNo-aeteo-emo tom-s “wanes-W WM WOM‘ more” e “lawn-mnnu-WMO' meoqesnesamuo-Ose v” e ewmmmmvmmwom es "ummm-mve-equem Q MNWCMW.WNNOW 0 mmmvwam 7“; r=wvzvs wee-emu. A A mumfinwuflw-mfl ”OHM ' “WWW-W's”. Us!“ m emu‘vmwum—eam ““33“.” "WONICI - .mmwmewmww-m's ”0"..-4 I memmwmemn-«m—mm mow-nevus 'OQ'ROO .‘O'HIO “anaemic-menu’s“ ‘Q I ..a‘...~m~*~~.~_ I. ”NON-MWUMMH “NMCIWNWNM I :mMMMflsM.eqm-sflmnn~ I 0*! N'nso-assies-sa-mm'nsomssm mast-swans. I asset-ems “H'MNWU‘. "WNW“ ’WWONWWMM W'WOWNI'"U'MWNDM '0’”. M... “first".fl moms-mom'- 9‘. Mn. 9' «New 4' '4'". I «moose-e9 covenants sheen anemones-a 19020000" “NONI Q seeps! ones-00 us. «0 buss ”NMOUNO sense-mes wens v-e «es-ea 0' Wows as! use! meets! "meanest-Ins egovgnsoe-ousn mmMs-nlflms vim-one ma; . as v wee mee- , iii-M sec-m- sever-e g sees-e means—neon" eaves-Isl. vsva I." I'm as wmmmummyvnmm nus! eenuoeos cw mesh-s mam-en" a mmunmwmmwaawmm ewe—snow” C 0"" “Ma. uncommon-seesaw m!” 'ONM“. 2"" ‘ W'OMIMNWHNH“U"' HW'. N'H'ION as «mm eIs ems-set: me «use». sum I .nm-l wows-ts so! museums-- swan-anne- Imm‘ e. M w . I". wnmnmummmmmus ”a as oumene-anom ism-mmwmwe move-covenant“ MM I 'WMCW'MWCM m '0'; '0 O was ere-em. 186 Appendix K e Wood m. ”mamas”. I. D‘s-nave Ink-mael- val-um . u. Q mmsfimv—um—a m “mm-mm . C. ”WHAT “" I“! “..-—....fi vwwfin. Q mum-mmmune—g . ”uncommon-manuals. mum's-cum" m ”muss-lemmas. mmnsaemummomm "Immanuel-lemma“ gum-ammonmmmm mummmmmmvmmsm-ws mavens mama-seam M TOW . ”WNMIMme'M mmwmaummmosssmmtsesvm “VIM. C "IL”OIN "7" ”m1.“ ”2“" N CHI“. '0 use! "WM'NMWV “'2“. . ”MTOWMM fl mmummemvwe mm- " warts-smallness” "WWW II mmammmvmmme “ammo-mum ~ “mammalian-owners! " “Wu-1'." ""' N meson-amasvmmu-nsmm “WWOM ”HQ mam-mam. NURSING CHILD ASSESSMENT SATELLITE TRAINING WIVERSITY OF WASHINGTON SCHOOL OF NURSING. WJ-IO SEATTLE. WASHINGTON ”I95 USA (208) 543-8520 187 Appendix L STUDY OF MATERNAL BEHAVIOR WITH FIRST-BORN FCE 8999 SCHEDULE OF OBSERVATIONS AND MEASUREMENT (Primary Sample=x, Postnatal-only sample=0) MEASUREMENT 9mm ESE! §D§§l MIME); Dependent insignia Maternal Behavior Fetal Attachment Scale Barnard Feeding Scale Caldwell HOME Barnard Teaching Scale independent Enriching Mother/Father/Peer Scale Luster’s Developmental Hx Method of Delivery 22mm Questionaire 41 Questionaire s2 Center for Epidemiologic Studies Depression Scale Edinburgh Postnatal Depression Scale Maternal Social Support Index, Dyadic Adjustment Scale Infant Temperament Questionaire TIME 1 TIME 2 TIME 3 X 0 X 0 X 0 X X S O X S O X S O X S 0 X 0 X 0 X S 0 X 0 X S O X X S O X S O X S O X S 0 X X S O X X S O X S O LIST OF REFERENCES LIST OF REFERENCES Bateson, Patrick. (1983) in Oliveria, A. e Zsppells M. The Ihe Behavior 9: Hehsn Infante, Plenum Press. New York. pp. 57-70. Barnard, Kathryn. (1978) Nursing Chile Assessmehg Eeeding Scale, University of Washington, Seattle, Na. Barnard, Kathryn. (1987) Presentation ”Introduction to the Strategy of Assessment of Parent-Child Interaction: the NCAST Scales." 5th Biennial National Training Institute sponsored by National Center for Clinical Infant Programs held in Washington D.C. Belsky, Joy. (1981) “Early Human Experience: A Family Perspective.” Developmental Psychology, 17,(i), 3-23. Belsky, Jay. (1984) ”The Determinants of Parenting, A Process Model.“ Child Qeyelephehee 55, 83-96. Belsky, Jay, Lerner, R. M. & Spanier, G. B. (1984) The thld in Lhe family, Addison-Wesley Publishing Co. Reading, Mass. Boger, Robert P., a Smith, A. B. (1986) “Developing Parental Skills: An Holistic, Longitudinal Process.“ Infan; hehtal health Jogthel, Vol 7, 42, Summer, pp. 103-109. Bowlby, John. (1982) Ahhschment, 2nd Ed. Basic Books, Inc. New York. Bronfonbrenner, Urie. (1979) 1h: Ecolegy e: humeh Deyelenmehhe Harvard Univ. Press. Cambridge, Mass. Bronfonbrenner, U. a Mshoney M. (Eds) (1975) Influencee eh hymen Qeveloehent. 2nd. Ed. Dryden Press. pp. 168-189. Campbell, Donald T. a Stanley, J. C. (1963) gheerihenta! ehg Queei- Exeerjmehtal Qesigne fie; Reeesreh, Rand McNally College Publishing Co. Chicago. Carey, William B. (1982). Validity of Parental Assessments of Development a Behavior. American Jeurnal e: Dieeasee 1h ghjlghehe 136, 2, 97-99. Carey, N. B.& McDevitt, 8.0. (1978) Revision of the Infant Temperament Questionaire. Eegjatrics. Vol. 61, 35, 735-738. 188 189 Cochran, Monerieff M. a Brassard, Jane A. (1979) Child Development and Personal Social Networks. ghild Development, 50, 601-616. Cox, B. E. a Smith, E.c. (1982) The Mother’s Self-Esteem after a Cesarean Delivery. MON. 7, 309-314. Cranley, M.S. a Hedahl, K.J., a Pegg, S.H. (1983) Women’s Perceptions of Vaginal and Cesarean Deliveries. hetelhg Reeeareh, 32, 1, 10-15. Cranley, Mecca S. (1981) Roots of Attachment: The Relationship of Parents with their Newborn in Lederman, R. a Raff, B. Perinatal Parental Behavior. Nursing Research and Implications for Newborn Health: Qriginal Article Series XVII(6), pp. 59-83. March of Dimes Birth Defects Foundation, Alan R. Liss, Inc. New York. Creager, Ellen (i989) Deliverance. Detroit free Eheeet Section c, Wed. Dec. 6, p. 1. Crnic, Keith A., Greenberg, M.T., Ragozin, A.S., Robinson, M. M., a Basham, R.B. (1983) Effects of Stress and Social Support on Mothers of Premature and Full-Term Infants. Chjlg nexeTeemehtt 54, 209-217. Crockenberg, Susan B. (1981) Infant Irritability, Mother Responsiveness, and Social Support Influences on the Security of Infant-Mother Attachment. ghilg Dexeleemehtt 52, 857-865. Davis, Madeleine a Wallbridge, Davie (1981). BQHDQQL! ehg Seeeet Brunner/Mazel Pub., New York. ' Donovan Bonnie. (1986) The gesecean Birth Emeerienee, Beacon Press. Boston, Massachusetts. Epstein, Seymour. (1988) Personal Correspondence addressed to Thomas Luster, Ph.D. MSU. Fitzgerald, Hiram E. ,Strommen, E. A, McKinney, J. P. (1982) Qeveloementel Psxehelo 092, The Ihf eht eth oemg eh 119. Rev. Ed. The Dorsey Press, Homewood, Ill. Frommer, Eva a O’Shea, G. (1973) Antenatal Identification of Women Liable to Have Problems in Managing Their Infants. lfihjtjeh AQMLDAl e: Bezehlettxe Vol. 123, pp. 149-160. Garbarino, James a Sherman, D. (1980) High-Risk Neighborhoods and High-Risk Families: The Human Ecology of Child Maltreatment. Chile Qeveloement, 51, 186-198. Genevie, Louis a Margolies, Eva. (1987) The Metherheed Beeert, hem hemeh feel About gelhg Mothers. MacMillan Publishing Co. New York. Goth-Owens, T.L., Stollak, G.E., Messe, L.A., Peshkess, 1., a Watts, P. (1982) Marital Satisfaction, Parenting Satisfaction, and Parenting Behavior in Early Infancy. Tnfent Mental Heelth Jeernal, 3, 3. 190 Harlow, Harry F. (1971) Learning te Love. Albion Publishing Co. San Francisco, Ca. 1 Hammond, Mary, Bee, H., Barnard, K., Eyres, S. (1983) Child Health Asseesment, Pert 1!; Eellow-Ue et Ceeeng Grade, University of Washington, Seattle, HA. ' Helfer, Ray, a Kempe, c.H. (1976) Child Ahuse eng Neglect, The Eemllx ene Cemmenltxt Ballinger Publishing Co. Cambridge, Massachusetts. Hetherington, E. Mavis a Camera, Kathleen A. (1984) Families in Transition: The Processes of Dissolution and Reconstitution. Chapter 11 in Parke, Ross 0. The Family, University of Chicago Press. Chicago, Ill. Hill, R. (1949) Femllles under Stress. New York, Harper a Row. Hollingshead, August B. (1975) Four Facten Index e: Seelel Ctetnet Yale University, New Haven, Connecticut. Hunter, Rosemary S. a Kilstrom, N. (1979) Breaking the Cycle in Abusive Families. Amerjcan Ceernal e: Psychiatry, 136, 10, 1320- 1322. . I Klaus, Marshall H. a Kennell, John H: (1982) Eenent-Infant Cenelngt 2nd Ed. C. V. Mosby Co. St. Louis, Mo. Klaus, Marshall H. a Robertson, M.0. (1982) Bjnth, 1ntecaetjon. eng Atteehment, Johnson a Johnson. 35-61. Klein, M. a Stern, L. (1971) Low Birth Weight and the Battered Child Syndrome. Amenican Connnal e: Ciseaeee e: Chjlgnen, 122, 15-18. Kruk, Sue a Molkind, Stephen (1982) in Madge, N. EemTTTee et Bleht Heinemann Educational Pur. Heinemann Educational Pur. London, Eng. Lamb, Michael E. (1982) Early Contact and Maternal-Infant Bonding: One Decade Later. Peglatniee, 70, (5), 763-768. Leach, L. a Sproule, V. (1984) Meeting the Challenge of Cesarean Births. JOSH hureing, 191-195. Lipson, J.G. a Tilden, V.P. (1980) Psychological Integration of the Cesarean Birth Experience. Amenteen Journel QT Cntheeeyehletnyt 50, (4), 598-609. Magid, Kenneth a McKelvey, Carole. (1987) high high Children hithent A Coneeience, Bantam Books. Main, Mary. (1987) Presentation “Influencing and Interrupting Cycles of Maladaptation: Insights from Attachment and Objects Relations Theory and Research.“ 5th Biennial National Training Institute sponsored by National Center for Clinical Infant Programs in Washington, D.C. 191 Marieskind, Helen I. (1979) en Evalgetion et Cesarean Section in the United States. Final Report to the 0.3. Dept. Of HEN, Office of the Asst. Sec. for Planning and Evaluation/Health. June. McCubbin, H. I, a Figley, C.R. (1983) Stress end the FemilyI Vol. I, Brunner/Mazel. New York. McCubbin, H.I., Sussman, M.B., a Patterson, J.M. (1983). Seeiel Strees end the Family; Advances end Cevelonmente in EemiTy Streee Theory end Reseerch. Haworth Press. New York. McCubbin, H.I., a Thompson, A. I. (1987) Family Asseeement Inventories Ter Researeh end Erectiee, University of Wisconsin Press. Madison, MI. Meier, Gilbert N. 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