”MW. 6 . a _ B {.m \Fc fl. 5315 n. .s1 . 3. 3:; ABSTRACT EARLY PREDICTION OF PARENTING POTENTIAL By Ann Leard Wilson The significance of predictors of Parenting Potential, defined as mother-infant interaction that is functional in facili- tating positive child growth and development, was studied with 40 primiparous mothers and their newborns. Maternal attachment is considered as central to the quality of mother-infant interaction and is assessed in this study by measures of maternal responsive- ness. The process of seeking permission and cooperation from the medical community to conduct this study was a major part of the research project. A detailed description is provided of the process followed for securing hospital, physician, and patient permission and cooperation. An interactional approach was used to examine the nature of the mother-infant relationship. Both the mother and the infant were considered to be active participants in the parenting dyad. The variables used as predictors of Parenting Potential included back- ground information gathered from questionnaires administered during the mothers' last trimester of pregnancy and observational Ann Leard Wilson assessments of maternal and neonatal behavior made immediately following delivery and during the period of postpartum hospitaliza- tion. A The background data gathered during the last trimester of pregnancy included information about demographic factors, stress encountered during pregnancy, planning and management of pregnancy and hospital care, and personal resources for childrearing. The total scores from the Survey on Bringing Up Children were used as measures of concern regarding the latter variable. A delivery room observation scale was developed to assess maternal responsiveness during the first ten minutes following birth. Maternal responsive- ness during a feeding was also assessed approximately three days following delivery by a feeding observation scale. The Brazelton Neonatal Behavioral Assessment Scale was administered to assess each newborn's behavior. The significance of the variables used as predictors of Parenting Potential was evaluated by measures of maternal responsive- ness assessed on a repeated feeding observation made four weeks following delivery. Also at this time mother-infant adjustment was assessed by a postpartum research inventory, the Neonatal Perception Inventory and an openended interview. A stepwise multiple regression statistical method was employed as the major strategy of data analysis. The results indi- cate that maternal responsiveness in the delivery room significantly predicts maternal responsiveness during a hospital feeding Ann Leard Wilson (R2 = .22 p < .Ol). Age as a continuous variable and the choice to have a rooming-in arrangement in the hospital are both significant predictors of maternal responsiveness as it is assessed four weeks following delivery. Together, these two variables account for .51 of the variance in this dependent variable (p_< .Ol). Age, the most significant predictor, is discussed in terms of emotional and social stability. The greater predictive signifi- cance of age when combined with rooming-in is discussed as a function of the sensitive period hypothesis which suggests that maternal attachment is related to the amount of contact time a mother and newborn have together during the first hours and days following birth. The research findings which indicate an attenuation during the first postpartum month of the predictive significance of the responsiveness in the mother's behavior observed in the hospital can be explained by the separation which the mothers and infants encountered at birth. This suggestion is supported by the finding that mothers assessed as most responsive four weeks following birth were older and chose the hospital option of rooming-in. These mothers may have a predisposition for seeking the optimal contact they had with their newborns during their first postpartum days, and this additional contact time may affect the degree of their respon- siveness four weeks following delivery. It is suggested that further research with a large random sample is required to establish the predictive significance and the Ann Leard Wilson feasibility of the routine use of a delivery room observation scale. An investigation of the meaning of prenatal assessments of a mother's predisposition for contact with her newborn would also provide infor- mation useful to the early assessment of Parenting Potential. For the delivery of comprehensive health care, the research findings indicate that the use of the broad perspective provided by the concept of Parenting Potential is useful for assessing early indicators of the quality of the parenting relationship. A delivery room observation scale could provide a means of making assessments of early mother-infant interaction which can be used by hospital staff to provide more sensitive individualized care for their patients. Those who care for new mothers are encouraged to consider the support they give to their patients as enhancing the potential of future parenting relationships. EARLY PREDICTION OF PARENTING POTENTIAL By Ann Leard Wilson A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Family Ecology 1975 TO MY FAMILY ii ACKNOWLEDGMENTS I am tempted to only acknowledge "motherhood without which this study would have been impossible." Obviously this is true, but far more than the process of mothers birthing and parenting babies was entailed in the development of this study. It has been my contact with the many people who generously shared their time and efforts which has made this dissertation a personally enriching experience. I want to express my most sincere gratitude to the members of my committee who have guided me through my graduate program. Their special interest in this dissertation added to my own enthusi- asm for undertaking some of the more strenuous demands of such a study. Dr. Robert Boger, the chairman of my program committee, has shared my excitement in developing through my graduate work an integrative focus on family ecology. He has been of much assistance to me as I have attempted to coordinate my interests with an academic program. I greatly appreciate the help Dr. Ray Helfer, the chairman of my dissertation committee, has given me as I have struggled to develop a meaningful investigation of an area which I h0ped would contribute to the development of preventative programs for families with young children. His wise suggestions and novel ideas have added much to the unique quality of this study. Dr. Helfer has also intro- duced me to pe0ple and experiences which have given special meaning to my graduate work. I feel very fortunate in having had this oppor- tunity to learn from him. Dr. Linda Nelson and Dr. Lucy Ferguson have provided thought- ful suggestions which helped form the positive focus of the research project. Their perceptive critiques and editorial assistance have strengthened this dissertation. I am grateful for their contribu- tions to this work. The College of Human Ecology has given me the latitude to explore my interests in the area of infancy and early parent-child relations. The breadth of exposure to university faculty and commu- nity programs that I have enjoyed has provided a rich opportunity for learning and has stimulated the formulation and initiation of this research project. The faculty members in the Department of Human Development, College of Human Medicine, have been most helpful in the preliminary work and logistical planning essential for this dissertation. My special thanks go to Dr. Thomas Helmrath who assisted me throughout much of this planning and introduced me to many of the physicians and nurses whose cooperation was necessary for conducting the study. I also appreciate Dr. David Kallen's support throughout the develop- ment of my emerging interest in this area of research. Drs. Sharp, Johnson, Sheets, and Hazen and Ann Gillette, R.N. of the Model Cities Health Clinic permitted me to contact their iv patients as potential participants in this research. My thanks extend to them. I also want to thank the administration and nursing staff at E. W. Sparrow Hospital. The nurses' kind assistance truly helped make the hospital phase of the data collection a possibility. Mary Andrews, my statistical consultant, receives my warmest appreciation for her patience and continual support throughout the duration of this study. She has most capably offered suggestions about the study methodology and data analysis. The time she spent with the computer programming and interpretation of the results has been of immense assistance. I want to express my gratitude to the staff and to my fellow interns at the Michigan State University Family Life Referral Clinic where, over this past year, I have had the privilege of learning and growing as a family therapist. The clinic's tolerance of my erratic schedule for the duration of the data collection and my dominance of office space during the last days of writing has been greatly appre- ciated. Megan Ewald, who was born one year ago, has added a special meaning to this study. Her birth and development over this past year has given me a realistic view of how the warmth of human attachments nourishes the wonder of human growth. I thank Megan's parents for their friendship over my years as a graduate student. In the end it was the 40 mothers who permitted me to observe them and their babies at one of the most exhilarating moments of their lives together who did make this study a possibility. For me nothing could have been more fascinating to observe than the joyous moments of these families at the time the miracle of conception became a reality with the birth of a baby. I feel humble in having had this opportunity to study a process so deep a part of each of our lives. vi TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES LIST OF APPENDICES Chapter I. INTRODUCTION Purpose of the Study Conceptual Framework Assumptions Definitions . . Importance of the Study II. REVIEW OF THE LITERATURS . Attachment Behavior . . Animal Attachment Studies Human Attachment Studies Parenting Potential . Maternal Contribution to Parenting Risk Organic Indicators of Parenting Risk. . Psychosocial Indicators of Parenting Risk The Infant's Contribution to Parenting Risk Organic and Psychosocial Indicators of Parenting Risk Summary and Conclusions III. METHODOLOGY Research Design Measurement . Hypotheses and Methodological Questions Hypotheses . . Methodological Questions Instruments Instruments Administered at Time 1 Survey on Bringing Up Children . vii Page ix xii xiii Chapter Social Readjustment Rating Scale Instruments Administered at Time 2 Delivery Room Observation Scale Brazelton Neonatal Assessment Scale Feeding Observation Scale . . Instruments Administered at Time 3 . . Neonatal Perception and Bother Inventory Schaefer Postpartum Research Inventory . . Interview Assessment of Mother-Infant Adapta- tion . . Feeding Observation Scale Procedures for Securing Permission and Cooperation. for Data Collection . . . Procurement of Hospital Permission and Cooperation . . . Physician and Practice Contact Patient Contact . Procedures for Data Collection Sample Description . Background Information Age . . Marital Status and Length .of Marriage Ethnic Background . . . Income . Education . Pregnancy Planning, Hospital Care Arrangements, and Prenatal Education . . . . . . Medical Information Labor and Delivery . Newborn Characteristics Method of Feeding Data Analysis . . IV. RESULTS Research Findings V. DISCUSSION Contributions of the Study Limitations of the Study Suggestions for Future Research. . Implications of Research Findings for the Delivery of Health Care . . . . . . . . . VI. SUMMARY AND CONCLUSIONS APPENDICES . REFERENCES . viii 152 156 162 216 Table 10. 11. 12. 13. LIST OF TABLES Measurement Description . Sample Recruitment Mean and Standard Deviation of Age of Sample and Patients Refusing Study Participation . . Percent and Frequency Distribution of Sample by Marital Status and Length of Marriage Percent and Frequency Distribution of Sample by Ethnic Background . . . . . . . Percent and Frequency Distribution of Sample by Income Level . . . . . . . . . Percent and Frequency Distribution of Sample by Level of Education . . . . . . . . . . . Percent and Frequency Distribution Sample by Pregnancy Management Variables . Sample Labor and Delivery Information Sample Newborn Characteristics Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness in the Delivery Room from Background Variables . . . Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness in the Delivery Room from Background Variables and Labor and Delivery Variables . . . . . Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness during a Hospital Feeding from Background Variables . . . . ix Page 61 95 97 98 99 100 101 102 103 104 109 111 112 Table Page l4. Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness during a Hospital Feeding from Background Variables, Maternal Respon- siveness in the Delivery Room, and Neonatal Char- acteristics . . . . . . . . . . . . . . ll3 l5. Results of a Stepwise Multiple Regression Analysis Predicting Newborn Interactive Processes from Demo- graphic and Stress Variables . . . . . . . . . ll5 l6. Results of a Stepwise Multiple Regression Analysis Predicting Newborn Organizational Processes of State Control from Demographic and Stress Variables . . . ll6 l7. Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness during a Feeding Four Weeks Following Delivery from Neonatal Behavioral and Physical Characteristics . . . . . . . . . ll6 l8. Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness during a Feeding Four Weeks Following Delivery from Neonatal Behavioral and Physical Characteristics and Maternal Responsive- ness in the Delivery Room and during a Hospital Feeding . . . . . . . . . . . . . . . . ll8 l9. Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness during a Feeding Four Weeks Following Delivery from Background Variables . . . . . . . . . . . . . . . 119 20. Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness Four Weeks Follow- ing Delivery from Background Variables, Neonatal Characteristics, and Maternal Responsiveness in the Delivery Room and during a Hospital Feeding . . . . lZl 2l. Results of an Analysis of Variance of Maternal Responsiveness during a Feeding Four Weeks Following Delivery by Age . . . . . . . . . . . . . l22 22. Results of an Analysis of Variance of Maternal Respon- siveness during a Feeding Four Weeks Following Delivery by Choice of Rooming-in . . . . . . . 122 Table Page 23. Results of a Pearson Product Moment Correlation Analysis of Relationships between Background Varia- bles, Neonatal Characteristics, and Maternal Respon- siveness in the Delivery Room and during a Hospital Feeding and Mother-Infant Adjustment Assessed Four Weeks Following Delivery . . . . . . . . . . l24 24. Results of an Analysis of Variance of Maternal Responsiveness during a Hospital Feeding by Feeding Method . . . . . . . . . . . . . . . . l25 25. Results of an Analysis of Variance of Maternal Responsiveness during a Feeding Four Weeks Following Delivery of Feeding Method . . . . . . . . . l25 26. Results of Tests of the Internal Consistency Relia- bility of Measures of Maternal Responsiveness . . . l26 27. Results of a Pearson Product Moment Correlational Analysis of the Relationship Between Two Measures of Maternal Behavior during a Feeding . . . . . . . l27 xi LIST OF FIGURES Figure 1. Conceptual Schema of Research Design . 2. Time Frame of Data Collection 3. Flow Chart of Procedures Followed to Secure Necessary Permission and Cooperation for Data Collection xii Page 59 82 Appendix A. I'T'IUOW LIST OF APPENDICES Source List of Research Instruments . Supplemental Background Questions Delivery Room Observation Scale Interview Assessment of Mother-Infant Adjustment Explanation of Brazelton Behavioral Assessment Scale Distributed to Hospital Staff on Nursery Service . Initial Patient Contact Cards . Informed Consent Form Instructions to Subjects on How to Contact Investigator . . . . . . . Letter to Potential Subjects Concerning Research Project Matrix of the Pearson Product Moment Correlation Coefficients of the Ordinal Variables Employed in the Data Analysis . . . . . . . . . Pearson Product Moment Correlation Coefficients of Responses to Interview Questions and Background Variables, Neonatal Characteristics, Maternal Responsiveness in the Delivery Room and During Feedings, and Mother-Infant Adjustment Assessed Four Weeks Following Delivery. . . Pearson Product Moment Correlation Coefficients of Maternal Responsiveness During a Feeding Four Weeks Following Delivery and Measures of Mother-Infant Adjustment Four Weeks Following Delivery xiii Page 163 165 l67 170 172 179 181 183 185 187 212 214 CHAPTER I INTRODUCTION The rich potential of human life becomes a startling reality with the birth of a newborn infant. At birth the intricate process of human growth has already begun and will continue in a context which will affect the child's emerging development. From conception human growth occurs in an interpersonal context which provides for the emerging relationship between a mother and child. How the relatedness of these two individuals begins to be expressed in behavior will nurture the process of growth and the realization of the child's human potential. This study examines how mothers and infants begin to inter- act with one another. Their style of interaction contributes to the-quality of a mother's bonds of emotional attachment with her newborn which are intrinsic to her capacity to give nurturant care. Responsive behavior has been used as an important indicator of a mother's attachment to her newborn (Klaus & Kennell, 1970b), and an infant's visual exploratory behavior, important to developmental processes has been shown to be influenced by the degree of maternal responsiveness (Rubenstein, 1967). Maternal responsiveness is thus used in this study as a measure of attachment behavior, and mother- infant interaction is considered as a reciprocal process in the emergence of human bonding. Parenting Potential is the term employed in this study to identify parent-child interaction that is functional in facilitating positive child growth and devlopment. Maternal attachment, consid- ered to be central to the parenting relationship, represents a mother's capacity for caregiving and can be used to predict the Parenting Potential of the relationship. Behavior is a function of the context in which it is observed and reflects life experience and the environmental situation. Making this assumption about behavior necessitates that these factors be accounted for in this study. Information about the mother's back- ground and the p1anning and management of the pregnancy and hospital care is used to understand better the meaning of the responsive behavior observed. Newborn behavioral individuality is also assessed and considered as affecting the nature of the mother's responsiveness which reflects the degree of her maternal attachment.. The comprehensive research question to be explored in this study is: Can Parenting Potential, identified by the variance in scores of maternal responsiveness and assessments of mother-infant adjustment made four weeks following delivery, be predicted from background information and maternal and neonatal behavioral observations made at the time of delivery and postpartum hospitalization? Early maternal and neonatal behaviors may provide the first clues about future parenting style and the potential for the parent- ing relationship. When initial indicators of bonding are weak and an infant's behavior is not reinforcing to positive maternal behaviors, there may be a risk involved in the parenting relationship. The use of a broad focus to determine potential parenting problems enables preventive intervention prior to the development of parent-child relationships which may not facilitate the process of positive child growth and development. Parenting Potential can be evaluated using a variety of factors as indicators of the quality of the evolving relationship. The focus on early attachment behavior, central in this study, was chosen because of its accessibility to observational evaluation. The overt demonstration of the formation of emotional bonds can be readily observed under the fairly standard procedures followed in giving routine care to obstetric patients. With a wholistic perspective on the process of birth, the interpersonal context of initial maternal behavior can be examined. Modern medical practices which protect the lives of mothers and newborns have limited the liberty with which mothers may express responsive behavior toward their newborn infants. Close observations of early maternal behavior may provide insight into the importance of maternal responsiveness and how this interaction can be facili- tated in a setting safe for both mothers and their newborns. With this perspective on the process of birth, the early care a mother and newborn receive may be understood to play a role in enhancing the potential of a parenting relationship. Early maternal behavior may have important implications for future parent-child relations and the child's total development. Purpose of the Study The purpose of this study is to evaluate the use of assess- ments as predictors of the potential quality of a relationship between a parent and child. The predictive significance of these assessments will be established through an evaluation of mother- infant interaction four weeks following delivery. The process used to obtain the cooperation of both the community physicians and the hospital staff instrumental in con- ducting this study is an additional dimension of the research. Although gaining the support of essential institutions and indi- viduals is a critical part of all research with human subjects, involvement in the health care system is especially difficult for a nonmedical professional. How this cooperation was sought and secured is an important aspect of this study. Explanation of the process of securing permission and cooperation for conducting this study may be useful in opening doors of obstetric and newborn services of hospitals for future research studies and intervention programs. Provisions for educational input to the hospital staff and community physicians are included as part of the preliminary procedures essential for conducting this kind of study. This is an important facet of the study and one that will attempt to increase awareness of the unique role these professionals can play in supporting the development of positive mother-infant relationships. An effort will be made to help medi- cal professionals understand how the emotional climate of the care they provide to patients can affect the way a mother will establish an on-going relationship with her newborn. In summary, the purpose of the study is twoJfold. Emphasis is placed upon both the actual analysis of the data collected and the process of conducting the research. The design of the research represents a new direction in examining the parent-child relation- ship and evaluates a means of making early assessments of the qual- ity of early mother-infant interaction with a broad perspective on the parenting relationship. The focus of attention is upon more than the identification of children who are likely to suffer from severe developmental disorders. The study attempts to investigate both empirically and procedurally the feasibility of predicting from observations of early maternal and neonatal behavior the potential of a parenting relationship. Measures of maternal responsiveness are used in assessing maternal attachment which is considered to be central in the emerging parenting relationship. Eventually such measures may be useful in designing programs which can provide supportive services for families with young children. Conceptual Framework An interactional approach to the study of the mother-infant relationship is utilized in this research. This approach conceptu- alizes both mothers and infants as active individuals, each con- tributing to the nature of their on-going relationship. Using this approach, the mothers' and the infants' behavior is viewed as representing a dynamic dyadic system in which is manifest the nature of the reciprocity of both individual's interaction with each other. The interactional conceptualization of the mother-infant relationship is operationalized in this study with a focus on gross behaviors that can be easily observed and assessed. Not all the data to be collected in this study represent the nature of the con- tingent behaviors of a mother and infant as they respond to each other at one point in time. However, the cross-sectional sampling of behavioral observations utilized in the research design provides information about the unique nature of an individual mother's and infant's capacities to respond to each other. As the focus of this investigation is upon examining overt maternal and neonatal behavior, the interactional approach provides a useful perspective for making the appropriate observations. To provide a more comprehensive understanding of the attachment process and the ensuing mother-infant adjustment, an ecological perspective is used to assess how a mother's past experiences and present situa- tion also affect the behavior observed. These factors are assessed during a woman's last trimester of pregnancy, and assessments of the mother's and newborn's behavior are made during hospital observa- tions. The predictive significance of both the background variables and behavior observed in the hospital is evaluated with repeated observations and self-report assessments of mother-infant adjustment made during a home visit four weeks following delivery. These three points in time at which these data are collected are designated as Time 1 (T1), Time 2 (T2), and Time 3 (T3). Figure 1 illustrates the dynamic interfaces of variables which affect the maternal and neonatal behaviors identified as the focus of the investigation. These observed behaviors are in turn conceived as mediating the quality of the future parenting rela- tionship. Adaptation between mother and infant which is not posi- tive is considered as having potential pathological consequences for the child's future behavior and development. Assumptions The following assumptions will be made in examining the early interaction of maternal and newborn behaviors: l. The period of human infancy is the critical period for the establishment of human bonds of attachment which will mediate the nature of the parenting relationship and the child's overall development. 2. All behavior occurs in interaction. The mother- infant relationship involves a dyadic system in which both mother and infant contribute to the nature of their mutual interaction. 3. Overt behavioral indicators of maternal attachment are first observed in a mother's responsiveness to her newborn in the delivery room. This behavior represents the outcome of nine months of antici- pation and the maternal investment in giving birth. 4. The factors immediately preceding delivery influ- ence this maternal behavior e.g., length of labor, degree of pain, type of anesthesia, difficulty of delivery. How these factors influence maternal behavior is unknown. 5. An observation of mother-infant interaction during a feeding is a representative sample of the quality of the parenting relationship. 6. The biological nature of a woman's function in giving birth has necessitated the primary emphasis on her initial behavior in this study. Demographic and Experiential Variables 1.00 3.00 7.00 mother —~ gray area = observed behaviors The variables and behaviors as they appear in Figure l are: 1.00 Demographic and experiential factors 2.00 Management of pregnancy and hospital care 3.00 Labor and delivery 4.00 Maternal behavior in the delivery room 5.00 Maternal behavior during a hospital feeding 6.00 Neonatalbehavioral and physical characteristics 7.00 Mother-infant adjustment four weeks following delivery 8.00 Feeding behaviors four weeks following delivery Figure l.--Conceptual Schema of Research Design Definitions Mother: The individual who gives birth to a child. Caregiver: The individual who gives nurturant care to a dependent infant or child. Parenting: The active engagement of roles a caregiver and dependent infant assume in relation to each other. Mother-Infant Interaction: The reciprocal behavior manifest in the parenting relationship that reflects both the mother's and the infant's individual style of responsiveness to each other. Maternal Responsiveness: The intentional focus of behavior on an infant which is either initiated by the mother or elicited by the infant. Maternal Attachment: The extent to which a mother feels that her infant occupies an essential position in her life as measured by the degree of maternal responsiveness. Parenting Potential: Mother-infant interaction that is functional in facilitating positive child growth and development. Predictors of Parenting Potential: The following variables are factors which influence a mother's capacity for parenting: 1.00 Demographic and experiential factors 1.01 age 1.02 income 1.03 education 1.04 marital status and length of marriage 1.05 personal resources for child rearing 1.06 stress encountered during pregnancy 2.00 Management of pregnancy and hospital care 2.01 planning of pregnancy 2.02 choice of hospital care for infant 2.03 prenatal education 3.00 4.00 5.00 6.00 10 Labor and delivery 3.01 length of labor 3.02 father's responsiveness in the delivery room Maternal behavior in the delivery room 4.01 total score of maternal responsiveness in the delivery room Maternal behavior during a hospital feeding 5.01 5.02 5.03 total score of maternal responsiveness during a hospital feeding. ratio of time mother spends looking at infant to total time of feeding breast or bottle feeding Neonata1 behavior and physical characteristics 6.01 6.02 6.03 6.04 6.05 6.06 newborn interactive processes newborn motoric processes newborn organizational processes of state control newborn organizational processes of physiologi- cal response to stress physical appearance of newborn discrepancy between actual and desired sex of newborn Indicators of Parenting_Potential: The quality of the parenting relationship is assessed by the variance of scores in the fbllowing variables: 7.00 Mother-infant adjustment assessed four weeks following delivery ’ 7.01 7.02 7.03 7.04 7.05 7.06 7.07 maternal perception of newborn behavior attitudes toward caregiving maternal self-report of physical health feelings of maternal attachment reported by mother mother-infant adaptation to parenting rela- tionship maternal recall of first contact with newborn maternal recall of difficulty of labor and delivery 11 8.00 Feeding behaviors four weeks following delivery 8.01 total score of maternal responsiveness during feeding four weeks following delivery 8.02 infant responsiveness during feeding 8.03 ratio of time mother spends looking at infant to total time of feeding 8.04 breast or bottle feeding Importance of the Study Over the years there has been much interest among clinicians and researchers in understanding how an infant begins to form attach- ments to his parents. Recently, attachment has begun to be studied in terms of how parents develop emotional bonds with their children. The medical attention received by the problems of child abuse and neglect and the developmental disorders of children whose critical condition at birth required that they be separated from their parents has contributed to this new approach to the study of attachment. Bonding failure is now viewed by many as functional in the etiology of many forms of emotional and physical pathology seen in children. An examination of the attachment process from the parents' perspec- tive provides a point of view that is useful in examining the earli- est of parenting behaviors. As an attempt to document through standard observations in the delivery room and during a first feeding the initial spontaneous responses of mothers to their newborns, this study will provide information that will contribute to the understanding of the attach- ment process. These observations combined with the prenatal ques- tionnaires and the neonatal assessments provide information useful 12 in evaluating how a mother's background and responsiveness and her newborn's behavioral capacity will contribute to the quality of their parenting relationship. Such an evaluation represents an attempt to enlarge the focus of the delivery process to include a programmed assessment of maternal and neonatal behavior that can be used to identify how appropriate supportive assistance can be provided for young families. Through a sensitive means of early assessment and immediate intervention, families can receive rein- forcement for their positive behavior or preventative assistance before problems become manifest in the parent-child relationship which may begin to affect the child's behavior and development. The cooperation of the medical community needed to conduct this study requires an involvement in research which utilizes a broad perspective for examining the well being of obstetric patients. This is important as a means of orienting the attention of those who care for new mothers and their newborns to the importance of early mother-infant interaction and its significance for the potential parenting relationship. CHAPTER II REVIEW OF THE LITERATURE Attachment Behavior The phenomenon of attachment is a fundamental developmental process which emerges during the first year of a child's life. The role that human attachment plays in facilitating emotional growth and well-being has been thoroughly described in the classic studies of maternal deprivation. The work of Provence and Lipton (1962), Freud and Burlingham (1943), Spitz (1946), and Bowlby (1966) have described the psychopathological consequences that institutional rearing can have on the development of young children. These authors have suggested that only consistent experiences over time can lead to an infant's establishment of an internal mental repre- sentation of the person who gives him care. Such a mental image fosters a young child's sense of relatedness in maintaining an inter- active relationship with the caregiver and a feeling of security in being able to leave the caregiver to explore the near environ- ment. Situations which do not encourage an infant's attachment to adult caregivers deprive the individual of a capability in forming the human bonds necessary for maintaining meaningful interpersonal relationships. Attachment provides the nurturance for physical and emo- tional growth. Fraiberg (1967) has explained that in the absence 13 14 of human ties,a conscience cannot be formed and qualities of self- observation and self-criticism fail to develop. She noted that the feeling of distance from others that is experienced by an unattached individual is accompanied by an emotional range impoverished of joy, guilt and remorse. Cognitive studies contribute information that is helpful in understanding the emerging processes of attention, perception, learn- ing and retention which mediate how a child attaches to his care- givers. Influenced by the Piagetian concept of object conservation, studies emphasize how an infant's ability to conceive of his mother as a permanent figure is related to the quality of his attachment to her. Bell (1970), through observations of infants in a contrived situation, found that infants who respond to a separation from their mothers with signs of attachment but without upset, ambivalence or defensiveness have more accelerated conceptions of person permanence as opposed to inanimate object permanence. In interviewing the mothers regarding their play with and interest in their infants, a positive relationship was revealed between sensitive and devoted mothering attitudes and practices and the infants' concept of person permanence. These practices and attitudes can be understood as affecting the quality of the early relationship between a mother and her infant. Before cognitive mechanisms can actively operate to facili- tate selective social behavior, an infant must first experience a fundamental attraction to other humans. How an infant differen- tiates a human individual as a unique object in the environment is 15 contingent upon both his innate sensory capabilities and the stimu- lus qualities of those with whom he interacts. It is increasingly acknowledged that infants are born well endowed with a capacity for processing sensory visual stimulation, e.g., the ability to focus their vision on objects and to follow slowly moving targets. Inter- estingly, newborns are best able to focus on objects eight inches away from their faces or about the distance of the mother's face during a feeding. The auditory system at birth is also well developed with a high degree of functional complexity. The neonate can make dif- ferential responses to stimuli which vary in pitch, intensity, and duration. Newborns are also born equipped with sensitivities to skin pressure and touch. A newborn's tactile sensitivity varies accord- ing to body part stimulated, the area around the mouth being the most sensitive to touch. Smell and taste sensitivities have also been demonstrated in newborns. Infants are also able to make proprioceptive discriminations appropriately adjusting their bodies in response to shift in posture. How does a human caregiver function as an attractive and preferred stimulus object for the newborn's selective attention? Rheingold (1961) noted that humans have built into them a number of features that make them the focus of an infant's attention. She has claimed that the human's constant movement which emits a great deal of highly varied stimulation that can appeal to a number of the infant's different sense modalities simultaneously makes the 16 person an appealing focus of attention. That the human is also responsive to the infant's own behavior in a continuous and recipro- cal pattern of interaction is of importance in stimulating the selective attention of the newborn. Kagan and Lewis (1965) showed that the human face alone possesses characteristics such as contrast, movement and three dimensionality which are especially likely to catch an infant's attention. Similarily, Fantz (1963) demonstrated the salience of the human face as a stimulus object for newborns. His studies have shown that neonates only two to six days old pay more attention to a disc with human features painted on it than to any other stimuli of similar shape and size. Newborns also demonstrate selective attention to human auditory stimulation. Hutt, Lenard, Bernuth, and Muntjewerff (1968) showed that infants are more likely to respond positively to sounds having some characteristics of the human voice at a younger age than they can demonstrate responsiveness to faces. Given sensory ability and stimulus objects, cognitiVe mechanisms begin to function as an infant between the ages of 4 and 8 months learns to distinguish different individuals and to recog- nize his mother as his familiar caregiver. Emotional bonds are forthcoming as the child selectively seeks proximity with those with whom he shares an attachment. Bowlby (1958), a psychoanalyst with a biological perspec- tive, maintains a dynamic point of view on attachment. He describes 17 the attachment process as an interaction between innate behaviors of the infant such as crying, sucking, smiling, clinging and follow- ing and the parental responses which they elicit. Such a conceptu- alization underscores the role each partner plays in the creation of the human bond emerging between parent and child. The early years of a child's life are thus the vital ones for the development of attachments between caregivers and their children. The availability of caregivers willing and able to pro- vide an emotionally responsive climate for growth will affect the child's capacity for attachment and subsequent emotional and physi- cal development. Attachment as an emotional investment in care- giving needs to be evident in parents' early responsive behavior towards their child if an environment for nurturing children's capacity for attachment to their caregivers is to be created. Quickening has been identified as a turning point during pregnancy when a woman begins to develop stronger feelings of attachment to her child. It is at this time when a psychological readjustment also appears to take place that the pregnant women begins to deve10p a more realistic relationship with her yet unborn child (Bibring, 1959). The growth of a mother's attachment to her child can thus be traced prenatally to a woman's feelings toward her unborn child. Data from a study of the mourning response of mothers to the death of a newborn infant have suggested that a substantial degree of affectional bonding precedes a woman's tactile contact 18 with her infant (Kennell, Slyter, & Klaus, 1970). Evidence from this study also have indicated that mothers who are pleased to be pregnant and those who had tactile contact with their infants before their death experienced a longer and perhaps more intense period of mourning than those mothers who did not report such feelings or experience early tactile contact. These findings lend support to the notion that the emergence of a woman's feelings of attachment begins prior to birth and are intensified with initial physical contact with the newborn. Animal Attachment Studies Various animal studies provide information helpful in con- ceptualizing the natural variables facilitating immediate maternal bonding. Ethological studies have noted that when goats, sheep, or cows are separated from their newborns for the first four days after birth, these animals show a failure to care for their young when they are reunited. However, after a separation of a mother and her newborn on the fifth day after delivery, there is no apparent dis- ruption in the mothering behavior (Hersher, Moore, 8. Richmond, 1958). These findings indicate the importance of the timing of the first contact between the mother and her newborn following birth. Another study involving half wild kaffir buck which had been rendered unconscious during birth with chloroform and ether showed that these mother animals refused to accept their newborns when they regained consciousness. Morais (cited in Newton & Newton, 1962) reported that when the buck were rendered unconscious 19 immediately after birth and before they were allowed to view their young, acceptance was immediate with the return of consciousness. This study indicates that the procedural management of the delivery and the timing of contact are important variables mediating the acceptance of the young. Chimpanzees also exhibit behavior which displays the importance of the management of delivery for future maternal behavior. It has been noted that when giving birth in captivity the mother is likely to be afraid of her newborn and will not allow it to cling to her coat (Lawick-Goodall, 1971). 'The amount of contact permitted between a mother and her newborn appears also to be an important mediating factor involved in future attachment. In a study of rhesus monkeys, the amount of visual and auditory contact permitted between a mother and newborn was manipulated, and it was demonstrated that mothers deprived of full contact with their newborns showed a marked decrease in the amount of time and care they gave to their offspring (Harlow & Harlow, 1965). Previous experience has been shown to affect the course of maternal behavior. Scott (cited in Brody, 1966) has shown that ewes who were artificially fed as lambs are able to nurse their own off- Spring but otherwise ignore their own lambs. Orphan rhesus monkeys who lack experience with their own species are frequently ineffective and brutal mothers (Harlow, Harlow, & Hanson, 1966). Rat studies provide similar findings. Female rats, when reared so that they are unable to lick their own abdomens and posterior bodies, give 20 minimal tactile stimulation to their young. These same rats, when prevented from carrying objects, have shown an inability to make nests and retrieve their young (Schneirla, 1951). The behavior and appearance of an infant animal have also been noted to affect his mother's caregiving. As a rhesus monkey develops more independent behavior, he reinforces his mother's caregiving behavior less, and she begins to alter her nurturant behavior towards him (Harlow & Harlow, 1965). It has been noted that when the infant langur's typical coat, size, vocalizations and awkward movements disappear, maternal behavior also ceases (Jay, 1963). These ethological reports highlight variables which affect maternal attachment manifest in caregiving behaviors. Findings from animal studies provide information helpful in making critical assessments of how human maternal behavior emerges. Animal studies, however, have the liberty of manipulating experientiaI and environmental variables to clarify hypotheses concerning how maternal behavior can be experimentally affected. Although ethical considerations forbid the kind of behavioral experimentation con- ducted in examining animal maternal behavior, laboratory and naturalistic observational studies have provided information con- cerning human behavioral mechanisms which function to facilitate the caregiving relationship. It has been possible to conduct in hospital settings some experimental research with human mothers and their newborns. Contemporary hospital management of maternity care 21 has created practices which limit how mothers can initiate contact with their newborns. Experiments can be conducted by liberalizing these practices, without harmful medical consequences, to investi- gate how maternal behavior may be affected by the environmental constraints imposed by routine hospital care. Both the naturalistic and experimental investigations have provided intriguing insight into the study of human attachment behavior, and these findings will be reviewed. Human Attachment Studies Studies with human mothers and their newborns reveal that a pattern of behavior exists in how a mother first initiates con- tact with her infant. Klaus and Kennell (l970a) examined tactile interaction through a quantitative analysis of photographs taken of mothers during their first ten minutes of interaction with their infants. Their data provide evidence of an orderly progression of what they identify as species specific behavior. A mother begins contact with her infant by applying finger tip touch on the infant's extremities before she begins to have palm contact with the infant's trunk. The data gathered indicate that 52% of the first three minutes of initial contact is spent in finger tip inter- action with the newborn on his extremities and 28% of the time is spent in palm contact on the trunk. During the last three minutes of the contact time, 26% of the time was spent in finger tip inter- action on the extremities while 62% of the time was spent in palm contact on the trunk. Interestingly, this same pattern of behavior 22 has been observed with a mother's first interactions with her pre- mature infant; the rate of acceleration from finger tip touching to palmar contact occurring more slowly. In attempting to establish a feeling of relatedness, gaze interaction between a mother and her newborn is noted throughout the literature as an important function for subsequent parenthood. Moss and Robson (1968) have stated that to be looked at is tanta- mont to being acknowledged and to be acknowledged is a prerequisite for both social interchange and the establishment of more permanent attachments. These researchers found that a pregnant woman's expression of interest in her yet unborn child is related positively to the amount of face to face gazing between her and her infant assessed when the infant is l and 3 months old. Eye contact mediates a substantial part of the nonverbal transactions that transpire between a mother and infant (Robson, 1967). During the first contact a mother has with her newborn an intense interest in eye to eye contact has been noted. With an understanding of the importance eye contact plays in eliciting attachment, it is of interest that visual fixation and visual following are the only naturalistic neonatal reflexes which do not drop out over time. The newborn's ability to visually fixate upon an object and to follow a moving target is a relatively advanced behavior compared to overall maturation at the time of birth. Rheingold (1961) has gone so far as to say that visual and not physical contact is the basis for sociability. 23 Robson (1972) stated that "with gaze as the conductor of social orchestration, speech and the smiling response play a con- stant cbunterpoint" (p. 308). Observations of mother-infant pairs indicate that speech and smiling help modulate the potentially arousing and disrupting effects of visual contact. Language is intimately linked to reciprocal gazing, and it is noted that mothers and infants vocalize to one another mainly during gaze interchanges. Maternal responsiveness to newborn vocal signals has also been demonstrated. The newborn's cry or distress signal can be distinguished by its three different patterns. Newborns have a hunger cry progressing from an arhythmical low intensity cry to a louder rhythmical form. They also have an angry cry having a somewhat similar form but with a different sequence of component parts, and a pain cry with a sudden onset, a pause and then a series of gasping cries. Wolff (1969), through spectographic analysis of crying episodes, has been able to identify these three patterns and has found that mothers can fairly easily distinguish the different patterns so as to respond appropriately to their distressed infants. Formby (1967) has demonstrated that mothers are also able to discriminate the individual cry of their own infants from the cries of strange newborns. Noting these patterns of neonatal and maternal behavior which facilitate the attachment of a mother and child to each other, revealing studies have been conducted to investigate the 24 effects of manipulating the quality of a mother's initial inter- action with her newborn. In their most recent study the Case Western research group divided 28 primiparous mothers into two treatment groups having different amounts of contact time with their newborns (Klaus, Jerauld, Kreger, McAlpine, Steffa, & Kennell, 1972). One group received the usual hospital treatment and was allowed the standard amount of physical contact time with their newborns. The second group received sixteen additional hours of contact time. The mothers' backgrounds and infants' characteristics were similar. Three separate assessments of the mothers and their infants were made on two different occasions, once one month follow- ing delivery and once one year after the child's birth. These assessments included a standardized interview, an observation of maternal performance during a pediatric examination of the infant and a filmed study of the mother feeding her infant. Results frOm this study show that one month following delivery the extended con- tact group was more reluctant to leave their infants with baby- sitters and stood and watched their infants more closely during a physical examination than did mothers in the control group. The extended contact group also showed greater soothing, eye to eye contact and fondling during the feedings. Results from the one year follow-up revealed similar differences between these two groups in response to the questions about baby-sitters and in behavior observed during the physical examination. 25 The findings from the Klaus et a1. (1972) research which shows that contact time may play a role in mediating the quality of parental attachment influenced the development of a tentative hypothesis that there may be immediately following delivery a "maternal sensitive period" (p. 463). The separation of a mother frdm her infant at birth is viewed as possibly impairing the forma- tion of the vital human bond of attachment. Several studies have been conducted to investigate the effects of manipulating the amount and quality of contact time a mother is permitted to have with her pre-term infant. In one study, Leifer, Leiderman, Barnett, and Williams (1972) have shown that mothers of full term infants who experience periodic full contact with their newborns during their first two to three days of hospitalization smiled at their infants and held them closer to their bodies than did the mothers of premature infants who had been separated from their newborns following delivery. This significant difference was noted during standard observations made 30 to 40 days following birth. Another study (Klaus & Kennell, l970b) used an analysis of time lapse photographs 0f mother-infant interaction during a feeding to compare the behavior of one group of mothers who, because of their newborn's medical condition, had been separated from their infants for 20 days with a group of mothers who were per- mitted physical contact within the first five days of life. The data from this study collected one month after hospital discharge 26 indicate that compared to the early contact group the late contact mothers burped their babies less frequently, changed their positions less, held their infants with less proximal contact and were generally less skillful in feeding their infants than the mothers who had experienced early contact with their newborns. The credibility of the notion of a maternal sensitive period is most clearly evident in examining the develOpment of children who experience a separation from parental contact for a prolonged period of time following birth. Through retrospective studies of populations of pre-term or high risk infants, it has been noted that these infants who had less contact with their parents following birth have a higher tendency toward developmental disorders later in childhood than do full term infants. In spite of an absence of relevant organic pathology,such severe developmental disorders as failure to thrive and child abuse have been recognized as being associated with early mother-infant separation during the neonatal period (Shaheen, Alexander, Trus, Kowsky, & Barbero, 1968; Klein & Stern, 1971). The studies reviewed provide information about how the initial timing of maternal contact may affect parenting behaviors and the development of attachment. These findings are relevant in understanding how hospital care may be more farsighted in its provision for the management of a mother's early contact with her newborn. An acknowledgment of the disturbances in parent-child interaction that have been most clearly identified with the popu- lation of families who have encountered early separation from 27 their newborns because of their critical condition should make it apparent that more sensitive care needs to be given to these special patients. Human maternal attachment, however, is a complex process which defies simplistic explanations. Leifer et a1. (1972) has indi- cated that eliciting and maintaining maternal attachment involves a “confluence of factors not all equally influential at any one point or over time" (p. 1217). Attachment is as much a function of maternal variables representing historical, situational and biological factors as it is influenced by the newborns' behavioral individuality. Parenting Potential Attachment has thus been described as a dynamic process involving many factors which over time mediate the future of a mother's interaction patterns with her infant. Mother-infant interaction is also viewed as a subsequently dynamic behavior. The interaction itself has been described as a fit between mother and infant (Escalona, 1968), an interactive mesh (Brazelton, 1961), intricate ballet (Spitz, 1965) and as an interactive spiral (Ainsworth & Bell, 1969). Each of these descriptions emphasizes that it is through the behavioral interaction that takes place between a mother and her infant that a relationship develops to become either harmonic or dissonant. Parenting Potential is con- sidered as mother-infant interaction that is functional in facilitating positive child growth and development. It is when the relationship fails to be harmonic that it can be considered 28 at risk for future parenting problems which may lead to deve10p- mental disorders in the child. To prevent dissonance in the relationship from becoming destructive, an early detection of a parenting relationship can facilitate supportive preventive intervention. The identification of patterns of variables creating vulnerability to dissonance and dysfunctional interaction is necessary. The early behaviors mani- fest in a mother's first attempts to relate to her infant may provide revealing information concerning her investment and will- ingness to give nurturant care to her newborn. The newborn's behavioral repertoire will, of course, affect a mother's early caregiving behavior. This first intersection of behaviors pro- vides a part of the foundation for the relationship which will develop between an individual mother and her newborn. To assess the potential for the parenting relationship, it is necessary to examine how a mother and infant will contribute to their mutual interaction. With attachment as a focus for the fundamental bonding process, the quality of the parenting relationship is viewed to a large extent as contingent upon the subjective emotional tie between a parent and newborn. How feelings of attachment develop and how they affect the future relationship involve the use of a broad perspective for examining the salient influences which function to determine the nature of the behavior observed between parent and child. 29 An examination of both organic and psychosocial factors as they are related to the behavior of infants and mothers is necessary to assess the potential of the parenting relationship. An examina- tion of both the present situation of the mother as well as her personal past experience of being mothered is also important. Organic and psychosocial factors are often related to each other as they pertain to the well being of the mother and infant and they interact with each other in terms of the mother-infant relationship. Fluid boundaries are drawn in examining how these factors influence parenting. Traditionally, studies have investigated neonatal and mater- nal behavior and characteristics from a clinical perspective and have focused upon factors which may have pathological consequences for the mother's behavior and the child's development. The following review will discuss these research findings which contribute to an understanding of how variables related to a mother's background and pregnancy and a newborn's individual behavior may be related to the risk of the future quality of the parenting relationship. This dissertation applies these findings in the selection of the variables used as predictors of Parenting Potential. Maternal Contribution to Parenting Risk' The term risk when applied to an obstetric patient usually refers to the possibility of a woman's developing a complication in pregnancy and/or delivering an infant with manifest disabilities. The relationship between these complications and the risk of the 30 potential parenting relationship will first be explored. The dis- cussion will begin with a view of the prenatal environment which a pregnant woman provides for her yet unborn child. Interpretations of any study of prenatal influences upon fetal outcome suffer from an inability to show causal relationships. The nonexperimental nature of this kind of human research necessi- tates that correlational findings be evaluated comparatively with findings from other studies. Joffe (1969) highlighted this particu- 1ar handicap of prenatal research in noting the inability to separate the contribution of genetic variables and postnatal environmental factors from the prenatal influences which research efforts try to identify. Genetic differences by themselves may dispose children to characteristic behavioral disorders. As it is not the aim of this review to distinguish causal links but rather to identify possible determinants of potential parenting problems, correlational evidence is sufficient for indicating the likelihood of emerging problems. Historically and culturally, folklore has made references to the prenatal influences which affect a pregnant woman and the devel- oping fetus. Until recent scientific investigation of the prenatal environment, these old tales have been considered as irrelevant magic unassociated with the realities of perinatal development. Recent studies have investigated how external emotional and physical factors can affect the prenatal environment and can be related to the nature of the child's physiological and psychological make-up and the sub- sequent mother-infant relationship. The mother's attitude toward her pregnancy and impending parenthood have also been found to be related to her interaction with her newborn. 31 Organic Indicators of ParentingiRisk Medical findings increasingly indicate that the prenatal environment is related to the risk encountered by the fetus and new- born. Pasamanick and Knobloch (1961) use the term "reproductive casualty" (p. 7) to refer to how prenatal insult can lead to the risk of bearing a child with a disability. In developing a Maternal and Child Health Index for use in prenatal clinics, Nesbitt and Aubry (1969) have used these variables in assessing risk: age, marital status, parity, past obstetric performance, medical- obstetric ills, reproductive tract abnormalities, nutrition, psy- chological state and socioeconomic status. It has been noted by these physicians that past obstetric performance is a strong indicator of risk, as history of a prior fetal death or delivery of a low birthweight infant doubles a woman's chances of a recurring fetal loss. The medical-obstetric ills that have been shown to be important indicators of high risk pregnancies are diabetes, chronic hypertension, endocrine dis- orders, and fetal maternal blood group incompatabilities. Preg- nancy in very young (under 18) and older women (over 35) is also associated with perinatal loss. The difficulty of quantifying the risk related to race, marital status, psychological state and socioeconomic status make these factors difficult to assess in relation to their relative influence on perinatal outcome. Their interrelationships will be discussed later. 32 Nutritional status is also a part of this complex of vari- ables and has known effects on the developing fetus and its later development as a growing infant. A most startling finding in regard to this prenatal influence was reported by Winick (1969). He has claimed that when the mother's protein intake is below a critical level during pregnancy that 50% of the potential DNA content of the brain and other vital organs may never be replicated in a developing fetus. Exposure during pregnancy to the external influences of drugs, radiation, and cigarette smoking have also been indicated as influences on intrauterine development of the embryo and fetus (Montague, 1962). Research findings from a prenatal clinic in Syracuse indi- cate that two-thirds of the women considered as high risk obstetric patients can be identified early in pregnancy (Aubry & Pennington, 1973). It is most interesting that those involved in this clinic claimed that it is clear that the risk factors for perinatal out- come are virtually the same as those for maternal outcome. The findings indicate that only 20% to 30% of the mothers with no problems during pregnancy are likely to have newborns which require special care following birth. How the special care that infants born with disabilities require can contribute to the potential risk of the relationship will be considered. Psychosocial Indicators of Parenting Risk The human is the only species which has the distinction of rearing its children beyond the procreative cycle. Noting this, 33 Benedek (1970) has indicated that the motherly quality of a woman is not a simple response to hormonal stimulation brought about by preg- nancy and the ensuing necessity to care for the young. For the human, two resources contribute to the quality of a woman's mothering behavior. Both physiological factors influencing the birth process and lactation and also the expression of an individual woman's per- sonality which has developed under environmental influences can modify a woman's ability to give care to a dependent child. Benedek (1970) described parenting behavior as a function of the human mental apparatus which receives its direction from the mother's "empathic reaction“ (p. 158) to a child's needs. The empathic reaction evolves from a woman's ability to modify drive patterns through an integration of memory traces into personality organizations and ego functions. The manifestation of this process can be evaluated in a woman's adaptation to caring for her newborn. In a comprehensive longitudinal examination of maternal adaptation, it was demonstrated that the quality of a woman's adapta- tion to motherhood could be predicted by her adaptation to preg- nancy (Shereshefsky, Liebenberg, & Lockman, 1973). In this study it was shown that the personality characteristics of nurturance and ego strength and the woman's capacity to visualize herself as a mother were indicative of a positive adaptive response to preg- nancy and subsequent parenthood. As a concurrent measure of adapta- tion, it was found that a woman's accomodation to her infant and her aCceptance of the maternal role is highly related to the quality of the woman's relationship with her husband during this time. 34 The positive relationship noted in the Shereshefsky et a1. (1973) study between pregnancy adaptation and maternal adaptation provides information helpful for understanding how prediction of Parenting Potential can be made. The trend noted as existing across time can be identified as an indication of how maternal adaptation functions from the time of conception to the child's early infancy. Parenting Potential is certainly related to how a woman adjusts to the physiological and psychological changes inherent in the process of pregnancy and caregiving. The following review will cover factors related to a woman's psychosocial background that may con- tribute to the potential risk of a parenting relationship. Emotional Factors and Psychosomatic Reactions to Pregnancy.-- Obstetric complications have been investigated in relation to maternal emotional and attitudinal variables. Habitual abortion, prolonged labor, toxemia, hyperemesis (excessive vomiting), and pre- mature delivery have all been studied in light of how the psychologi- cal state may dispose women to these somatic conditions. As men- tioned before, methodological problems often cloud specific rela- tionships as most frequently data are collected only after the pregnancy has begun. Under such conditions it is impossible to determine the temporal ordering of psychological stress and physio- logical consequences. Existing data specify there are relation- ShlPS between the psychological state and somatic conditions; how- ever, the direction of the effects of these variables is unknown. Habitual aborters, women having a history of three or more consecutive spontaneous abortions, have been found to have traits of 35 dependency, compliance, and sacrificial attitudes related to child bearing. These women have been shown to benefit from psycho- therapy in later being able to deliver a full term infant (Weil & Tupper, 1960). Prolonged labor and delivery room complications have also been reported to be associated with maternal anxiety dur- ing pregnancy (Davids & DeVault, 1962). McDonald, Gynther, and Christakos (1963) have explored this relationship between anxiety and obstetric complications using 86 women of lower socioeconomic status. They found that four personality factors from the Minnesota Multiphasic Personality Inventory (MMPI) distinguished the two groups differing in anxiety and obstetric complications. The group with more complications showed less ego strength, more ergic tension, less self-sentiment and more guilt proneness. McDonald (1968) reported that toxemia, defined as excessive edema, significant proteinuria and hypertension, has been attributed to emotional disturbance by several different investigations. Using semistructured interviews the relationship between vomiting and attitudes toward children was studied in 100 primiparous mothers by Chertok, Mondzain, and Bonnaud (1963). These investigators found a positive relationship between vomiting and ambivalent maternal atti- tudes toward having children. Using both interviews and Rorschachs, Harvey and Sherfey (1954) related anxiety levels with vomiting. They found vomiters as being characterized by frigidity, pervasive immaturity and as making a consistent association of gastro- intestinal dysfunction with sexual disorders. 36 In examining the psychogenic etiology of permature births Blau, Sluff, Easton, Welkowitz, Springarm,and Cohen (1963) did a retrospective study matching 30 women who delivered prematurely in the absence of accountable medical factors with 30 women who delivered full term infants. These investigators used age, race, socioeconomic status, education, and parity as the basis for their matching. The premature group showed distinctive clinical and sta- tistical differences including more negative attitudes to the pregnancy, greater emotional immaturity, more body narcissism,and less adequate resolution of the familial Oedipal problems. Taking a more heuristic approach in examining expressed attitudes and feelings of pregnant women as they are related to physical complications of pregnancy, Heinstein (1967) made the general statement that the stress of pregnancy accentuates somatic difficulties that are already present prior to the pregnancy. Clifford (1962) reported similar findings using 50 unwed and 50 married multiparous and 50 primiparous women. Heinstein (1967) found that pregnant women with positive attitudes and feelings about pregnancy also have fewer physical complaints and fears. A cluster of attitudes and feelings indicative of general moodiness, depression, and overdependence was signifi- cantly associated with physical complications. Women who rejected being pregnant showed greater anxiety, depressions, dependencies, unhappiness in their marriages and attitudes reflecting sexual maladjustment. Together with these rejecting attitudes were 37 feelings of alienation and uselessness all being associated with gastro-intestinal disorders late in pregnancy. Research findings have indicated that social stability also influences adjustment during pregnancy (Davids & Rosengren, 1962). Women who are dissatisfied with their social status and are other- wise socially unstable have been noted to be less happy to be pregnant, more anxious and generally emotionally maladjusted. In his review of the role emotional factors play in obstet- ric complications,McDonald (1968) reported that there is consistent evidence that women who experience any of the variety of obstetric complications have higher anxiety levels and use fewer repressive type defenses than women who have normal pregnancies and deliveries. He conceptualized these findings as indicating that stress in the form of unresolved conflicts about pregnancy causes anxiety which results in adaptive attempts to cope with the stress. He asserted that with prolonged anxiety adaptive attempts fail and autonomic nervous system activation occurs with complications in the physio- logical functions of a system showing maximal activation. Although there appears to be a strong trend in these research findings supporting the notion that maternal anxiety is related to obstetric complications during pregnancy and delivery, Aubry and Pennington (1973) were not able to gather enough evidence from their clinic population to show that emotional factors should be given consideration in evaluating medical risk in their popula- tion of patients. They found, however, that maternal age, race, 38 marital status, parity,andrnnxjtion are fairly good predictors of potential risk to the neonate. Support for these findings can be given by the research findings made by Grimm and Venet (1966). This research involved 105 normal pregnant women who were followed through their entire mater- nity cycle. Although these findings indicated that there is some degree of relationship between early emotional and attitudinal char- acteristics and emotional adjustment later in the maternity cycle, there was no relationship found between these characteristics and the physical condition of either the mother or her child. The com- plexity of unraveling the interrelationships makes it difficult to interpret any of the findings in terms of specific factoral rela- tionships. Whether or not these emotional factors are related to the physical outcome of the pregnancy, they reveal maternal character- istics that may become manifest in organic complications during pregnancy. Since these complications have a psychogenic etiology, they may be considered as risk factors which may effect the potential of the future interaction between a mother and her infant. Support for this view can be found in research which assumes a broader span of time and which investigates prenatal factors as they are related to neonatal and infantile behavior. These studies,which are reviewed next, explore the bridge between pregnancy and the mother-infant rela- tionship. Evidence of how a maternal evironment can constitute intrauterine influences that may become manifest in an infant's behavior will be explored. 39 Emotional Factors, Intrauterine Environment,and Neonatal Behavior.--In viewing life on a continuum it becomes necessary to consider intrauterine experience as the first encounter a develop~ ing human organism engages in with its environment. Fetal life, as manifest in movement detected by a mother, has been shown to be related to motor, adaptive,and total scores of infants' later scores on the Gesell scales administered at twelve, twenty-four, and thirty-six weeks (Walters, 1965). This study dealt only with a physically detectable correlation between pre and postnatal varia- bles but does indicate a link in development across the perinatal time span. Sontag (1941) originated research investigating the signifi- cance of fetal environmental differences. His work has shown that fetal hyperactivity observed in the prenatal period is often associ- ated with the mother's emotional stress and tends to continue post- natally with irritability, crying, food intolerance, and loose stools. More recently Ottinger and Simmons (1964), in a study investigating the behavior of human neonates and prenatal anxiety, found that scores on an anxiety scale, administered in each trimester of pregnancy, were related to amounts of neonatal crying electroni- cally recorded during the first four days of life after birth. In another survey of 100 mothers and their infants, relationships were observed to exist between emotional difficulties of the mother dur- ing pregnancy and a general syndrome in the infant's behavior of restlessness, fussiness, excessive crying, irritability, sleepiness, 40 vomiting, and loose stools (Turner, 1956). Turner concluded that prenatal stress might affect the reactivity of the fetal nervous system and alter the infant's whole pattern of behavior. Ferreira (1960) also found evidence of how environmental factors can influence the prenatal development of the fetus. He indicated that mothers and newborn infants with deviant behavior as evaluated by trained nurse-observers on the basis of the infants' crying, amount of sleep, degree of irritability, bowel movements, and feeding had negative maternal attitudes prior to the infants' delivery. These negative attitudes were assessed by the mothers' high scores on a scale of fear of harming the baby and on a rejec- tion of pregnancy scale. Other studies have investigated the relationships between prenatal anxiety and later child rearing attitudes. Davids, Holden, and Gray (1963) found that women who had been highly anxious during pregnancy had less desirable parental attitudes as indicated on the hostility and control scales on the Parent Attitude Research Inventory (PARI). They also found that the children who were being reared by women who were highly anxious during pregnancy did less well on the Bayley Infant Mental scale at eight months of age than did infants reared by mothers who had exhibited little anxiety dur- ing pregnancy. Doty (1967) in her study of the relationships among atti- tudes in pregnancy and other maternal characteristics found that these attitudes vary as a function of social class membership and 41 previous pregnancies. She found that lower class women, especially multiparae, admit more emotional disturbance and express greater rejections of pregnancy and maternal role taking than do other groups. Interestingly, these negative attitudes in pregnancy were correlated with the number of infant problems among all groups except the lower class. These findings could reflect actual differences in the infants' behavior or could reflect that lower class mothers are less attentive or more repressive in regard to their infants' behavior. Doty's work (1967) confirmed the findings made by Davids et a1. (1963) suggesting that attitudes during pregnancy can predict child rearing attitudes. Her work showed that negative attitudes toward child rearing were reflected on the hostility, fostering of dependency, fear of harming the baby, avoidance of conmunication, and dependency of mother scales on the PARI admin- istered during pregnancy. The studies which bridge pregnancy and neonatal behavior indicate that an infants' behavior which does not reinforce mater- nal attachment can be related to maternal anxiety or negative atti- tudes toward child rearing during pregnancy. Thus, irritable behavior in difficult infants can be related to maternal psycho- logical state during pregnancy. The same factors related to the psychogenic nature of somatic difficulties of the mother during pregnancy have also been attributed to the behavior patterns of the newborn. It can thus be seen how Parenting Potential is associated with both the infant's and the mother's behavior. 42 Identification of these maternal characteristics associated with potential problems could facilitate appropriate intervention that could ameliorate the somatic conditions of both the mother and the infant and lessen the likelihood of a risk for the potential rela- tionship. Status of Familngelationshjps, Experiential Background, and Adjustment to Parenting.--To complete this investigation of the maternal side of the parenting relationship, the situational and experiential factors that are a part of the mother's background and present life circumstances will be discussed as possible indicators of Parenting Potential. Rapopart (1963) described the birth of a child as a critical transition in the normal expectable development of the family life cycle. She identified four characteristics which are unique to this event: (a) it is a point of no return, (b) it has novel components for people experiencing it, (c) it can provoke acute disequilibrium in individual and family systems, and (d) the mode in which this normal crisis is handled is important to future outcomes of family relationships. In assuming that the birth of a child, especially a first child, most likely leads to some disruption in all families, it can be understood how stressful situations which already exist in a family can compound the normal period of adjustment. This stress can, of course, be reflected in the nature of the infant's develop- ment as it is mediated by the mother during her pregnancy and throughout the perinatal period. 43 Along with normal strain on a family that accompanies the birth of an infant, another assumption can be made regarding child bearing. With the availability of effective contraceptives and the acceptance of abortion as a legitimate means of terminating preg- nancy, it can be assumed that childbearing is a consequence of motivated human action (Flapan, 1969). It is important to bear in mind these two facts in evaluating how situational and experiential factors can effect Parenting Potential. Klaus and Kennell (1970b) listed steps involved in a mother's development of attachment to her newborn. These steps are planning the pregnancy, confirmation of the pregnancy, accepting pregnancy, fetal movement, accepting the fetus as an individual, birth, seeing the baby, touching the baby, and caretaking. Pregnancy is a matura- tion process itself involving different developmental stages. These authors cited Caplan's (1960) proposition that a woman's ability to accept pregnancy and to perceive of the fetus as a separate individual are indicators of her accomplishment of two important adaptive tasks of pregnancy which are also a part of the attachment process. In recognizing the importance of the prenatal period for the attachment process and its influence upon the child's future development. Cohen (1966) identified the kinds of stress situations which can be dysfunctional in the adaptive process that is a part of pregnancy. These stress inducing situations can also be considered as attributing to the potential for parenting problems. Moving to a new geographical area, marital infidelity, death of a close friend or relative, previous abortions or loss of previous children can all 44 contribute to the retardation of developing feelings of attachment to the unborn infant. Any one of these or other situational varia- bles that heighten this normally stressful period increases the likelihood of parenting disorders that can facilitate developmental difficulties for the infant. Isolation from support of family or other individuals intensifies the strain of any one of these stress inducing situations. An assessment of a mother's background must also include more than her immediate situation as it relates to her capacity for child rearing. It is important to examine her experiential back-- ground to know how she, herself, was nurtured as a young child and how this might influence her motivation for bearing a child. The absence of a mothering imprint which develops with the childhood experience of receiving nurturant care is considered as a strong indicator for potential parenting problems and especially for child abuse. This experiential deficit is also manifest in an inability to trust and in unrealistic expectations of child behavior (Kempe & Helfer, 1972). These experiential factors are especially relevant in light of the assumption that was made by Flapan (1969) that child bearing is a function of motivated behavior. Studies have shown a tenuous relationship between unwanted pregnancies and poor personal and school adjustment of children so conceived (Pohlman, 1967). Today, however, the more important question to be explored is what are parents' motives in conceiving children. It has been noted by those 45 who have worked with abusive parents that these individuals' motiva- tions for parenthood reflected a desire to have an infant who will give them the nurturance they failed to receive as developing child- ren. When this unrealistic expectation is not met, crisis situa- tions can precipitate into abusive patterns of interaction between parent and child. The Infant's Contribution to Parenting Risk Parmelee and Haber (1973) have defined the "risk infant" (p. 376) as any newborn or young infant who has a high probability of manifesting in childhood sensory or motor deficits and/or mental handicaps. The objective of these researchers was to identify the risk infant to enable the most beneficial medical and educational intervention. Brazelton (1973a) views early assessment of the risk for developmental disorders as essential in intervening to prevent a compounding of problems which can occur when an environment cannot adjust appropriately to an infant. Inappropriate parenting can easily lead to this compounding. ‘Qrganic and Psychosocial Indicators of Parenting_Risk There has been a growing realization that factors related to pregnancy and delivery can be crucial determinants of deviant child development. The term reproductive wastage was first used to indi- cate how prenatal events can lead to either lethal or sublethal consequences for the newborn. The lethal manifestations were con— sidered as abortions, stillbirths, and neonatal deaths, while 46 sublethal components of prenatal insult were considered to include cerebral palsy and other disabilities. In 1961 Pasamanick and Knob- lock (1961) revised this notion with the term reproductive casualty that describes the harmful events that take place during pregnancy and delivery which result in damage to the fetus or newborn. The formu1ation of these concepts has provided the schema of a continuum for examining a newborn with consideration given to its prenatal development. It was these researchers' proposition that, depending upon the degree and location of the prenatal damage, disa- bilities ranging in severity from cerebral palsy and epilepsy to different types of learning and behavioral disorders resulted from minor degrees of prenatal damage which lowered an infant's threshold to stress. Pasamanick and Knoblock (1966) also associated abnormal- ities with certain life experiences and identified socioeconomic status as being functional in determining the nature of fetal out- come. Wolff (1967) has asserted that the continuum of reproductive casualty has facilitated an understanding of childhood disorders as being related to each other. He has also noted that birth injury, constitutional vulnerability, social deprivation, and emotional trauma all make significant contributions to psychiatric morbidity. Chess (1970) has contributed to Wolff's interpretation of the continuum of reproductive casualty. She has also proposed that, along with the physiological disorders which make it difficult for a child to cope with the demands of his sociocultural environment, a child's temperament is an indicator of his potential for 47 developing behavior disorders. She has defined temperament as a child's behavioral style or the manner in which the child character- istically reacts to individuals and situations. The vulnerability associated with traits of temperaments, she has asserted, should be considered in evaluating a child's risk of encountering developmental disorders. Chess's work has differentiated specific attributes in infants during their first five weeks of life and has identified patterns of temperament which are likely to make a child vulnerable to damaging interaction with the environment. These traits that constitute vulnerability to stress are the infant's activity level, rhythmicity, pattern of approach and withdrawal, adaptability, quality of mood, intensity of reaction, threshold of responsiveness, distractibility, attention span, and persistence. Using these traits as descriptive measures, Chess has developed clusters of behaviors to identify individual children as either "easy children," "difficult children," or "slow to warm up children" (Pp. 127-129). According to her schema the easy children are positive in mood, highly regular, readily adaptable, low or mild in intensity of their reactions and usually affirmative in their approach to new situa- tions. In contrast, difficult children,who are at the greatest risk of developing behavior disorders, are irregular in biological functions, have predominantly negative responses to new stimuli, are slow to adapt to environmental change and have a high frequency of negative mood expressions and intense reactions. The slow to warm 48 up children are characterized by a combination of negative through mildly intense initial responses to new situations and by gradual adaptation after repreated contact with the stimulus. 1 Drilleen (1964) indicated from her work with longitudinal studies of premature infants whose birth weights were three pounds or less, that overactivity and restlessness were common behavior problems of these children who survive into childhood. Pasamanick, Rogers, and Lilienfield (1956) also indicated that the behavior disorders of childhood of overactivity, restlessness, and distracti- bility can be causally related to perinatal factors involved in the pregnancy and in the birth of the infant. Ucko (1965) in his study of the relationship between asphyxia at birth and later behavior of children indicated that the temperamental traits of unusual sensi- tivity and overreactivity to stimuli may be associated with neonatal asphyxia. Each of these noted characteristics associated with obstetric complications or prematuritvaould be classified by Chess as a trait of a difficult child. It was her contention that with recognition of this behavioral style it is possible to devise strategies of deal- ing with the child and of adapting his environment to reduce the child's chances of developing a behavioral disorder percipitated by his contribution to the parenting relationship. Parental behaviors also need adaptation to prevent creating unnecessary stress for the child or the parent. Psychophysiological research has contributed information useful in understanding the discrete variables which function to 49 dispose an individual infant to having a characteristic temperament. Individual differences in a variety of behavioral dimensions have been identified in infants. These differences in behavior have differential effects on how a mother will interact with her newborn. Korner (1974) reviewed research regarding specific behavioral variables salient in affecting the caregiving an infant receives. As noted previously, the quality of an infant's visual gaze behavior has a major effect on eliciting maternal feelings of attachment. Korner, in citing her own research (1970) has shown that reliable individual differences eXist in how frequently newborns display spontaneous alert visual behaviors. In another study she conducted with Thoman (Korner & Thoman, 1972), she has reported that newborns readily respond with alertness to different types of maternal minis- trations. Korner concluded that variation in the neonate's sensory responsiveness should feed into the child's level of arousal and subsequently qualitatively affect the mother-infant relationship. In the same review, Korner (1974) drew attention to the fact that not only does the infant's general arousal and, particu- larly, irritability have an effect on the caregiver, but also the infant's relative soothability plays a role in affecting the mother- infant relationship. She noted that a mother's capability to sooth her infant is of central importance in her emerging feelings of effectiveness and competence as a mother. In the study conducted with Thoman (Korner & Thoman, 1972) Korner found that infants dif- fered significantly from each other in how soothable they are and how much they cry after completion of soothing intervention. 50 It has been widely acknowledged in the developmental liter- ature that there are differences in how parents respond to male and female infants. In a conclusive statement regarding these differ- ences, Lewis (1972) noted that boys in general receive more proximal holding contact with their caregivers and girls receive more distal visual and auditory stimulation from their parents. To understand how the newborn contributes to the caregiving received, studies have begun to detect sex differences that are apparent in newborn behavior that may exert a subtle influence on caregiving. ' From her survey of the developmental literature, Korner (1974) tentatively asserted that female newborns appear to be more receptive to certain types of stimuli and are orally more sensitized than male newborns. She also noted that females are in no way less active or expressive than males. Korner reported that there is sug- gestive evidence that male newborns may be endowed from birth with greater physical strength and muscular vigor. Clarifying howindividualinfants vary in these ways shows how flexible a mother must be to adapt to the individual characteris- tics of her newborn's behavior. Robson and Moss (1970) illustrated how a mother's subjective feelings of attachment can diminish when caregiving fails to sooth appropriately an infant's irritable crying and other demands. Acknowledging the variability in infant state behavior, levels of arousal and sex related behavior, the caregiver's essential function can be understood as assisting an infant to regu- late his sensory input and motor repsonses. To coordinate caregiving 51 efforts with infant behavior is delicate work which requires a sensi- tivity to the individual traits of the infant. The infant can cer- tainly be understood to be an active participant in making this a smooth or difficult task for a parent to undertake. Brazelton (1973a) has recognized the variable ability that individual newborns have in being able to compensate their behavior and development in disorganized depriving environments. He has reported that neonatal problems are compounded early in life with inappropriate interaction with a physical and social environment. To predict a newborn's contribution to the likelihood of what Brazelton has called "failure in the environment interaction" (p. 361), he has expressed a need for s0phisticated methods of assessing newborn behavioral characteristics. Findings from a predictive study on infants and their families conducted by Escalona (1973) support Brazelton's concern about the confounding that the interaction between a neonate and his environment can have on a child's development. These researchers have found that although in general infant behavioral characteristics are not maintained over time, certain children carry into the pre- school years pathological behavioral attributes that were noted when the children were 16 weeks old. In light of these findings, Escalona asserted that when development and adaptation proceed stressfully and not entirely successfully certain early patterns of behavior are more likely to remain intact and continue in unaltered form at later ages. 52 In his review of neonate assessment procedures, Brazelton (1973a) has suggested that indicators of the effects of intrauterine experience should be examined to detect their role in neonatal development. Assessment of the neonate's immaturity or dysmaturity are of important predictive value in suggesting long termintrauterine deprivation which can affect the cellular development of the fetus. A clinical assessment of the placenta and cord blood at birth is another indicator of risk for the newborn, for it may reflect intrauterine nutritional deprivation and reduced potential for the infant. In assessing neurological functioning of the newborn, Brazel- ton (1973a) has claimed that the depth of depression and disorganiza- tion after birth and the curve of recovery may be the best indi- cators of central nervous system compromise and may be valuable in predicting infants at risk for developmental difficulty. He indi- cated that complex integrated behaviors such as level of arousal and total body tone, rather than discrete tendon or skin reflexes, are better evidence of insults to the neonate's brain caused by intrau- terine, labor ordelivery difficulties. Brazelton's Neonatal Behav- ioral Assessment Scale (1973b) evaluates both the infant's use of state to maintain control of reactions to environmental and internal- stimuli and the infant's response to various kinds of stimulation. Use of such an instrument can lead to a predictive means of identifying an infant's behavioral disposition before a newborn ever leaves the hospital. Preventive intervention can then be planned and 53 parents can be informed of the temperamental tendencies of their individual infants. Parents can then be helped to care appropriately for their infants, decreasing the likelihood of emerging behavioral problems. Without such help these difficult newborns have an increased potential of becoming involved in a non-positive parent- child interaction that can lead to developmental pathology. The importance of making early assessments of infantile development was also stressed by Greenberg (1970). He has asserted that the appearance of unusual behavior in infants indicates faulty development, vulnerability to stress and the greater probability for later development of abnormalities in cognitive, sensorimotor, social, and emotional functions. In his work he has assumed that iabnormal development in infants who are not handicapped by neurologi- cal disorders is a consequence of inadequate care and stimulation. The mother's behavior in relatiOn to her infant he claims to be a derivative of her personality traits. This conception fails to consider the bilateral nature of the relationship but does indicate the interaction of the mother and the infant in the parenting rela- tionship. Even in the absence of neurological disorders behavioral differences do exist between infants which can mediate the type of relationship which emerges between an infant and parent. The likelihood of this constitutional nature of the infant's behavior becoming involved in a compounding cycle as indicated by Brazelton was overlooked by Greenberg. Not only is a mother's behavior in relation to her infant's individuality important, but her perception of her infant has also 54 been noted to be related to the newborn's developmental outcome. The complex of a mother's perception of her infant's behavior and the newborn's developmental outcome has been highlighted in a longitudinal study conducted by Broussard and Hartner (1970). These authors developed an instrument designed to measure a primipara's perception of her newborn's behavior as compared to an average infant's behavior. Crying, spitting, feeding, elimina- tion, sleeping, and predictability were the criteria used in the evaluation made by the mothers one month after their infant's delivery. One hundred twenty full term first born infants were used as subjects and were divided on the basis of their mothers' evaluation into a high and a low risk group for possible emotional and developmental disorders. When these subjects were four and a half years old they were evaluated by two child psychologists for the need of thera- peutic intervention. A statistically significant association was evident between the mothers' evaluation and its prediction of their infants' behavioral outcome as judged by a professional. These findings have been interpreted by the authors in two ways. The results may indicate that unique personality characteristics or innate genetic characteristics representing a true picture of the infant can be detected very early in a newborn's behavior by its mother. The other interpretation given explains the predictive relationship as representing a self-fulfilling prophecy in that maternal expectations may become manifest in the child's develop- ment. In either case, maternal perceptions can be considered an 55 important variable related to the infant's future development. These noted perceptions could be used as an indication of the potential parenting relationship. This review has covered both physical and temperamental characteristics of newborns which have been associated with the perinatal environment. These factors, viewed on a continuum relative to the nature of the perinatal insult or to individual behavioral characteristics, dispose an infant to the vulnerability of becoming a partner in a parenting interaction that does not facilitate positive growth of development. In his study of maternal attachment Klaus (Note 1) has developed the axiom, "You can't love a dish rag." This in sum depicts the role an infant plays in creating a risk situation out of parenting interaction. The "dish rag" infant or baby whose responses are incongruent with maternal overtures fails to release positive maternal attachment or to rein- force nurturant care. The reciprocity between mother and infant has been shown to be in part contingent upon the infant's behavior. Summary and Conclusions Escalona in her classic work Roots of Individuality (1968) first drew attention to the interaction between sensitivities of individual infants to different sensory modalities and characteristic stimulation patterns of individual mothers. This focus on the inter- action of maternal and infant variables is central in this review which attempts to describe the ways in which patterns of experience for individual infants and the behavior styles which evolve from 56 them are the product of the response of both partners in the rela- tionship. The findings reported in this review all indicate that from conception interrelationships exist among maternal attitudes, emotionality during pregnancy, child rearing styles, socioeconomic status, obstetric complications,and infant behavior. A chronological progression has been followed in examining these factors as they are related to the potential of the parenting relationship. The review began with a description of factors which dispose a woman to a high risk pregnancy. Maternal attitudes and emotionality during pregnancy are related to obstetric complications, child rearing attitudes, and to behavior patterns of the newborn infant. Intrauterine environ- mental factors were then discussed as they relate to both the mother and the infant. A mother's situational circumstances and expe- riential background of having received nurturant care were also considered as they play a role in parenting behavior. Neonatal outcome and the infant's physical and environmental characteristics were next reviewed. All these factors must be considered in evaluat- ing Parenting Potential. In considering the potential of a parenting relationship the interaction of these possible variables has been explored. Long term follow up studies of infants placed in categories on the basis of hypoxia, asphyxia, or prematurity, without regard to other peri- natal or neonatal events, have not been successful in defining the degree of risk to an infant's future development (Parmelee & Haber, 1973). The concept of Parenting Potential can, however, facilitate 57 the broader perspective necessary for examining the variety of pre and postnatal variables operating in this interaction. A major study conducted by Werner, Simonian, Bierman, and French (1967) on the cumulative effects of perinatal complications and deprived environment on the physical, intellectual, and social development of preschool children provides support for a compre- hensive approach to the assessment of child development. Smith, Flick, Ferriss,and Sellman (1972), in identifying the apparent multi- determined nature of developmental outcome, have also concluded that a multivariate approach is necessary to determine the predictive accuracy of factors believed to be related to developmental outcome. The research design proposed by Davids (1968) provides an appropriate framework for examining Parenting Potential in light of the multideterminant nature of the factors identified by others as important indicators of developmental outcome. He suggested that if mothers were studied prior to childbirth, and then if the mothers and their children were studied at subsequent times in formative stages, it would be possible to discover the bilateral effects of a child's temperament and behavior and the mother's attitudes and behavior on the child. Such an approach could provide definitive information that would more clearly specify indicators of the potential risk of a parenting relationship. Aubry and Pennington (1973) stated that the common goal of modern obstetrics and pediatrics is to maximize the quality of fetal, newborn and infant life in such a manner as to give every individual conceived the greatest optimal physical, mental, and 58 emotional development. To maximize this human potential, this review highlights the need for a perspective on develOpment as more than a function of biological ontogeny. Pregnancy must be approached with delicate attention paid to the intimate interactions between a dependent organism and the environment which will provide for its emerging capacities. The nurturance and stimulation which parenting provides come from generic feelings of parental attachment to the newborn child. These feelings of parental attachment become manifest in the earliest interactions between a mother and her newborn and influence the quality of their relationship and the child's attainment of his human potential. CHAPTER III METHODOLOGY Research Design The time frame illustrated in Figure 2 was employed for the data collection in this study. T1 T2 T3 3rd Trimester of Hospital 4 Weeks Postpartum Pregnancy Figure 2.--Time Frame of Data Collection. This is a descriptive study which used a prospective repeated measures design. At each point in time during the data collection different measures were made of maternal and/or neonatal variables assumed to affect or reflect maternal attachment and the process of mother-infant adjustment. The data collected during the third tri- mester of pregnancy (T1) permit an analysis of the extent to which demographic, experiential, and stress factors during pregnancy and the planning and management of pregnancy itself predict behavioral indications of attachment and the future mother-infant adjustment. 59 60 The data collected during the time of the mother's and the infant's hospitalization (T2) provide assessments of the overt mani- festations of the mothers' responsiveness to their newborns and eval- uations of the newborns' behavioral characteristics. These data are then used to predict mother-infant adjustment four weeks following birth (T3) assessed by responses to psychological inventories and observations of mother-infant interaction.1 These measures permit an analysis of the predictive validity of the measures made during pregnancy and the immediate postpartum period. Measurement Presented in Table l is information about the measures employed in this research. A description of the type of data col- lected and the instruments used are listed according to the time frame of this study and the number by which the research variables are identified. A complete listing of the variables by their numbers appears on pages 9-11. Hypotheses and Methodological Questions To answer the comprehensive research question concerning the early prediction of Parenting Potential, the folloiwng hypotheses and methodological questions were posed: Hypotheses Ho 1: There are no relationships between the background varia- bles (1.01-2.03) and a woman's maternal responsiveness to her newborn in the delivery room (4.01). 1Originally the T3 data was to be collected six weeks follow- ing delivery. 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Consequently, extensive contact with the entire spectrum of the hospital had to be made to inform these individuals of the purpose of the study and of how their cooperation would be essen- tial. The procedure for seeking permission was linked to the process of seeking cooperation; how the hospital came to be involved with the study will be described in terms of the actions taken. Dr. Thomas Helmrath, a member of the faculty of the College of Human Medicine at Michigan State University, who also serves as chief of staff of the Newborn Service at E. W. Sparrow Hospital, helped make the initial contacts with the key personnel to inform them of the general nature of the proposed study. Approximately five months before the proposal was submitted to the hospital research committee, Dr. Helmrath distributed a paper prepared by the investigator entitled "Perinatal Indicators of High Risk Parenting" (Wilson, Note 6). This paper was read by members of the nurSing staff and physicians, and it served as an introduction to the general nature of the study to be conducted. The investigator was also working closely with Dr. Ray Helfer of the College of Human Medicine. This association facilitated the credibility of the study as an attempt to make early predictions about patients who may be high risk parents. Prior to the submittal of the proposal for committee approval, several other actions were taken to expose the hospital staff to the 84 content of the proposed research. The investigator attended weekly discharge conferences for the Neonatal Intensive Care Unit where the issues of family attachment were discussed in reference to each of the newborns whose cases were reviewed. Through these meetings general acquaintances with the house officers and nursing staff were established. Another preliminary step taken before beginning with the data collection was the establishment of contact with the nursing staff in Labor and Delivery. The investigator spent several weekends with this service observing deliveries and discussing the nature of the proposed research with the nursing personnel. The arrangements to make these observations were made by Dr. Helmrath through the office of the Head of the Department of Maternal and Child Nursing. The time spent with this service was the beginning of the future development of a working rapport with these individuals. The topic of attachment was also the subject of a presenta-“ tion that was given at Pediatric Grand Rounds. The investigator and another graduate student doing a similar project presented talks in which the general nature of the research was explained. At this time questions from the group attending the presentation began a rather lively discussion of the hospital's role in facilitating attachment. Throughout these preliminary contacts close ties were maintained with the pediatric social worker who provided helpful advice on procedural and logistical formalities. Once the hospital research committee granted approval of the study, contacts were establsihed with key personnel in the nursing 85 department. The Head of the Department of Maternal and Child Nursing asked the investigator to present a talk about the study at a meeting of head nurses of the Labor and Delivery, Postpartum, and Nursery Services. Presented at this meeting was a thorough description of the observations to be made in the hospital, and information concern- ing the entire scope of the study and its implications for patient care were discussed. It was at this meeting that the idea of video taping mothers in the delivery room was first presented to the staff of head nurses. The video taping was a necessary preliminary task that needed to be completed so that a rating scale could be developed for use in the formal data collection of the research project. At first the nurses' reactions were guarded with comments about how crowded the room would be, how the physicians might refuse, and how patients might not be willing. After discussion, the head of the Department and the head nurse in Labor and Delivery agreed it would be worth a try on a limited basis. The group was assured that all attempts would be made by the investigator to be as unobtrusive as possible. The investigator requested that the nursing staff be quite frank in letting her know if she was ever disrupting to hospital procedures. On another occasion a talk was given as a part of the nurs- ing staff's continuing education program. At this time the staff nurses were asked to engage in a discussion of possible variables that could be used in assessing maternal responsiveness in the delivery room. This provided an excellent opportunity again to 86 explain the nature and purpose of the study and to elicit the nurs— ing staff's input to the study. This effort helped increase the hospital staff's interest in the uniqueness of the research and emphasized how their cooperation would be a major contribution to the project. Prior to this meeting a description of the Brazelton Neonatal Behavioral Assessment Scale (Appendix E) was distributed to the entire Newborn Service. At this time questions about how the exam is administered were answered and the significance of its findings were discussed. It was necessary that the investigator administer 10 Brazelton exams before she could be tested for reliability. Per- mission to use newborns for these practice exams was granted through the attending physician who also contacted a private pediatrician. Newborns under these physicians' care were used in preliminary trials after their mothers gave verbal consent. Since this was a new pro- cedure in the nursery, time was spent with the nurses explaining the exam each time it was administered. After several weeks of work- ing in the nursery the investigator became known to the staff who were helpful in arranging for the exams to be administered. When the actual collection of the data began, cooperation was maintained through informal contact, mainly over coffee in the nurses' lounge. Throughout the extent of the data collection con- tinuous attempts in as nonthreatening manner as possible were made to stress the importance of the Labor and Delivery Nurses calling the investigator when one of the study patients was admitted to the 87 hospital. It was after several informal talks with one of the nurses that a system was developed to facilitate this contact. Notes were placed on the patients' prenatal records which are filed in the hospital. The nurse's suggestion of attaching notes on these records was an excellent one since they are pulled and placed in each patient's chart when she is admitted to the hospital for delivery. Although the patients were asked to call the investigator when they left home for the hospital, in many cases they forgot and the nurses' call provided the only way of informing the investigator of the patient's admittance to the hospital. Occasional boxes of warm cookies brought to the nurses and an honest attempt at maintaining congenial relations most likely helped contribute to the good working relations that were maintained. The house staff physicians were also included in the informal dis- cussions about the study. The investigator was contacted in time to attend each of the deliveries. This record speaks well to the rela- tions that were established and the real effort made by the nursing staff to be of assistance to the investigator. The feeding observations were made in the postpartum ward several days after delivery. The nurses were informed of how these observations were to be conducted, and they required very little cooperation on the part of the hospital staff. The nursery nurses' assistance was needed only in helping to arrange for babies to be wheeled to the treatment room where the Brazelton Exam was admin- istered. Attempts were always made to explain the exam to the 88 nurses, and they were most helpful in providing information concern- ing the newborn's feeding schedule. Physician and Practice Contact Once the hospital research committee approved the proposal, steps were taken to seek cooperation with a group practice and public health clinic. The study protocol required that the physicians be willing to have an observer present in the delivery room and to have his patients contacted and asked to participate in the study. The choice of which group practice to contact was made by Dr. Helmrath. The practice that was selected was chosen because of its size and the general sensitivity of this group of physicians to the issues involved in the study. An appointment was made with the senior member of the practice at which time the investigator explained the nature of the :proposed involvement. Contact was also made at this time with the Obstetric Nurse Practitioner who had extensive contact with each of thepatients receiving care through this office of physicians. It took several weeks of working with the clerical staff and the nurses working in this practice before the logistics of the procedure for contacting patients was established. After several visits to the office, one of the receptionists explained to the investigator the practice's system of sorting the patient's charts. All the obstetric charts are bound in color-coded folders and filed on the same shelf of the automatic filing system. After learning this system, the investigator, with the help of the clerical staff, 89 pulled each of the charts of primiparous patients with an expected date of delivery within the time frame of the data collection. From the chart the woman's name, due date and telephone number was noted. This information provided the investigator with a complete list of all potential subjects to be contacted. The next step involved attaching to each of these charts a card (Appendix F) signed by the physicians and addressed to the patient. On this card was a brief statement explaining the nature of the study and an introduction of the investigator as a student doing a research project. A list of all potential subjects was given to the receptionist who checked off the names of patients, who were given the cards as they arrived in the office for their appointments. It was the clerical staff's assistance in explaining how the charts are filed that greatly helped in developing this system for contacting patients. The nurse practitioner was also most kind in introducing the investigator to the patients after the cards were given to the potential subjects. The nurse also carefully answered each patient's questions and described the study in a positive manner. After several weeks of contacting patients through the pri- vate practice, contact was made with a public health clinic. It was felt that patients from this practice would add to the heterogeneity of the sample. The initial contact was made through Dr. Helfer, who spoke with a senior physician of the Family Practice Center who ' attends at the clinic selected. With the initial contact made, the 90 investigator met with the clinic coordinator, who granted permission to use the clinic's patients as potential subjects. Obtaining this permission was facilitated by prior contact with the private practice. The clinic had developed a rigid policy of screening proposed research studies to protect its patients from being used as subjects because of their low poverty status. .The clinic coordinator, who expressed a great deal of interest in the study, did not perceive ' this study as exploiting the patients and immediately provided access to the patients' charts. The same procedure used in the private practice for making contact with patients was established with this clinic population. However, contact was a more simplified process with these potential subjects since the clinic has two scheduled times when patients are seen on a routine basis for pre— natal care. This schedule provided an establiShed time when the investigator could meet with the patients to explain the study. Patient Contact After each of the patients received the card introducing the investigator, direct contact was made with the patient. The investi- gator met the patients in the office or clinic during each woman's last trimester or pregnancy. This contact was made either in a semi-private part of the waiting room or in one of the physicians' offices where the patient could feel free to talk and ask questions. At this time the investigator introduced herself as a graduate stud- ent in child development working with the pediatric department of the Michigan State University medical school. The woman was told 91 that the project was studying early mother-infant interaction in order to understand better how a mother begins to know her baby. It was explained to the woman that, if she chose to participate in the study, she would be asked to fill out a questionnaire while waiting for her doctor's appointment. The investigator also explained to the woman that, if she agreed to be in the study, she and her baby would be observed in the delivery room, during a feeding, and that the baby would be giVen a behavioral examination. The follow-up part of the study was also explained, and the women were told that four weeks following delivery they would be visited at home to be observed again during a feeding and to fill out another questionnaire. The patients were assured that all information would be kept strictly confidential,identifiable only by a number. If the patient agreed to participate in the study, she was given an informed consent form to sign (Appendix G). At this time she was also asked to respond to the initial questionnaire. Each woman was given a card (Appendix H) with the investigator's home and page-boy telephone number and was asked to call these numbers when she left home for the hospital. In cases where the patient chose to discuss the study with her husband before agreeing to consent, a letter describing the study (Appendix I) was given to the woman and arrangements were made to make telephone contact with her to arrange for another meeting in the doctor's office. If the patient refused to participate in the study, an attempt was made to understand the reason for the refusal. 92 It was apparent that the personal contact made with the patients by the investigator greatly facilitated their granting permission. On a preliminary basis the nurse practitioner intro— duced the study to six patients and each of these women refused to participate. With personal contact by the investigator, two women changed their minds but a few continued to refuse. It is of impor- tance to note that on two occasions when permission was refused in the doctor's office, it was granted when, by coincidence, the inves- tigator met with the patient at the hospital after her admission to the hospital. It seemed that at this time the women were faced with the reality of the situation and they no longer cared if another person was present in the delivery room. On several occasions when the investigator was unable to make contact with a patientin the office or clinic, contact was made for the first time in the hospital during the patient's early stages of labor. It is significant to note that at this time each of the patients contacted agreed to participate. It appears that though women were approached only when they were judged fully capable of granting informed consent, they were much more willing to agree to participate in the study when the hospital setting and the delivery process seemed more real to them. Procedures for Data Collection At T1 the data were collected at the same time permiSSion was granted by the subjects to participate in the study. In the great majority of cases this took place in the obstetrician's office when the subject was waiting for her routine prenatal visit. 93 The data collected at T2 during the subjects' hospital stay involved careful coordination with the hospital staff and the inves- tigator. Either the subject or the nursing staff contacted the investigator when a subject was admitted to the hOSpital. When the subject was taken to the delivery room the investigator,dressed in a scrub dress, stood against the side or back wall of the room with a clip board and made the observational ratings. The feeding observations were made by an observer trained by the investigator who sat near the mother's bed during the feed- ing. The observer scrubbed and gowned and compiled with the hospi- tal regulations concerning visitation to the postpartum floor. The Brazelton exams were administered by the investigator in the hospital treatment room which was dimly lighted and heated to a 80° tempera- ture. This room is isolated from the sounds of nursery and provided a quite place to examine the newborns. The investigator scrubbed and gowned complying with hospital procedures. As the investigator made the observations with both the Delivery Room Observation Scale and the Brazelton Neonatal Behavioral Assessment Scale the possibility of observer bias does exist. Every attempt, however, was made to maintain objectivity with the use of these instruments. The procedural logistics of the data collection required that this arrangement for data collection be implemented. At T3 the data were collected during a home visit made when the infants were between the ages of 4 and 5 weeks old. The mean age of the infants at the time of the assessment was 30.4 days 94 with a S.D. of 3.49 days. For each of these assessments one of the two trained research assistants called the mother and arranged for a convenient time to make the home visit when the baby would be feed- ing. To prevent possible bias, the research assistant who had not observed the mother and newborn in the hospital administered the questionnaire and the interview and made the feeding observation during this home visit. The entire visit took between 45 minutes to one hour to complete. All data was collected for this study between March 1, 1975, and July 3, 1975. The first delivery room observation was made on March 8, 1975. Sample Description The women asked to participate in this study were being cared for by the two group medical practices which had agreed to cooperate with the research project. Only primiparous women and their newborns having minimum Apgar Scores of eight at the five minute evaluation were included in the sample. An attempt was made to contact every primiparous patient in each practice who was expected to deliver within the time frame of the data collection. Contact was made with all but approximately five patients who ' delivered before the investigator was able to discuss with them the possibility of their cooperation with the study. The recruitment of the sample is described in Table 2. Seventy-five potential subjects were approached and asked to partici- pate in the research project. Eleven women in the private practice 95 ow — op NF mo NF mu 4wpmo “mom mmwcm>wpmo FmUPvmz mmcm< mmaemm mucmwumm .ucmEpwacumm mFQEmm--.~ ubm 5 yrs. N%N% N.% N % 11% Private practice 4 12.1 6 18.2 5 15.2 12 36.4 6 18.2 Clinic ' practice 3 42.9 3 42.9 - --- 1 14.3 - --- TOTAL 7 17.5 9 22.5 5 12.5 13 32.5 6 15.0 The 40% of the study population who were unmarried or who conceived out of wedlock contrasted markedly with the 17% of the unmarried patients who refused to participate in the study. Of the entire group who refused to participate, 85% were married for more than nine months with 61.5% being married for more than 2.5 years. As a group, those that rejected participation in the study were older and were married for a longer priod of time than those women who agreed to participate. Ethnic Background Table 5 indicates that the sample population as a whole was 85.0% white and 5.0% black. There was one Oriental and three Mexican-Americans in the research sample. Income As indicated in Table 6, there was a clear difference in income levels between the two groups in the sample population. In 99 TABLE 5.--Percent and Frequency Distribution of Sample by Ethnic Background. White Black Oriental Other N % N % N % N % Private practice 30 90.9 2 6.1 O O l 3.0 Clinic practice 4 57.1 0 O 1 14.3 2 28.6 TOTAL 34 85.0 2 5.0 l 2.5 3 7.5 the clinic population, 85.7% had an income of less than $4,000 but only 24.2% of the subjects in the private practice had this low a level of income. All subjects in the clinic group had incomes below $6,000 while only about 30% of the subjects in the private practice were represented at this income level. The remainder of the subjects in the private practice were distributed throughout the range of income categories, with 60% of this group earning more than $10,000 a year. In the total sample population, 50% earned more than $10,000 a year. Education Table 7 shows that as a group, the clinic subjects had less education than those being cared for by the private practice. Of the subjects in the clinic practice, 42.9% had only an eighth grade education and 57.1% of these subjects had not graduated from high school. In the private practice, 84.8% had completed high school 100 o.mp m o.o~ m m.~ m m.~ m o.mm a, swcm & z w z N z N z x z a z ooo.o~» ooo.omumpw coo.mpuopw ooo.opuom ooo.mnem ooo.¢w .Pm>m4 msoucm Xa opaEmm mo cowpsapcumwo zucmzcmcu ucm u:wocma--.e m4mwcm N z a z N z a z a z a 2 oz mm> pomucou umuwewg cvumcweoom oz mm> coppmusum Pmamcmcm coFuao menu Pmuwamo: mcpccmpa zucmcmmca .mwpnmwcm> acmEmmmcmz zucwcmmca An opasmm compznwcumwo xucmaamcm use ucwucmm--.m m4m<~ 103 population, 67.5% of the subjects preferred to have a rooming-in arrangement which would permit them nearly unlimited contact with their newborn. The two groups did differ in their participation in pre- natal education programs. While 63.6% of the private practice sub- jects attended special classes, only 28.6% of the clinic subjects received some kind of prenatal education. Medical Information Labor and Delivery As shown in Table 9, the mean length of the subjects' labors was 10.56 hours with a S.D. of 5.11 hours. Twenty-eight of the deliveries were spontaneous and 12 required the use of forceps. Of the 40 deliveries, one was a breech presentation and the remainder were vertex presentations. TABLE 9.--Samp1e Labor and Delivery Information. Length of Delivery: Presentation: Labor Spontaneous Forceps- Vertex Breech ’ _ . Outlet Low Mid M 5.0. N N N N N N Total Sample 10.56 5.11 28 7 3 2 39 1 During labor all but two of the subjects received some form of medication between one and ten hours prior to the delivery. The medication consisted of moderate amounts of sedative and/or analgesic 104 drugs (10 to 75 mg of valium, vistaril, demerol). The dosages were judged to be insufficient to have affected the subjects' behavior at the time of delivery. Thirteen of the women received para-cervical anesthetic blocks during labor. At the time of delivery, with the exception of two subjects who were given spinal blocks, all subjects received "a local anesthetic alone or in combination with a pudendal anesthetic and/or small amounts of nitrous oxide. Newborn Characteristics Table 10 shows that in the sample of 40 newborns, 18 were female and 22 male. The mean birth weight of the newborns was seven pounds, four ounces with a S.D. of 13.9 ounces. The mean Apgar score of the total sample at one minute was 8.23 with a S.D. of 1.25. The mean Apgar score of the total sample at five minutes was 9.03 with a S.D. of .43. TABLE lO.-—Sample Newborn Characteristics. Sex: ‘ Birth Weight Apgar Score Apgar Score Male Female 1 minute 5 minutes N N . M S.D. M 5.0. M S.D. Total Sample 22 18 7 lbs. 4 02. 13.9 02. 8.23 1.25 9.03 .43 105 Method of Feeding At the time of the hospital feeding observation, 18 of the mothers were bottle feeding their newborns and 22 were breast feed- ing. By the time of the four-week postpartum home visit, 27 of the mothers were bottle feeding. Five mothers in the sample had stopped nursing during the first month and had begun to bottle feed their infants. Data Analysis The background information about the subjects in this study was analyzed separately by each of the two populations from which they were recruited. This strategy was employed just for the analysis of the data required for the sample description. The results of the research reported represents a collective analysis of all data collected in the study. The nature of the research question required as much variation as possible in the measurements, and the heterogeneity of the.two sample populations combined provides for this need. Multiple regression analyses using a stepwise procedure . were employed to investigate the predictive significance of the obser- vational measures used in this study. Pearson Product Moment Corre- lations were used to clarify relationships between the specific behavioral observations made at different points in time, and observed behaviors and attitudnal assessments were made at the time of the home visit four weeks following delivery. Analyses of vari- ance were employed to evaluate the internal consistency reliabilities 106 of the observational rating scales used and the relationships between specific variables and the mean total scores of maternal responsiveness. A probability level of .05 was used to reject the null hypotheses. Multiple regression, the primary strategy used for the analysis of the data in this study, provided a means of examining the effects and magnitudes of the effects of more than one inde- pendent variable on one dependent variable. This analysis technique was used to identify a linear prediction equation and to evaluate its predictive accuracy. A stepwise technique was used with the multiple regression analyses performed. This procedure determines the order of the inclusion of the variables in the overall predictive equation by the respective contribution that each variable makes to the variation of the dependent variable. The variable which accounts for the great- est amount of the variance in the dependent variable is entered first in the equation. The variable that explains the greatest amount of variance in conjunction with the first is entered second in the equa- tion. The ordering of the variables noted in the tables represents this stepwise procedure of adding variables in terms of their rela- tive contribution to the overall prediction of the dependent variable. The formula for a multiple regression equation is: Y=A+BIXI+BZX2 107 In the formula "Y" represents the dependent variable and "X1" and "X2" represent the independent variables. "A" in the formula is the “constant," so labeled at the end of each variable list repre- sented in the tables. The constant, or Y intercept of the linear equation, represents the predicted value of Y when X = O. The "B1" in the formula is the partial regression coeffi- cient and stands for the expected change in the dependent variable (Y) associated with a change of one unit in X] when X2 is held con- stant. Similarly, "B2" stands for the expected change in Y with a unit change in X2 when X1 is held constant. These partial regression coefficients or regression weights are identified in the tables as "Beta" and stand for the relative contributions of the independent variables to the dependent variable. The overall accuracy of the prediction equation is repre- 2 reflects the proportion of variation explained sented by "R ." The R by the variables in the regression equations. The standard error of Beta, noted in the tables as “Standard Error of Beta," represents the variance of the partial regression coefficient. "Cumulative Probability" represents the degree of confidence with which the pre- diction equation including each of the reported variables can be interpreted as having occurred by chance. The notion "stepwise p" appearing at the bottom of each table indicates the probability that the noted predictor independent variables (or that variable and the preceding variables) could be a chance occurrence. CHAPTER IV RESULTS Research Findings The results of the data analyses will be presented in terms of the specific research hypotheses.‘~ Hg_l: There are no relationships between the background variables and a woman's maternal responsiveness to her newborn in the delivery room. In order to investigate this hypothesis, a stepwise multi- ple regression analysis was implemented. The total score of maternal responsiveness in the delivery room was used as the depend- ent variable, and the background variables were used as the independ- ent variables. As indicated in the results of the analysis reported in Table 11, the two variables which contribute most to the signifi- cant relationship are age and choice of rooming-in, their respective probability levels being .006 and .029. Hypothesis 1 is rejected. To further investigate the factors contributing to maternal responsiveness in the delivery room, the following hypothesis was generated. Hg_la: Factors related to labor and delivery do not effect the relationship between background variables and maternal responsiveness in the delivery room. 1A matrix of the Pearson Correlation Coefficients of all ordinal variables used in the data analyses is presented in Appendix J. 108 109 TABLE ll.--Results of a Stepwise Multiple Regression Analysis Pre- dicting Maternal Responsiveness in the Delivery Room from Background Variables. .2 31:12:? 3:113:11; Age .1656 .1802 .5441 .009** Choice of rooming-in .2779 7.662 3.530 .002* Planning of pregnancy .3296 8.852 3.515 .002 Prenatal education .3481 3.743 4.393 .004 Income .3614' -2.864 1.520 .007 Length of marriage .3893 2.821 1.919 .009 Stress during pregnancy .4091 - .0172 .0136 .012 Personal resources for child rearing .4335 .2499 .1966 .014 Education .4417 1.380 2.068 .022 Constant 7.000 12.90 *stepwise p_< .05 **stepwise p_< .01 110 With the variables father's responsiveness in the delivery room and length of labor added to the multiple regression equation, Table 12 shows that father's responsiveness contributes most to this new equation, with rooming-in continuing to account for approximately 10% of the variation of the dependent variable. The probability levels of these two variables are respectively .006 and .029. Age in this new equation becomes the least predictive variable when it is combined with these additional factors. These findings support the rejection of Hypothesis 1a. Ho 2: There are no relationships between the background variables and a woman's maternal responsiveness to her newborn during a hospital feeding. As indicated on Table 13, age and choice of rooming-in are the two most salient predictors of the dependent variable, total score of maternal responsiveness during a hospital feeding. These two variables contribute to the multiple regression equation with probability levels of .006 and .052. Thus the null hypothesis is rejected. To investigate the significance of other measures of maternal behavior and neonatal behavior, Hypothesis 2a was developed. Ho 2a: Neonatal behavioral and physical characteristics and maternal responsiveness in the delivery room do not effect the relationship between the back- ground variables and a woman's maternal respon- siveness to her newborn during a hospital feeding. The results of adding these additional variables to the regression equation are reported in Table 14. As indicated in the table, with a broader range of variables being considered, the total 111 TABLE 12.--Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness in the Delivery Room from Background Variables and Labor and Delivery Variables. .2 34:32:? 3:213:11; Fathers' responsive- ness in delivery room .1836 .4974 1.288 .OO6** Choice of rooming-in .2830 7.573 3.603 .002* Planning of pregnancy .3384 7.785 3.797 .002 Stress during pregnancy .3704 - .017 .014 .002 Length of labor .4031 .2540 .2956 .003 Prenatal education .4167 3.052 4.817 .005 Income .4240 -2.304 1.748 .008 Length of marriage .4350 2.086 2.179 .013 Personal resources for child rearing .4475 .1918 .2085 .020 Education .4600 1.200 2.133 .028 Age .4614 .1499 .5602 .047 Constant 8.522 13.43 *stepwise p_< .05 **stepwise g_< .01 112 TABLE l3.--Resu1ts of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness during a Hospital Feeding from Background Variables. R2 3:12:21: 3:215:90; Age .1855 .7485 .4655 .006** Choice of rooming-in .2653 3.755 3.120 .003* Education .3008 -2.302 1.794 .005 Stress during pregnancy .3226 — .0119 .0117 .007 Planning of pregnancy .3336 4.193 3.007 .013 Prenatal education .3563 4.389 3.759 .018 Personal resources for child rearing .3691 .0906 .1681 .027 Income .3803 41.551 1.386 .040 Length of marriage .3960 1.448 1.642 .052 Constant 31.463 11.037 *stepwise p_< .05 **stepwise p_< .01 113 TABLE l4.--Results of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness during a Hospital Feeding from Background Variables, Maternal Respon- siveness in the Delivery Room, and Neonatal Character- istics. . 2 Standard Error Cumulative Variables R Beta of Beta Probability Total score of maternal responsive- ness in the delivery room .2228 .2210 .1454 .002* Length of marriage .2916 .2281 1.308 .002 Choice of rooming-in .3181 1.920 3.101 .003 Age .3345 .8456 .4842 .006 Education .3726 -3.012 1.655 .006 Personal resources for child rearing .3918 - .1495 .1694 .008 Prenatal education .4060 4.161 3.725 .013 Newborn interactive processes .4127 -1.207 1.897 .021 Planning of pregnancy .4163 1.168 2.710 .036 Constant 29.85 10.25 Note. The variables income, stress during pregnancy, discrepancy between actual and desired sex of newborn, newborn motoric processes, newborn physiological response to stress, and newborn physical appearance did not contribute significantly to the multiple regression equation. *stepwise p_< .Ol. 114 score of maternal responsiveness in the delivery room becomes the most predictive variable of maternal behavior during a hospital feeding. This variable has a probability level of .002, and the variables age and choice of rooming-in are no longer significant predictors, having probability levels in this new equation of more than .05. The null hypothesis 2a is therefore rejected. ‘flg_§: There is no relationship between a woman's maternal responsiveness to her newborn in the delivery room and her responsiveness to her newborn during a hospital feeding. The Pearson Product Moment Correlation Coefficient of total score of maternal responsiveness in the delivery room and the total score of maternal responsiveness during a hospital feeding is .4720 (p < .01). This finding reported in Appendix J supports the rejection of the null hypothesis. Ho 4: There are no relationships between the background variables and neonatal behavioral characteristics. To test this hypothesis, each of the four behavioral dimensions assessed in the neonatal evaluation were used as depend- ent variables. These variables are interactive processes, motoric processes, organizational processes of state control, and organiza- tional processes of physiological response to stress. Of these four behavioral dimensions, significant relationships were identified between the background variables and the newborn's interactive processes and organizational processes of state control. Hypothesis 4 is thus rejected. As shown in Table 15, age contributes most to the multiple regression equation used to predict the dependent variable of 115 TABLE 15.--Results of a Stepwise Multiple Regression Analysis Predicting Newborn Interactive Processes from Demographic and Stress Variables. . 2 Standard Error Cumulative Var1ables R Beta of Beta Probability Age .1214 .0762 .0307 .028* Length of marriage .1712 -.1712 .1107 .031 Planning of pregnancy .1918 .2082 .2179 .051 Constant .0868 .5039 Note. The variables education, income, and stress during pregnancy did not contribute significantly to the multiple regression equation. *stepwise p_< .05. interactive processes. This prediction is significant at .028. It is reported in Table 16 that income is the strongest predictor of the newborn's ability to control state behaviors. This variable contributes to the multiple regression equation, with a probability level of .008. Ho 5: There are no relationships between neonatal behavioral and physical characteristics and maternal responsiveness during a feeding four weeks following delivery. The results from the stepwise multiple regression analysis shown in Table 17 indicate that only the newborn's interactive processes predict later maternal responsiveness. Because this pre- dictor has a probability level of .035, this analysis supports the rejection oftherunl hypothesis. 116 TABLE 16.--Resu1ts of a Stepwise Multiple Regression Analysis Predicting Newborn Organizational Processes of State Control from Demographic and Stress Variables. 2 Standard Error Cumulative var'ab'es R Bata of Beta Probability Income .1704 .1637 .0996 .008* Stress during pregnancy .2003 -.0012 .0009 .016 Length of marriage .2360 -.1891 .1299 .020 Age .2510 -.0272 .0324 .034 Constant 1.643 .6283 Note. The F-Levels of the variables education and planning of pregnancy were insufficient for these variables to be included in the multiple regression equation. *stepwise p_< .01. TABLE 17.--Resu1ts of a Stepwise Multiple Regression Analysis Predicting Maternal Responsiveness during a Feeding Four Weeks Following Delivery from Neonatal Behavioral and Physical Characteristics. . 2 Standard Error Cumulative var'ab'es R Beta of Beta Probability Newborn interactive processes .1115 4.005 2.041 . .035* Discrepancy between actual and desired sex of newborn .1592 4.129 2.852 .040 Constant 24.19 4.728 Note. The variables physical appearance of newborn, newborn physio- logical response to stress, newborn state control, and new- born motoric processes did not significantly contribute to the multiple regression equation. *stepwise p_< .05. 117 Hypothesis 5a was generated to explore further the predictive capability of maternal behavioral variables in combination with the neonatal behavioral and physical characteristics. Ho 5a: Maternal responsiveness in the delivery room and during a hospital feeding do not affect the relationship between neonatal character- istics and maternal responsiveness during a feeding four weeks following delivery. It is indicated in Table 18 that the newborn behavioral characteristic interactive processes contributes less to the depend— ent variable than does the total score of maternal responsiveness measured during the hospital feeding. However, in combination with this variable, the newborn interactive processes continue to account for 11% of the variation in the dependent variable that was identi- fied when newborn characteristics alone were used as predictive variables. The probability levels of the total score of maternal responsiveness during a hospital feeding and the newborn interactive processes are .001 and .014. These results from the analysis support the rejection of the null hypothesis. Hg_§: There are no relationships between background variables and maternal responsiveness during a feeding four weeks following delivery. Using a stepwise multiple regression analysis to predict the dependent variable maternal responsiveness during a feeding four weeks following delivery, age, and choice of rooming-in are the most predictive of the background variables. The data presented in Table 19 show that these two variables, having probability levels of .000 and .004, account for .5127 of the variation of this dependent variable. Hypothesis 6 is rejected. 118 TABLE lB.--Resu1ts of a Stepwise Multiple Regression Analysis Pre- dicting Maternal Responsiveness during a Feeding Four Weeks Following Delivery from Neonatal Behavioral and Physical Characteristics and Maternal Responsiveness in the Delivery Room and during a Hospital Feeding. 2 Standard Error Cumulative var‘ab'es R Be“ of Beta Probability Total score of mat. responsiveness during a hospital feeding .2760 .5510 .1729 .001* Newborn interactive processes .3853 4.141 1.895 .000* Discrepancy between desired and actual sex of newborn .4325 4.283 2.487 .000 Newborn physical appearance .4524 -2.224 2.240 .000 Total score of mat. responsiveness in the delivery room .4584 .0842 .1489 .001 Newborn motoric processes .4594 - .6797 2.559 .002 Newborn state control .4598 .3345 2.052 .004 Constant 5.615 10.36 Note. The F-Level of the variable newborn physiological response to stress was insufficient for this variable to be included in the multiple regression analysis. *stepwise p_< .Ol. 119 TABLE l9.-—Resu1ts of a Stepwise Multiple Regression Analysis Pre- dicting Maternal Responsiveness during a Feeding Four Weeks Following Delivery from Background Variables. .2 22:22:: 2:22 2:222:22. Age .3875 .6345 .4319 .000* Choice of rooming- in .5127 8.649 2.746 .000* Income .5383 .6935 1.161 .000 Prenatal education .5533 -4.619 3.263 .000 Education .5613 1.696 1.668 .000 Length of marriage .5664 1.200 1.533 .000 Personal resources for child rearing .5717 .0986 .1566 .000 Constant .9244 10.25 Note. The F-Levels of the variables planning of pregnancy and stress during pregnancy were insufficient for these varia- bles to be included in the multiple regression equation. *stepwise p_< .01. 120 Hypothesis 6a was generated to evaluate how predictive the background variables would be in combination with neonatal character- istics and maternal behavior. Hg_§a: Neonatal behavioral and physical characteristics and maternal responsiveness in the delivery room and during a hospital feeding do not affect the relationship between background variables and maternal responsiveness during a feeding four weeks following delivery. As shown in Table 20, the variables age and choice of rooming-in remain the most salient predictors regardless of their combination with the measures of maternal and neonatal behavior. Their respective levels of probability remain unchanged at .000 and .004. The null hypothesis 6a is not rejected. Analyses of variance of the mean total scores of maternal responsiveness during a feeding four weeks following delivery across age groups and by choice of rooming-in were conducted to further clarify these findings. The subjects were divided into two groups: those less than or 24 years of age and those older than 24 years of age. As reported in Table 21, the analysis revealed a significant difference (p < .006) between these two groups, with the older group having higher scores of maternal responsiveness. When the total sample was divided into two groups by the age 26, differences in the mean scores were no longer significant (p < .081). The analysis of variance of mean total scores of maternal responsiveness during a feeding four weeks following delivery across the groups preferring the hospital option of rooming-in and those not selecting this option is reported in Table 22. The analysis 121 TABLE 20.--Resu1ts of a Stepwise Multiple Regression Analysis Pre- dicting Maternal Responsiveness Four Weeks Following Delivery from Background Variables, Neonatal Character- istics, and Maternal Responsiveness in the Delivery Room and during a Hospital Feeding. . 2 ‘Standard Error _Cumu1ative Var1ab1es R Beta of Beta 'Probability Age .3876 -.O738 .5036 .000* Choice of rooming-in .5127 7.672 3.148 .001* Total score of mat. responsiveness during a feeding .5463 .4784 .1751 .000 Discrepancy between actual and desired sex of newborn .5754 4.282 2.442 .000 Income .6066 1.891 1.889 .000 Newborn interactive processes .6399 3.025 1.889 .000 Education .6563 3.374 1.896 .000 Prenatal education .6720 -6.615 3.818 .000 Newborn state control .6865 -2.951 2.748 .000 Planning of pregnancy .7000 -3.135 3.330 .000 Personal resources for child rearing .7162 .1959 .1741 .000 Newborn physical appearance .7197 -1.112 2.217 .000 Length of marriage .7220 .7046 1.667 .000 Total score of mat. responsiveness in delivery room .7422 -.0532 .1535 .000 Newborn physiological processes .7251 2.719 9.287 .001 Newborn motoric processes .7261 .6365 2.517 .002 Stress during pregnancy .7265 .0023 .1218 .004 Constant -17.42 22.71 *stepwise p_< .01. 122 TABLE 21.--Results of an Analysis of Variance of Maternal Responsive- ness during a Feeding Four Weeks Following Delivery by Age. Sum of Squares DF Mean Square Between Groups 629.7242 (1) 629.7242 Within Groups 2866.1758 (38) 75.4257 TOTAL 3495.9000 (39) F = 8.3489. 2 = < .01 TABLE 22.--Results of an Analysis of Variance of Maternal Responsive— ness during a Feeding Four Weeks Following Delivery by Choice of Rooming-in. Sum of Squares DF Mean Square Between Groups 556.0140 1 556.0140 Within Groups 2939.8860 38 77.365 TOTAL 3495.9000 39 Fg= 7.1869, p_< .05 reveals a significant (p_< .011) difference between these two groups. The group choosing rooming-in had higher total scores of maternal responsiveness at the time of the feeding observation made four weeks following delivery than did the group which did not chose this option. 123 I O \I There are no relationships between background variables, neonatal characteristics and maternal responsiveness in the delivery room and during a hospital feeding and mother-infant adjustment assessed four weeks following delivery. The correlational analyses employed to investigate this hypothesis identified the significant relationships reported in Table 23. The Postpartum Research Inventory scales for concern for baby, ignore baby, depression, negative aspects of parenting, and the two scales of psychosomatic anxiety, overall health, and total number of symptoms are significantly related to the variables being examined as predictors of Parenting Potential. The findings reported in Table 23 also indicate that there is a positive relationship between the degree to which a mother is bothered by infant behavior (Bother Inventory) and the degree of concern about a mother's personal resources for rearing children measured by the Survey on Bringing Up Children. A negative rela- tionship, however, was identified between a mother's perception of her infant's behavior and the evaluation made of the infant's state control assessed several days following birth. Each of these find- ings contributes to the rejection of Hypothesis 7. Hg_§: There is no relationship between breast or bottle feeding and the total score of maternal responsive- ness on the Feeding Observation Scale. Two feeding observations were made to assess maternal responsiveness. The first observation was made in the hospital approximately three days following delivery (T2), and the second observation was made four weeks following delivery (T3). As 124 TABLE 23.--Results of a Pearson Product Moment Correlation Analysis of Relationships between Background Variables, Neonatal Characteristics, and Maternal Responsiveness in the Delivery Room and during a Hospital Feeding and Mother- Infant Adjustment Assessed Four Weeks Following Delivery. Personal resources for child rearing: bother inventorya .2840 Age: 3 concern for baby overall healtha total # symptomsa -.4056 .3144 . -.3102 Income: a a concern for baby ignore baby overall healtha total # . symptoms -.2830 -506O , .4111 -.2591 Education: a a concern for baby ignore baby overall healtha -.3299 -.5480 .3652 Length of marriage: concern for babya total # symptomsa .5097 -.3263 Planning of pregnancy: depressiona .2771 Choice of rooming-in: negative aspects of child rearing .2655 Stress duringpregnancy: concern for babya ignore babya depressiona total # symptomsa .4033 .2611 .4115 .3965 Newborn state control: b maternal perception of newborn ignore babya -.3375 -.2782 Physical appearance of newborn: a overall healtha total # symptoms -.3065 ~ .2664 Total score of maternal responsiveness in delivery room: total # symptomsa -.3627 Total score of maternal responsiveness during hospital feeding: ignorea -.3171 Note. Only correlations with p_< .05 are reported . 5scale from Postpartum Research Inventory (Schaefer & Manheimer, Note 4) bscale from Maternal Perception of Newborn Inventory (Broussard & Hartner, 1971) 125 reported in Table 24 the analysis of variance of the mean total scores of maternal responsiveness during the hospital feeding indi- cates that there is no significant difference between the total mean scores of the two groups using different methods of feeding their newborns. However, the analysis of variance of the mean scores of total maternal responsiveness during a feeding four weeks following delivery indicates with a probability level of .002 that there is a significant difference between the mean scores for the groups of breast and bottle feeding mothers. Those mothers who breast fed their infants showed more responsive behavior than the mothers who bottle fed their infants. This analysis is reported in Table 25. TABLE 24.--Results of an Analysis of Variance of Maternal Responsive- ness during a Hospital Feeding by Feeding Method. Sum of Squares DF Mean Square Between Groups 171.4586 (1) 171.4586 Within Groups 2420.1414 (38) 63.6879 TOTAL 2591.6000 (39) F = 2.6922, p_= > .1 TABLE 25.--Results of an Analysis of Variance of Total Scores of Maternal Responsiveness during a Feeding Four Weeks Following Delivery by Feeding Method. Sum of Squares DF Mean Square Between Groups 806.9769 (1) 806.9769 Within Groups 2688.9231 (38) 70.7611 TOTAL 3495.9000 (39) F = 11.4042, e= < .01 126 Methodological Question 1 What is the internal consistency reliability of the Delivery Room Observation Scale? The analysis of variance, reported in Table 26 employed to investigate the reliability of this scale, indicates that the instru- ment is internally consistent with a reliability coefficient of .8195. Methodological Question 2 What is the internal consistency reliability of the Feeding Observation Scale? Separate reliability analyses were run on the data collected during the feeding observations made at T2 and T3. The results of the analysis of variance of the observations made at T2 indicate that the instrument is internally consistent with an alpha of.849l. The results of the analysis of the data from the T3 observation indicate that the instrument is internally consistent with a higher reliability coefficient of .8915. These findings are reported in Table 26. TABLE 26.--Results of Tests of the Internal Consistency Reliability of Measures of Maternal Responsiveness. Reliability . Coefficient F DF Probab1lity Delivery Room Observation Scale .8195 6.7461 12 .0001 Feedin Ob Scale (T2) .8491 19.7001 8 .0001 Feeding Ob Scale (T3) .8915 20.1496 8 .0001 127 Methodological Question 3 Is there a relationship between the Look Ratio (time mother spends looking at her infant to total time of feeding) and the total score of maternal responsive- ness on the Feeding Observation Scale? The correlation coefficients presented in Table 27 indicate that there is a significant positive relationship (p_< .05) between the Look Ratio and the total score of maternal responsiveness during the feeding. ’These significant relationships exist only for the specific feeding observations during which both measures were made. TABLE 27.--Resu1ts of a Pearson Product Moment Correlational Analysis of the Relationship between Two Measures of Maternal Behavior during a Feeding. Total Score on Feeding Total Score on Feeding Look Ratio Observation Scale T2 Observation Scale T3 T3 Look Ratio .3660* .2532 .2378 T2 Look Ratio .0704 .537* T3 fp_< .01 CHAPTER V DISCUSSION The results of the research for this study will be discussed in four parts. The first part will discuss how the research find- ings reported in this dissertation contribute to an understanding of what may be used as predictors of Parenting Potential. Considered next is the extent to which methodological constraints limited the nature of the findings of the study. The final two parts of the chapter discuss suggestions for future research and the implications of the research findings for the delivery of health care. Contributions of the Study The stepwise multiple regression analyses performed in this study enable comparative examinations of the strengths of variables as predictors of the primary dependent variable, maternal responsiveness. The findings of this research specifically evaluate the relative predictive ability of measures of maternal and neonatal behavior assessed at the time of hospitalization and also of demo- graphic and questionnaire background information gathered during the women's last trimester of pregnancy. The behavioral observa- tions made of the findings four weeks following delivery provide 128 129 the measures of maternal responsiveness which are used to assess attachment and Parenting Potential. The results indicate that the performance of the variables as predictors is a function of the time at which assessments are made and the combination of variables that are used together in one stepwise multiple regression analysis. This is clearly evident in the interesting interplay of the background variables age and choice of rooming-in and the total scores of observed maternal responsive- ness assessed in the hospital and during a home visit four weeks following delivery. Age is coded in this study as a continuous variable. When only background variables are considered in the regres- sion equation as predictors of maternal behavior in the delivery room, the variables age of mother and choice of rooming-in are the most predictive, together accounting for .28 of the variation in the total scores of maternal.responsiveness. The older mothers and those who chose the rooming-in option are shown to have been most responsive four weeks following delivery. The predictive ability of age dramatically drops, becoming marginally significant in the overall equation when the labor and delivery variables-~length of labor and father's responsiveness--are considered in combination with the background variables. When all the variables are evaluated as predictors, it becomes clear that the mother's behavior in the delivery room is more a function of the support she receives from her husband (if present) than it is of her age. The length of a 130 woman's labor appears to be of minimal predictive significance, although the analysis suggests that the length of labor has a posi- tive effect on maternal responsiveness at the time of delivery. The choice of rooming-in, suggestive of a mother's inten- tion to maintain as much contact as possible with her newborn, predicts with equal significance maternal responsiveness when only background variables or background and labor and delivery variables are included in the regression equations. In each equation the choice to have rooming-in accounts for 10% of the variation in this dependent measure. This finding reflects the salience of a mother's desire, expressed prenatally, to have optimal contact with her new- born and her actual responsive behavior at the time of delivery, regardless of her husband's presence and/or behavior at this time. An examination of maternal responsiveness during a feeding several days following delivery indicates that again, when the pre- dictive significance of the background variables is assessed, age of the mother and choice of rooming-in are the best predictors of this behavior. However, in combination with the behavioral measures of maternal responsiveness in the delivery room and newborn character- istics, the background factors continue to contribute to the overall regression equation but fail as significant individual predictors of maternal behavior several days following birth. The results show that at this point in time maternal behavior is most significantly related to response measures made at the time of delivery. These findings may be interpreted to indicate that maternal behavior, as it is assessed in the hospital, is stylistically 131 consistent, reflecting the mother's initial overt attempts to attend to and attach to her newborn infant. This initial display of maternal behavior reflects the father's responsiveness to both the mother and newborn and the mother's intent expressed prenatally to maintain an optimal amount of contact with her newborn during their hospital stay. The results reveal that certain dimensions of newborn behavior can be predicted from the background information about the mother. These dimensions, newborn interactive processes and state control, are each predicted by different combinations of demographic variables and the amount of stress encountered by the mother during pregnancy. The newborn's interactive processes or capacity to respond to social stimuli were measured by an assessment of the infant's ability to orient, to cuddle, and to be consoled. This capacity can be understood to reflect the infant's ability to be responsive to parental overtures to establish a rewarding inter— personal relationship with the newborn infant. Maternal age is a significant predictor of the newborn's interactive process, account- ing for 12% of the variation in the variable assessed several days following birth. Though this is a small percentage of the variation, it is of importance to note that older mothers have newborns who exhibit a greater capacity to orient to both visual and auditory stimuli. The variable income level is shown by the results to predict how well a newborn is able to organize his state behaviOrs. The assessment of this newborn behavioral characteristic of state 132 control was made with the scale items which measure state lability and irritability and rapidity of the newborn's build-up of states from being asleep, to crying. This finding can be interpreted in terms of the factors that are related to income status that may affect the prenatal environment. The variables stress during pregnancy, length of marriage, and age also contribute to the overall regression equation which when complete accounts for 25% of the total variation in newborn state control. The amount of stress and length of marriage have negative Beta values, indicating that the less stress a mother encountered during a pregnancy, the less difficulty her infant has in controlling his behavioral responses to change in state. Though the variables having overall significance account for only a little over a third of the total variation in these two newborn behaviors, these findings do provide intriguing evidence of possible prenatal effects on fetal development. Other studies have indicated that maternal responses to pregnancy and maternal stresses during pregnancy are related to both infant behavior in the immediate postnatal period and to maternal adjustment and maternal care. Sontag's (1941) early observations of the relation- ship of maternal stresses during pregnancy to infant behavior have been confirmed by more recent investigations (Ottinger & Simmons, 1964; Ferreira, 1960). It is especially interesting to consider the findings of this research study concerning the effects of income on state control in terms of Doty's findings (1967) which revealed a 133 positive relationship between low social class, emotional disturb- ances during pregnancy, and later maternal and infant behavior. The combination and direction of effects of the variables identified in this study as predictors of interactive processes and state control clearly indicate that the newborn behaviors found to be predictable reflect a prototype of stability or lack of sta- bility in the individual mother's life situation. It can be under- stood that perhaps the stress generated from events occurring during pregnancy or the more generalized stress accounted for by age, education, income, marital status, and pregnancy p1anning do in fact have effects on the newborn's development in utero which become manifest in behavioral patterns less reinforcing to parental ministrations. The results so far reported indicate that, when considered alone, background variables assessed prenatally predict maternal responsiveness in the delivery room and during a hospital feeding. When, however, background variables are considered in combination with other behavioral measures, the strength of their predictive ability, with the exception of the choice of rooming-in, decreases. It appears that during the period of hospitalization, maternal behavior is consistent across time and situations. A shift in the predictive significance of the behavioral and background variables occurs when their ability to predict maternal responsiveness four weeks following delivery is assessed. When observations of both mothers and newborns during their hospitalization are used as predictors of later maternal behavior 134 during a home visit, it is apparent that both the infant's inter- active processes assessed three days following birth and the mother's responsiveness during a hospital feeding are significant predictors, alone or in combination with each other, of maternal responsiveness four weeks following delivery. This predictive relationship is, however, altered when the background variables are considered in combination with the behavioral measures. The results of the regression analyses indicate that alone or in combination with the measure of maternal and neonatal behavior the variables age and rooming-in are most predictive of maternal behavior four weeks following delivery. Although the Beta value is negative for the age variable, its minimal weighting makes this direction of little relevance. The analysis of variance conducted clearly shows that the older mothers in the sample are more responsive to their infants during this feeding observation. Whereas behavioral factors are more salient than the back- ground predictors of maternal behavior during the mother's and infant's hospital stay, the background factors of mother's age and desire expressed during pregnancy to maintain close contact with her infant following birth predict most powerfully how responsive her behavior will be towards her newborn during a feeding four weeks following birth. How a mother responded to her newborn in the delivery room and during a hospital feeding and the newborn's behavioral characteristics decrease in their predictive ability during the four weeks following delivery. The significance of age 135 and rooming-in increases when their predictive ability is evaluated by measures of maternal behavior assessed four weeks following delivery. The importance of the variable maternal age can thus be understood as significantly affecting both maternal responsiveness and neonatal interactive capacity. That older mothers exhibit more responsive behavior toward their month old infants and that neonates born to older mothers are more responsive to visual and auditory stimulation provide evidence of how these mother-infant pairs may have mutually reinforcing patterns of behavior from the beginning of their relationship. It can be suggested that these mothers and infants have a better potential for a positive parenting relation- ship. ‘ It is of special importance that it is the variable newborn interactive processes which is the behaviorally significant pre- dictor of maternal responsiveness. It is clearly substantiated throughout the literature that the visual interaction between a mother and her newborn is of essential importance for the emergence of feelings of attachment and relatedness. In their studies of maternal influences on early social visual behavior, Moss and Rob- son (1968) have found that a pregnant woman's expression of inter- est in her yet unborn child is related positively to the amount of face-to-face gazing she and her infant engage in when the baby is l and 3 months old. These researchers' findings are supported by the results of this study which indicate that the choice to have 136 rooming-in is a significant predictor of later maternal responsive behavior. The behavioral observations of mothers' behavior during a feeding, used as measure-s of maternal responsiveness in this study, were compared by a simple measure of the ratio of time a mother spends looking at her infant to the total time of the feeding. The correlation coefficients from the analysis indicate that the ratio measures are significantly related to the more comprehensive assessments of discrete maternal behaviors comprising the total score of maternal responsiveness. This finding is illustrative of how maternal visual attention alone can be used as a representative sample of more complex measures of responsive behavior. Maternal attachment, which is used in this study as an index of Parenting Potential has been described, using empirical data, as a process which evolves during the first three months of an infant's life. Robson and Moss (1970) found that a mother's lack of emotional involvement in her infant is characteristic of the immediate post- partum period. The findings from their sample indicate that for the first three to four weeks at home, mothers most frequently report feelings of fatigue and insecurity. At this point maternal energies were reported as being most focused on mastering tasks of infant- care and on appeasing the unpredictable demands of their infants. Interview data from this dissertation (Appendix K) indicate that there is a negative relationship between how soon women first report experiencing feelings of love or attachment to their newborns 137 and their assessments of their personal health four weeks following delivery. The findings, however, also reveal that no relationship appears to exist between the self-reported feelings of attachment and observations of maternal responsiveness during a feeding four weeks following delivery. This disparity between reported feelings of attachment and behavior does not appear when mothers are asked in more general terms "how things are going" between them and their infants. The women's responses to this more global kind of question are related positively to both their reported physical health and to their total score of responsiveness assessed four weeks following delivery. Though the variable overall health is not related to other measures of mother-infant adjustment at four weeks, the research findings indicate that positive relationships do exist between this variable and several of the background variables shown to be pre- dictive of later maternal responsiveness. The significant positive relationships are those between this variable and age, income, and education. The normative data presented in the Robson and Moss (1970) study of attachment and the descriptive information gathered in this study from interviews indicate that a woman's overall assess— ment of her personal health appears to be related to the vitality of her emotional relationship to her infant. Her responsiveness in this study is also shown to be related to the responsiveness of the infant during a feeding and negatively related to the degree to 138 which she reports that she ignores her infant (Appendix L). There may, however, be more contributing to maternal behavior than these findings reported by the mothers themselves. Klaus et a1. (1972) through experimental manipulation of the amount of time given to mothers to be with their newborns following birth have identified what they feel may be a sensitive period for maternal attachment. Their findings, indicating that there may be positive effects on attachment behavior following at least one hour of additional contact time between mother and infant in the first three hours following birth and five hours of additional time each day during the first three days, support the hypothesis that a sensitive period for attachment does exist. The distant emotional tone toward their infants and general sense of being fatigued and overwhelmed which Robson and Moss (1970) saw in the attitudes expressed by the mothers in their study may be in part a function of the care these women and their newborns received as obstetric and nursery patients. If a sensitive period for attachment immediately following birth does exist, the evolution of feelings of attachment which was identified by these investigators as taking approximately three months may be understood as the consequence of the limited [contact time women are granted with their newborns following birth. Though data analyses in this study indicate that the older age of a mother and her preference for rooming-in are the most Signifi cant predictors of maternal behavior four weeks following delivery, information from interviews with these mothers indicates 139 a significant though mild relationship between self-assessment of their overall situation one month following delivery and the assess- ments made of their responsiveness in the hospital both in the delivery room and during a feeding. Such findings can be inter- preted as indicative of the establishment of a positive trend. Those mothers being most responsive at delivery and during a feeding several days later also expressed in an interview four weeks after delivery the most positive pictures of the adjustment between them- selves and their infants to the parenting relationship. Although maternal responsive behavior in the delivery room and during a hospital feeding do continue to contribute to the overall regression equation predicting maternal responsiveness four weeks following delivery, their significance as variables is of minor importance. The reason that this trend established in the hospital is not manifest in significant proportions in the behavior assessment of maternal responsivesness four weeks following delivery can be explained in terms of the notion of a sensitive period for human attachments. Perhaps the limited contact time permitted these mothers interferes with the establishment of the strength of this initial trend of responsive behavior. It would subsequently follow that, though separated during the recovery period, those mothers who desired rooming-in were able to have more contact time with their newborns. This additional time and their expression of interest in the baby which it represents can be interpreted as con- tributing to the increased measure of maternal responsiveness observed in these women's behavior four weeks following delivery. 140 Although the findings from these studies which have investi- gated the effects of additional contact time have positive implica- tions for roomig-in, several studies have explored this hospital care option as an independent variable. McBryde (1951) reported that when rooming-in became compulsory in the ward and private newborn service at Duke Hospital, there was a marked dr0p in the numbers of telephone calls made to the hospital by the mothers following their discharge requesting advice on baby care. It was also noted that when rooming-in became compulsory there was an increase in breast feeding among the patients. A study conducted in Sweden (Greenberg, Rosenberg, & Lind, 1973) compared 50 primiparous mothers assigned to have rooming-in with 50 mothers who were not given this option. The women were matched by age, socioeconomic characteristics, and age and education of the father and randomly assigned to the two groups. The findings from the study showed that the daily eight hour presence of the newborn in the mother's room in the first postpartum week resulted in significant differences in the two groups. The day before dis- charge the rooming-in mothers judged themselves to be more confident and competent in caring for their newborns. They also thought they would need less help in caring for their newborns at home and could attribute more to their newborns' cries than could the mothers who did not have rooming-in. These findings add strength to the results reported in this dissertation which indicate that the mother's choice of 141 rooming—in predicts maternal responsiveness four weeks following delivery. The additional time with the newborn may enhance feel- ings of attachment as well as caregiving ability. The importance of maternal responsiveness has been illus- trated in a variety of investigations for the longitudnal effect it has on infant development. Schaefer and Bayley (1963) suggest with their extensive analyses of correlations of maternal behavior and child development that both maternal acceptance and involvement during infancy are correlated with favorable early development. Moss and Robson (1968) indicate that mothers' attitudes which are positive, accepting, and which express eagerness for close inter- action with their infants are positively related to infant develop- ment. Stern, Caldwell, Hershey, Lipton, and Richmond (1969) have empirically shown that overt demonstration of affection is related to enhanced infant development, social and play initiative, and ability to cope with stress. Furthermore, it has been shown that physical handling that is gentle, firm, close, and relatively fre- quent seems to have a beneficial effect on the infant's early cogni— tive and motor development and on his attachment and responsiveness to his mother (Ainsworth, Bell, Blehar, & Main, Note 7). Studies also indicate that styles of maternal behavior with an infant may stabilize during the early weeks and months following delivery. Bell and Ainsworth (1972) report that their findings indicate that a mother's responsiveness to her infant's crying during the first three months is significantly correlated with 142 maternal responsiveness throughout the first years of life. Moss (1967) has also shown a highly significant correlation between obser- vations of maternal behavior made at three weeks and at three months. These findings highlight the relevance of maternal behavior in terms of its stability over time and its relationship to future child development. Clark-Stewart (1973) summarizing the research literature to date, identifies the optimal mother as an individual who is affectionate, accepting, nonrestrictive, aware of and respon- sive to her infant's needs and wishes, and who immediately and contingently gives care or stimulation to the infant according to his state, capacity, and developmental level. This is quite a demanding role for any woman to play and reflects how maternal char- acteristics must mesh with the infant's behavioral disposition. The outcome measure used in this dissertation assesses many of these qualities during the observation of mother-infant interaction during a feeding. Maternal responsiveness has been discussed in terms of the variables affecting the overall adjustment between mother and infant and in terms of the hypothesis regarding a sensitive period following birth during which time attachment may be enhanced with the amount of contact time provided. The most potent predictor identified in this investigation, age of the mother, has yet to be discussed in light of these findings. It is significant to note that in this study all mothers were primiparous and the variable age needs to be considered in relation to this fact. 143 Very little, if anything, is known about child rearing patterns as they are related to maternal age. In one exhaustive search of the literature conducted to find studies helpful for developing programs for young mothers, no studies were identified which used age as the primary focus of the research (Williams, 1974b). There is the contribution of studies which have investigated the stresses and supports which affect maternal care. Elmer's (1967) study of abusive and nonabusive mothers found that among the childbearing and family structure variables contributing to the likelihood of physical abuse were maternal age of less than 21 and the conception out of wedlock of the abused child. It is of increasing concern to those involved with infant care programs that one half of all births occur to mothers below the age of 20 (NICH&HD, Note 8)- It is also true today that 10% of American women become pregnant during high school. The majority of these women will not marry but will keep their infants (Williams, 1974a). The findings from this study which show that maternal age most significantly predicts maternal responsiveness in the four week follow-up assessment of mother-infant interaction highlights the importance of age to the quality of maternal care. In a study which employed national survey data it was shown that early motherhood is closely associated with a high incidence of marital dissolution, poverty, and limited education (Bacon, 1974). It can be assumed from data like these that social and emo- tional stability increase with age. The findings of this disserta- tion may be interpreted to show that overall stability may be more 144 significant than maternal behavioral reactions observed in the hospi- tal setting. The sensitive period hypothesis can also be used to interpret the findings from this study. If there is a critical period for attachment, younger mothers may be more vulnerable to the effects of being separated from their newborns immediately , following birth. Adoption agencies in the United States and Canada report some evidence that very young mothers who keep their infants but choose to have them cared for in group settings later have a tendency to relinquish their children for adoption several years following birth. There is some speculation about the effects of group care practices on these mothers' developing feelings of relatedness to their infants (Williams, 1974a). The findings from this dissertaion may be reflecting differential effects of the separation of the newborns and mothers in conjunction with maternal age. If Parenting Potential is to be predicted from background information and actual behavioral observations of maternal behavior in the hospital, the findings from this study would indicate that attention be paid to the age of the mother and her desire expressed prenatally of wanting to maintain optimal contact with her newborn evaluated by her choice of the hospital Option of rooming-in. The significance of the hospital observations of maternal behavior as less predictive than age can be explained as a function of the overall salience of age and the social stability which it represents or by the hospital management procedures which limit contact time. 145 In either case, there is an attenuation of the effects of the first behavioral manifestations of responsive behavior in the younger mothers. The findings which indicate that age and income and other measures of social stability also predict more desirable newborn behavioral characteristics further highlight the importance of an assessment of these basic factors in predicting the potential of the parenting relationship. Although newborn and maternal behavior in the hospital pro- vides some indication about future parenting capacity, evaluations of such behaviors can best be interpreted as representative of a stylistic trend reflective of positive acceptance of the newborn. This behavioral style is of less significance than the maternal desire for and the assumed optimal contact time that these mothers had with their infants during their first days following delivery. The combination of age and desire for contact together provide the best prediction of future behavior. It would be wrong to concldde from these findings that skill in maternal care innately accompanies increased age. Studies with monkeys show that even in primates the so-called "instinctive" nurturant behavior is heaVily dependent upon a mother's prior life experiences and learning (Harlow et al., 1966). Human child rearing must be considered as a learned response. These findings which indi- cate that it is age and rooming-in which together most significantly predict behavior at four weeks underscores the importance of what 146 may be a maternal predisposition for contact. It is this predisposi- tion that may be most reflected in the parenting behavior assessed in this study and may be most predictive of the potential in the parenting relationship. Limitations of the Study The low predictive significance of the behavioral observa- tions made prior to the mother's and infant's hospital discharge has been explained in terms of a possible interruption of a stylistic trend apparent in the mother's behavior during the hospital stay. This finding may also be interpreted as a function of the limitation of the sample population that was used. Observations with a random sample of women may have yielded different results. The limited variation in the total scores of maternal responsiveness in the delivery room and during a feeding that was apparent in the observa- tions that were made could have limited the predictive capability of these measures. The insignificant correlations between the observational assessments and measures of mother-infant adjustment evaluated from the self-report questionnaires and interviews can also be explained in terms of the limited variation in the responses. Though the sample used in this study represented a heterogeneous mixture of women in terms of background information, the variance in the responses to questionnaire items and interview questions was limited. It is to be noted that of the range provided in the Survey on Bring- ing Up Children (Helfer & Schneider, 1975) the subjects' total 147 scores were all below the level of moderate degree of concern related to the individual mother's personal resources for childrearing. In spite of the limitations imposed by the lack of variation in the sample on the measures used, these findings provide reason to speculate on the possibility of a disparity between actual behavior and reported attitudes. The importance of maternal attitudes has been examined by Davids, Holden, and Gray (1963), who indicated that attitudes toward childrearing are established prior to the birth of a child. These attitudes they showed to be in turn related to performance on the Bayley Infant Mental Scales. The findings in this dissertation indicate the importance of assessing variation in both behavioral and attitudinal measures of mother-infant interaction. There is certainly reason to believe that the attitudes expressed by a mother will also in some form be expressed in her behavior as she relates to her child. The limitation apparent in the behavioral assessments can perhaps also reflect more than the lack of variance inherent in the study sample's behavior. The moments immediately following birth may be an inappropriate time to be making the first assessments. It was the suggestion of the nurses that perhaps a better time to observe the mother—infant interaction would be in the recovery room prior to the admittance of the baby to the transitional nursery. Members of the nursing staff felt that the mothers seem to be more relaxed and less intimidated in the recovery room than they appear to be in the more surgical surroundings of the delivery room. 148 This reference made to the nature of the setting in which the data were collected highlights the importance of considering the totality of the situation and the circumstances which affect maternal behavior as it is assessed in the delivery room. The ecological perspective used throughout the study facilitates an understanding of how environmental and experiential factors may influence the total scores of maternal responsiveness. The positive finding that the father's responsiveness in the delivery room affects maternal behavior is an example of how the ecology of the setting is functional in affecting behavior. Certainly, the effects of drugs, fatigue, pain, type of delivery, and behavior of the nurses and physicians can also be considered to play a role in influencing the maternal behavior. A consideration of how culture permits the way in which emotiOns are expressed is also important. All these variables must be considered when evaluating the nature of the behavior observed. The operationalization of the variables used in this study may also have limited the nature of the study findings. The failure of the early measures of maternal responsiveness to predict future behavior may be attributed to the variables that were selected as predictors and the combinations of the variables that were used in the regression analyses. Had different variables been considered together or apart from the ones included in these data analyses, their differential impacts may have been found to vary from the findings that have been reported in this study. The statistical method used in this study also affected the nature of the findings reported. While discriminative cluster 149 analysis or factor analysis could have been employed, the stepwise multiple regression analysis was chosen because of the use of varia- bles in this study which had not before been operationalized as predictors. Other statistical treatment of the data may influence the nature of the findings. After a consideration of these methodological limitations which may have affected the study findings, it can also be suggested that behavior during the period of time following delivery may in fact be irrelevant to future parenting style. However, further investigations need to assess the validity of the instrument used, and it would be inappropriate to make this assumption until replica- tions of the study indicate with clarity the relevance of the measure made. Emphasis should be placed on the finding that the total delivery room score did predict the responsiveness of maternal behavior during a hospital feeding. This information indicates that though long-term prediction does not appear from this sample to be possible, behavior in the delivery room predicts maternal behavior several days following delivery. Such an indication provides evi- dence that the score of the Delivery Room Observation Scale can be employed as an assessment useful in identifying women in need of supportive assistance during their first few days with their newborn. Such support could help to alleviate a women's hesitancy to display more overt responsive behavior which may intensify her feelings of attachment and relatedness to her newborn. 150 Suggestions for Future Research The significant predictive trends which account for mild amounts of the variation identified in this research justify a more comprehensive inventigation of the findings reported in this study. The research requires replication to verify that background informa-~ tion has more long-term predictive significance than do the behavioral observations. Since the mothers' desire expressed during pregnancy to have rooming-in did predict maternal responsiveness four weeks following delivery, it would be worthwhile to investigate the pre- dictive capability of other prenatal assessments. Perhaps such data is alone as predictive of future behavior as observations of respon— siveness made during the mothers' and newborns' hospital stay. If in fact demographic variables and maternal predisposition for con- tact and care giving are most predictive of future responsive behavior, screening programs could effectively utilize such informa- tion. It would be especially interesting to investigate women's rationale for their choice of rooming-in. An exploration of reasons given for this choice may provide insight into the advantages of this option. The perceived advantages of rooming-in perhaps could be provided to patients through other forms of hospital care. Rooming-in may represent different advantages to individual mothers. An understanding of the range of these reasons could provide clues about what has been called in this dissertation as a maternal pre- disposition for contact and care giving. 151 If future findings again show that the Delivery Room Observa- tion Scale has little predictive power, clinical impressions would suggest that this scale, in spite of its limitations, has the poten- tial of being used to evaluate behavioral manifestations of maternal behavior at the time of birth. These evaluations could be used to inform nurses on each shift of initial maternal behavior as it is observed in the delivery room. These observations can then be used to provide appropriate supportive care for the mothers during their postpartum hospital stay. Before the scale is implemented for even these purposes, it needs to be refined and tested using a large random sample of obstetric patients. Such a field study would reveal if the scale is sensitive enough to pick up differences in maternal behavior. Further testing would also indicate if there are significant differences in maternal behavior when it is evaluated with a standardized observation during the first ten minutes follow- ing delivery. Methodological issues link these two questions which require research investigation. A field study of how the scale could be routinely implemented would also need to be conducted to investigate the feasibility of its hospital use. It would be important to know if nurses can routinely make reliable observations and if the notations of the observations affect the postpartum care the mothers receive. Another study that would provide useful information helpful in planning for the postpartum care of a mother and newborn would involve an evaluation of the effects of doing a Brazelton exam on 152 a newborn with the mother present. A notation of the mothers' reac- tions to watching their newborns' performance combined with observa- tional data from the delivery room and a feeding could provide insight into how the mother and newborn may adjust to each other during their first days together. Again, it would be of interest to know how back- ground variables function to mediate the effects of these initial behaviors of the mother and the newborn. Implications of Research Findings for the Delivery of Health Care The nature of the sample used in this study limits the kinds of generalizations that can be drawn from these research findings. It must be understood that since a random sample was not used, the conclusions drawn can only be considered in terms of the population of subjects who participated in the research project. Certain clinical impressions, however, can be shared. Observations made during the data collection of this study are supported by other research findings and can be used in giving patient care. Hospital staff are especially encouraged to apply the findings reported throughout the literature in the area of maternal attachment that eye to eye contact plays a very important role in mediating the interactions of mothers and their newborns. It was the observation of the investigator in the delivery room that as soon as the newborns were wheeled in their carts close to their mothers' sides the mothers' affectual response heightened as they began, with animated expression, to talk to and touch their newborns. 153 The talking seemed only to begin when a mother was given the opportu- nity to touch and to look at her newborn. Providing a mother with optimal contact with her newborn from the moment the baby is removed from the sterile field and/or after the cord is cut certainly should receive the attention of all those present in the delivery room. It was also of interest to the investigator how she was received by the families participating in the study. The mothers often seemed pleased when they saw the investigator when she arrived at the hospital prior to the deliveries. The investigator many times was the only familiar face for the mothers when they came to the hospital. The women sometimes had had little contact with the physician in their clinic or group practice who happened to be on call at the time they were admitted for delivery. The hospital staff were also, of course, unfamiliar to the patients before they are admitted. Seeing someone familiar seemed to be comforting to the patients and often to their husbands, many of whom had only heard about the study from their wives' descriptions of it. After delivery the mothers (and fathers) appeared to honestly enjoy having the Opportunity to talk about their newborn and the experience of delivery with someone who had attended the birth and who had had contact with them during their pregnancy., The parents also seemed to enjoy knowing that the investigator was going to be doing a behavioral examination on their newborns. It became clear that the fragmentation of the care the mothers receive provides little continuity from the doctors' office to the hSOpital and 154 between the three shifts of the three services in the hospital, labor and delivery, postpartum, and the nursery. The mothers appeared to enjoy having a familiar person visit them in the hospital who had been interested in them when they were pregnant, who was present during their labor and delivery, and who also took a special inter- est in their newborns. The logistics of providing more continuous care are immense and there are good reasons for why the fragmenta- tion exists. However, more continuity of care could provide women more support at a time when they are at the threshold of assuming roles and behaviors they have never before experienced. This especially is the case with the young mother who may still be in the process of detaching from her own parents and thus having little energy for the demands of the newborn whose care has suddenly become her responsibility. This woman obviously needs special help while in the hospital and throughout the early months of her child's life. Individuals who work with obstetric patients often seem to have an intuitive feeling for the behavior they observe in terms of its meaning as it is related to potential maternal responsive behav- ior. What is needed is a way to record systematically such impres- sions so that they are not lost with the change in shifts or the patient's move from labor and delivery to the postpartum floor of a hospital. The Delivery Room Observation Scale could provide an instrument with which the observations could be made and recorded. Until such a scale can be developed, the general findings from this 155 study would indicate that observations made should be recorded as nursing progress notes. Effective management plans for patients whose behavior gives cause for concern need to be carefully designed and implemented to provide the special care these patients require. Modern medicine provides safe care for obstetric patients and their newborn infants. Efficient practices have been developed and are today implemented routinely in labor-delivery and post- partum services of hospitals. These practices are successful in accomplishing their mission of providing for the physical needs of patients. What is now needed is a broader focus for perceiving the needs of obstetric patients as including more than their physical well-being. The process of giving birth and being born is a major life event for mothers, fathers, and babies. It is an event which involves more than a physiological process and requires the sensitivity of all those who give care to pregnant and post- partum patients. ' Now that medical care can be efficiently delivered, it is time to examine how modifications in practices can be made to facilitate more effective care. A balance needs to be found which includes a means of providing for the total needs of a family with- out compromising the high standards for physical care which have developed with modern medicine. Such a balance can provide a perspective that accounts for both the emotional and physical needs of individuals. CHAPTER VI SUMMARY AND CONCLUSIONS This study evaluated measures that could be systematically employed to identify the potential of a parenting relationship. Measures of maternal responsiveness were used to assess maternal attachment considered to be central to the quality of the mother- infant relationship. Parenting Potential is the term used in this study to describe mother-infant interaction that is functional in facilitating positive child growth and development. The assessment of the major dependent variable, maternal responsiveness during a feeding four weeks following delivery, reflected both the mother's and the infant's interaction with each other. The research results provided evidence that variation in this dependent measure can be predicted from background information about the mother and behavioral assessments of maternal and neonatal behavior in the hospital. Though mild, relationships were shown to exist between background variables and behavioral ratings and self-report measures of the mother's and infant's adjustment to each other four weeks following delivery. The most significant finding apparent in the results of this study is the evidence provided that age and choice to have rooming-in are salient predictors of maternal responsiveness. This study also 156 157 provides evidence which supports the notion that maternal responsive- ness represents a bilateral interplay of both maternal and neonatal behaviors. It was shown that the newborn's capacity to respond to auditory and visual stimuli is predictive of maternal behavior in interaction with him. The newborn's behavior in turn was shown to be predicted by maternal age. These findings represent the importance of assessing age as predictive of a mother's potential attentive interaction with her newborn. The woman's decision to request rooming-in also, according to these findings, can be regarded as an important indication of maternal desire to establish a responsive relationship with her infant. Behavior observed in the delivery room and during a hospital feeding appear from the research results to be stylistically consis- tent and more a function of the impact of situation specific varia- bles rather than of maternal age. When used as predictors of future maternal responsiveness these hospital behavioral assessments con- tribute marginally to the overall predictive significance of a mul- tiple regression equation. The marked decrease over time of the predictive capacity of the hospital measures and the increased salience of the variables age and choice of rooming—in has been discussed in terms of the social and emotional stability assumed to accompany age. It is also suggested that these findings support the sensitive period hypothesis (Klaus et al., 1972) which indicates that the amount of contact time experienced between a mother and her newborn immediately following 158 birth enhances the process of attachment. The interruption of the behavioral style observed in the hospital may be a function of the immediate separation of the mother and newborn which the subjects encountered as obstetric and nursery patients. That the choice of rooming-in remained as a significant predictor would support this conclusion, indicating that those mothers desirous of this hospital option had more contact time with their newborns. The salience of age as a predictor may also indicate that younger women are more vulnerable to the suggested effects of separation. The combination of the predisposition for contact, reflected in the mothers' desire expressed prenatally for rooming-in, and maternal age provides the strongest evidence of the predictive ability of any of the variables examined in this study. Though the results of this research provide indications of these signifi- cant trends, interpretations of the overall findings must recognize the limited amount of variance which is accounted for by the iden- tified predictors. It is to be noted that the highly innovative quality of the administration of this research limited the kinds of measures made. Perhaps, if more attitudinal inventories or a more sophisticated method were employed for the hospital data col- lection, results from such measures could have had more predictive significance. The procedural complexity inherent in the process of seek- ing appropriate permission and cooperation for the data collection that was administered in this study is to be clearly recognized. 159 The process of working with key individuals in the medical community before beginning to collect the data represents a major component of this research project. The rapport that was established with the hospital personnel, whose assistance was essential for the data collection, is a major positive outcome of the study. These indi- viduals' acceptance of the investigator and their involvement with her in the process of data collection represents a successful entree of a behavioral science researcher into a medical system. With the progression of the study, it became clear that the nursing staff began to take an active interest in making observations of maternal behavior in the delivery room and on the postpartum ward of the hospital. Their questions, comments, and requests for recommenda- tions all reflected an increased sensitivity to the role they can play in the early identification of mothers with the potential for parenting difficulty. The Delivery Room Observation Scale developed for the data collection in this study has potential for being routinely adminis- tered. From the use of this scale in this dissertation, it can be concluded that, although its predictive significance is minimal, it does provide an assessment of a mother's immediate responsive behavior towards her newborn. It can be stated from the research findings that this initial overt display of behavior does predict later maternal responsiveness during a hospital feeding. In this sense, the total score on the Delivery Room Observation Scale is similar to the Apgar Score in that it has short term predictive significance 160 and clearly describes the mother's immediate reaction to her newborn following birth. As a means of assessment, scores from the Delivery Room Observation Scale can be used by the hospital staff to provide appropriate support to new mothers. Women who appear responsive and eager for contact with their newborns should receive encouragement for their responsive behavior. Women whose behavior appears hesitant or rejecting need sensitive assistance from those who care for them. Such a use of the scale would provide a systematic way for a hospital staff to become aware of the need to observe and record their impressions of their patient's maternal behavior. Human bonds of attachment provide the stimulus of nurturant care giving. The delicacy of their formation and the complexity of the human interaction which they represent demand the sensitive attention of all those involved in providing human services. The ontogeny of attachment begins with conception and the capacity for attachment reflects one's personal experience of having received nurturant care. A focus on the first behavioral manifestations of attachment between a mother and her newborn infant is rich with opportunities for assessing the strengths of their emerging bonds. It has been the purpose of this research to evaluate how such strengths can be measured and how such assessments can be used to predict the quality of future parenting. The major finding of the study indicates that maternal age and the desire expressed by the mother before delivery to have rooming-in most capably predict 161 future attachment manifest in maternal responsive behavior. It can be suggested from such findings that a woman's capacity for nurtur- ance may be inherent and can be expressed prior to the birth of her child. Such a capacity, or predisposition for nurturant caregiving, may well be linked to future parenting skill and the child's even- tual development as an individual with the same capacity for build- ing fulfilling bonds of attachment. APPENDICES 162 APPENDIX A SOURCE LIST OF RESEARCH INSTRUMENTS 163 APPENDIX A SOURCE LIST OF RESEARCH INSTRUMENTS Survey on Bringing Up Children Information about the use of this instrument is available from: Ray Helfer, M.D., Department of Human Development B-24O Life Sciences Michigan State University East Lansing, Michigan 48823 Social Readjustment Scale The instrument is available from: Department of Psychiatry, University of Washington School of Medicine Seattle, Washington 98105 Delivery Room Observation Scale Information about this scale is available from: Ann L. Wilson, Child Development Project University of Michigan Medical Center 201 East Catherine Street Ann Arbor, Michigan 48104 Neonatal Behavioral Assessment Scale The scale may be ordered from: J. B. Lippinoctt Company Philadelphia, Pennsylvania Feeding Observation Scale The scale is available from: Joh Osofsky, Ph.D., Department of Psychology Temple University Philadelphia, Pennsylvania 19122 Neonatal Perception and Bother Inventory Information about the use of this instrument is available from: Elsie E. Broussard M.D., School of Public Health, Room 209 University of Pittsburgh Pittsburgh, Pennsylvania 15213 Postpartum Research Inventory This instrument is available from: Earl S. Schaefer Ph.D. Department of Maternal and Child Health School of Public Health University of North Carolins Chapel Hill, North Carolina 27514 164 APPENDIX B SUPPLEMENTAL BACKGROUND QUESTIONS 165 APPENDIX B SUPPLEMENTAL BACKGROUND QUESTIONS Did you plan this pregnancy? 1. yes 2. No If you had the choice, what sex would you prefer your baby to be? 1. girl 2. boy If possible, will you request to have a rooming-in arrangement while you are in the hospital with your baby after delivery? 1. yes 2. no Have you attended Expectant Parent Classes since you have been pregnant? 1. yes 2. no If you are married, how long have you been married to your present spouse? 166 APPENDIX C DELIVERY ROOM OBSERVATION SCALE 167 FDR No. Date APPENDIX C DELIVERY ROOM OBSERVATION SCALE Response to Baby's Sex 1. no response, flat affect 2. negative verbalizations and/or disappointed response 3. diffuse display of emotion 4. some indication of pleasure,-smiles or positive verbali- zations (l) ____ 5. very positive response, smiles and happy verbalizations Immediate Attempt to Reach 1. no (2) ____ 2. yes Visual Trackigg of Baby to Cart 1. no (3) ____ 2. yes Questions re Physical Status 1. no ‘ (4) ___ 2. yes Comments Made About Baby 1. no verbalizations 2. negative rejecting tone and content to verbalizations 3. comments re a physical feature or term of endearment 4. comments re physical feature and term of endearment (5) ____ 5. comments showing recognition of personhood Distal Looking-Quality 1. no affect 2. rejecting tone 3. diffuse display of interest 4. some animation and attentiveness (6) ____ 5. much animation and curious attentiveness Distal Looking Quantity 1. never 2. quick glances or gaze on baby less than 50% of time 3. 50% of time looking at baby 4. 50-90% of time (7) 5. 90-100% of time 168 (8) (9) (10)__ (11)— (12)— (l3)____ (14)— 169 Proximal Touching (60 seconds) 1. none 2. tentative fingertip touching 3. whole hand on baby's hand, beginning to explore baby's body Talks to Baby 1. no attempt to talk to baby 2. general statements -- "Hello" 3. empathy in statements -- "You look tired" Use ofypronouns 1. no reference to baby 2. use of "it" 3. "it" and inappropriate pronoun 4. "it" or inappropriate pronoun first and then appro- priate use of pronoun 5. immediate use of appropriate pronoun Name 1. When asked -- no name chosen 2. When asked name used 3. Self initiated use of name fo cus of Attention (if father is present "baby“ includes "father") on self most of time 50% of gaze or verbalizations oriented on self 50% of gaze and verbalizations oriented on baby more than 50% of gaze and verbalizations oriented on baby 90-100% of gaze and verbalizations oriented on baby U'I «DWN—l General Tone 1. flat, no affect 2. negative 3. diffuse emotion 4. positive 5. joy Father Responsivity_(if he is present) no support or affect rejecting tone to interactions diffuse emotional response some support (talking, handling) very supportive, animated response to baby 01-5de 0 o o o o APPENDIX D INTERVIEW ASSESSMENT OF MOTHER-INFANT ADJUSTMENT 170 10. 11. 12. APPENDIX D INTERVIEW ASSESSEMENT OF MOTHER-INFANT ADJUSTMENT Mother-Infant Adaptation Questions How are things going? Since most babies become fussy at times, they often need someone to help them quiet down. Sometimes holding them or talking to the baby comforts them. Some babies don't seem to be comforted at all when they get fussy. How about your baby? What usually happens when he or she gets fussy? Some babies seem pretty much the same at one month as they did when they were born. Other babies seem to change somewhat. What can you tell me about your baby? How are the feedings (breast or bottle) going? Babies sometimes try to let their mothers know when they're hungry, tired, or just want to be held. How about your baby? Since some infants often have their days and nights mixed up at first, they may sleep better during the day and become more active at night, or they can be more awake during the day. Can you tell me when your baby becomes restful? With all of the activity involved in the first couple of weeks after mothers leave the hospital, some mothers are tired at the end of the day. How about you? Do you feel that you are get- ting enough rest? How have the usual daily chores beengoing? What seems to be the most difficult thing so far since you've been home? What seems to be the easiest thing so far since you've been home? Is there anything you and your baby seem to enjoy most, or don't like so far? Some babies smile after they are fed, or held, or spoken to. How about your baby? Maternal Attachment Questions Have you begun to have positive feelings or love for your baby? When? Have you begun to see your baby as a person with individual personality? When? Do you think your baby has begun to recognize you? When? Maternal Recall of Labor and Delivery Experience How do you remember feeling when you first saw your baby? When you think back to your labor and delivery, do you remember it as being: Very Neither hard hard Hard nor easy 171 Very Easy Easy APPENDIX E EXPLANATION OF BRAZELTON BEHAVIORAL ASSESSMENT SCALE DISTRIBUTED TO HOSPITAL STAFF ON NURSERY SERVICE 172 MICHIGAN STATE UNIVERSITY DEPARTMENT OF HUMAN DEVELOPMENT EAST LANSING ° MICHIGAN ° 48824 8240 LIFE SCIENCES January 17, 1975 To: Sparrow Hospital Newborn Service From: Ann L. Wilson You may have seen me in the nursery this past week Observing the babies and watching them respond to my bell, rattle and flashlight. I am a graduate student in Child Development and will be doing part of my dissertation research in the Sparrow Nursery. IMY proposal has been passed by the Hospital Research Review Board and presently I am preparing to begin.my study. My bell ringing etc. is part of the Brazelton Neonatal Behavioral Assessment Scale which I will be using in.my research. I will be going to Boston next month to standardize myself with those who developed the scale. In the next few weeks I ‘will be administering the scale fer practice so that I will be able to become a reliable examiner. The fbllowing is a short explanation about newborn.behavior and a description of the Brazelton Scale. If you have any questions about the scale or my research please feel free to ask or call me. I can be reached at these numbers: 353-7999 or 353-9242. I appreciate the help that many of you have given me and I trust you ‘will let me know if there are ways that I can be more cooperative. 173 174 For many years it was widely believed that newborns perceive the world around them as a buzzing, blooming blob of confusion. In the last ten years there has been a great deal of interest in disprov- ing such a conceptualization of the newborns' capabilities and today behavioral scientists talk about the ”competent infant." Research increasingly indicates that infants are born with well developed sensory capacities enabling them to discriminate visual stimuli, tonal qualities, odors and tastes. Along with the increased knowledge of the capabilities of newborns has come an awareness of the individual nature of each newborn's behavioral repertoire. These new findings have lead to an interest'hiunderstanding how an infant's unique constitution can affect his caretaker's behavior. Traditionally, research on parent- child relations focused on how parents shape their childrens' behav- ior neglecting to evaluate the child's contribution to the relation- ship. With this new perspective on infant behavior, researchers are now beginning to examine the role a newborn's behavior can have on the emerging parent-child relationship. T. Berry Brazelton, a pediatrician at Boston Childrens' Hospital and Clinical Assistant Professor at Harvard Medical School, has developed the Neonatal Behavioral Assessment Scale to be used to evaluate an infant's reSponses to environmental stimuli. This scale can consequently be used to evaluate how an infant will inter- act with his environment. It is Brazelton's belief that neonatal behavioral and physiological precursors of individuality need to be as clearly documented as do neurological precursors of future 175 development. His scale measures dimensions of an infant's capabil‘ ities that are relevant to his developing social relationships. In administering the Neonatal Assessment Scale, the infant's state of consciousness is carefully observed to evaluate how the newborn is able to use state behaviors to control reactions to environmental and internal stimuli. These observations are helpful in assessing the infant's ability for self organization. Brazelton has developed a schema for identifying six levels of an infant's state by describing behaviors ranging from deep sleep to intense cryi. ing. Brazelton claims that an evaluation of the infant's pattern of state behavior and transition from one state to another may be the best predictor of the infant's receptivity and ability to respond to stimuli in a cognitive sense. The scale was standardized with ”average” seven pound4-full term normal Caucasian infants whose mothers had not received more than 100 mg of barbiturates and 50 mg of other sedative drugs prior to delivery. As many infants are discoordinated for 48 hours after delivery, the behavior measured on the third day after delivery has been used by those who developed the scale as the expected mean. A nine point scale is used to assess the behavior demonstrated ~ on each of the behavioral items on the assessment scale. There is no optimal score for each item nor a summary score for the entire scale. The nature of the scoring system reflects Brazelton's belief that there is no such thing as “optimal behavior” as every baby's optimal behavior can be represented by a different cluster of scores. 176 The examination begins with the infant asleep, covered, dressed and about midway between two feedings. After an observation of the infant, stimuli are presented and the infant's reactions are evaluated. The following is a list and brief description of the individual items on the scale. The appropriate state of the infant for the presentation of the stimulus 15 indicated in parentheses beside the title of each item. i-u u-9 IO. 11. 12. 13. 14. 15. 16. '17. 177 SUMMARY OF THE BRAZELTON NEONATAL BEHAVIORAL ASSESSMENT SCALE Response Decrement to light, rattle, ball, pinprick (AsleepStates) The newborn's capacity to decrease his response to repeated presentations of the same stimuli is called ”reSponse decrement" and is observed as the infant habituates or ”shuts down" his reaction to a stimulus. These items measure the amount of stimu- lation required before a shut down is reached. Orientation Response to inanimate viSual, inanimate auditory animate visual and animate auditory stimuli (Awake States) The ability to alert and fix on an object or sound is measured by the newborn's response of turning toward the direction of stimulation. This item measures the quality of the newborn's orienting response to these stimuli. Alertness (Alert State) ‘ This is measured when the infant brightens and widens his eyes. The frequency of this response throughout the exam is measured in this item. General Tonus (Awake States) This is a summary assessment of the resistance of parts of the infant's body to being handled by passive movement. Motor Maturity (Awake States) This is a measure of both the smoothness versus jerkiness of the infant's movement and the freedom of arcs versus restricted arcs of movement of arms and legs in flexion. full to Sit (Awake States) The infant's head and shoulder tone is evaluated as the examiner pulls the infant to a sit using his forefingers placed in each of the infant's palms. Cuddliness (Awake States) The infant's response to being held is measured in this item of the exam. Defensive Movements (Alert State) The infant's reactions when a small cloth is placed over the upper part of his face is assessed in this item. Consolability with Intervention (Crying to Awake or Asleep State) This measure is made when the infant is in an upset state and has been actively fussing to assess how much intervention is necessary before he quiets for at least five seconds. Peak of Excitement (Crying State) . The overall amount of motor and crying activity observed through- out the examination is measured by this item. 18. 19. 178 Rapidity of Buildup (From Awake to Crying State) The infant's use of states is assessed by this item by a measure of the timing and number of stimuli which are used before a transition is made from a quiet state to a more agitated one. .eritability (Awake States) This item measures the number of times the infant gets upset and the kind of stimuli which make him cry. 20. Activity (Alert States) 21. 22. 230 24. 25. 26. 27. This is a summary score of spontaneous and elicited activity seen durlng the entire observation. Tremulousness (All States) Observations throughout the exam for temors are assessed by this item. Amount of Startle During Exam (Awake and Crying States) Observations of both spontaneous and elicited startles are measured by this item. Lability of Skin Color (From Sleep to Crying States) This item measures the changes of color and vascularity which take place during the period of the examination. Lability of States (All States) The infant's reactions when a small cloth is placed over the upper part of his face is assessed in this item. Self-Quieting Activity (From Crying State to Awake or Asleep State) The activity which the baby initiates in a fussing state to quiet himself is measured in this item. Hand to Mouth Facility (All States) The infant's ability to bring his hands to his mouth and insert them is measured in this item. Smiles (Awake States) The number of smiles observed during the exam are recorded in this item. The neur0109ical assessment includes evaluation of these elicited responses: Plantar graSp G1abe11a Hand grasp Tonic deviation of head and eyes Ankle clonus Nystagmus Babinski Tonic neck reflex Standing Moro Automatic walking Rooting (intensity) Placing Sucking (intensity) lncurvation Passive movement of arms and legs APPENDIX F INITIAL PATIENT CONTACT CARDS 179 Dear Ms. Our practice is cooperating in a study of early mother-infant interaction being done by the College of Human Medicine, Michigan State University. A graduate student in Child Development, Ann Wilson, will be contacting you to give you more information about the details of the study. Your willingness to cooperate will be greatly appreciated. . Sharp, M.D. . Johnson, M.D. . Sheets, M.D. . Hazen, M.D. 09503 Dear Ms. Our clinic is helping with a study of newborns and mothers being done at the College of Human Medicine at Michigan State University. Ann Wilson, a graduate student in Child Development, will be contacting you to give you more information about the study. Your willingness to cooperate will be greatly appreciated. Model Cities Medical Clinic 180 APPENDIX G INFORMED CONSENT FORM 181 Number INFORMED CONSENT FORM Recently doctors and other people who work with families have become interested in learning more about how parents begin to know and rear their children. This study will provide information about young families that will be helpful in.better understanding early parent-child relations. Observations will be made of you and your baby in the delivery room and during a feeding. Your baby will also be given a behavioral examination and you will be asked to fill out several questionnaires before and after your baby's birth. All information gathered in this study will be confidential and your name and address will only be used to contact you. Only a number will appear on any of the information sheets used and not your name. I understand the above points and agree to voluntarily participate in the study. 'Witness Signed Address Phone Date 182 APPENDIX H INSTRUCTIONS TO SUBJECTS ON HOW TO CONTACT INVESTIGATOR 183 APPENDIX H INSTRUCTIONS TO SUBJECTS ON HOW TO CONTACT INVESTIGATOR Please call Ann Wilson when you leave home for the hospital. In the evenings she can be reaChed at 351-4802. If she does not answer at this number and during days call 487—7160. This is a page boy number. After the dial tone stops, give your name and say you are going to Sparrow Hospital. Thank you. 184 APPENDIX I LETTER TO POTENTIAL SUBJECTS CONCERNING RESEARCH PROJECT 185 MICHIGAN STATE UNIVERSITY DEPARTMENT OF HUMAN DEVELOPMENT EAST LANSING ° MICHIGAN ° 48824 8240 LIFE SCIENCES February 25, 1975 Dear Ms. Recently doctors and other professionals who work with families have become very interested in learning how mothers begin to know and understand their newborn babies. This information is very helpful for planning the kinds of care that can be given to women before and after delivery. For years people thought that babies were all pretty much alike. Now, it is an accepted fact that each baby, like each mother, is very different and requires different kinds of help. Here in Lansing we are fortunate that Sparrow Hospital and many physicians are interested in learning more about the early days of an infant's life. I am a graduate student and am doing research for my Ph.D. in child develOpment through the College of Human Medicine at Michigan State University. My study will provide new information that my be useful for developing programs for young families. I am asking patients of Drs. Sharp, Johnson, Sheets and Hazen to participate in this study. This would involve filling out several questionnaires and permitting me to observe you and your baby in the delivery room, m1rsery and during a feeding. I would also visit you in your home six weeks after your baby's birth. All information collected would be kept strictly confidential and you could drop out of the study any time. Your cooperation in this project would be eatl appreciated. If you have any questions ask Arlene or call me at {He numbers listed below. Your help would be of assistance to those of us working on the project. Thank you, Ann L. Wilson, M.A. Please feel free to call me at 353-7999 or 353-9242 during the day and 351-4802 in the evening. 186 APPENDIX J MATRIX OF THE PEARSON PRODUCT MOMENT CORRELATION COEFFICIENTS OF THE ORDINAL VARIABLES EMPLOYED IN THE DATA ANALYSIS 187 APPENDIX J MATRIX OF THE PEARSON PRODUCT MOMENT CORRELATION COEFFICIENTS OF THE ORDINAL VARIABLES EMPLOYED IN THE DATA ANALYSIS Codes for Correlation Matrix The folloWing are the codes of the ordinal variables presented in the matrix of Pearson Product Moment Correlation Coefficients. CONC CLINIC AGE INCOME ED LMAR PLAN RMIN PRENAT STRESS SEX TDELSC FATP FATR Total Concern Score on Survey on Bringing Up Children Code: Total concern score as a continuous variable. Omit Age Code: Age in years as continuous variable Yearly income Code: 6 categories from $4,000 to $20,000 Years of formal schooling Code: 6 categories from 8th grade to college completed Length of marriage Code: 4 categories from not married to more than 5 years Planning of Pregnancy Code: 0 = no 1 = yes Choice of Roaming-In Code: 0 = no 1 = yes Participation in Prenatal Education Progarm Code: 0 = no 1 = yes Total Score on Social Readjustment Scale Code: Total score as continuous variable Discrepancy between desired and actual sex Code: 0 = no 1 = yes Total Score on Delivery Room Observation Scale Code: Total score as continuous variable with a range of 0 to 52 Father's Presence in Delivery Room Code: 0 = no 1 = yes Score on Father's Responsiveness in the Delivery Room Code: Score on scale item 188’ LENGTH APGAR L APGAR 2 BRINT BMOTOR BSTATE BPHSY PHYAP LOOK 189 Length of Labor Code: Hours of labor as a continuous variable Apgar Score at 1 minute . Code: Score as continuous variable Apgar score at 5 minutes Code: Score as continuous variable Brazelton Neonatal Behavioral Assessment Scale Scorel - Interactive Process Code: 1 = concerning behavior 2 = average behavior 3 = good behavior Brazelton Neonatal Behavioral Assessment Scale Score] - Motoric Processes Code: 1 = concerning behavior 2 = average behavior 3 = good behavior Brazelton Neonatal Behavioral Assessment Scale Score1 - Organizational Process: State Control Code: 1 = concerning behavior 2 = average behavior 3 = good behavior Brazelton Neonatal Behavioral Assessment Scale Score1 - Organizational Processes: Physiological Response to Stress Code: 1 = concerning behavior 2 = average behavior 3 = good behavior Physical Appearance of Baby Code: 1 = ugly, 2 — average, 3 = attractive Look Ratio - Time mother spends looking at baby: Total feeding time Code: 10 minutes: 10 minutes >9 minutes 45 seconds: 10 minutes >9 minutes 15 seconds: 10 minutes >8 minutes 30 seconds: 10 minutes >7 minutes: 10 minutes <7 minutes: 10 minutes amwpmm II 1| 1| II II II 1See Adamson et al. (Note 4). MATRES MATPER BOTHER 190 Total Score of Maternal Responsiveness on Feeding Observation Scale Code: Total score as a continuous variable with a range of 0 to 54 Score on Neonatal Perception Inventory Code: Score as a continuous variable Total Score on Bother Inventory Code: Total score as a continuous variable with a range of 0 to 18+ The folloWing are scales on thePostpartum Research Inventory Code: IRRIT CONCERN NEG PUNIT IGN REASUR DEPRES HEALTH TSYMP LOOK2 TMATRES BRES ADJI ADJ2 ADJ3 Total score of scale items, higher scores indicate a stronger response to scale items Irritability Fear or Concern for Baby Negative Aspect of Childrearing Intrapunitive Ignorning Baby Need for Reassurance Depression Mother's Perception of her Overall Health Code: 5 categories range from very poor to excellent Total Number of Symptoms on Health Inventory Code: Total number of symptoms by their severity See LOOK See MATRES Total Score of Infant's Responsiveness on Feeding Observation Scale Code: Total score as a continuous variable Mother's Perception of Overall Adjustment Code: Mean score of scale items from Mother-Infant Adapta- tion interview, range from poor to good adaptation Mother's Perception of Mother-Baby Reciprocity Code: Mean score of scale items from Mother-Infant Adapta- tion range from poor to good adaptation Mother's Perception of Baby Adjustment Code: Mean score of scale items from Mother-Infant Adapta- tion interview, range from poor to good adaptation 191 ADJ4 Mother's Perception of Personal Adjustment Code: Mean score of scale items from Mother-Infant Adapta- tion interview, range from poor to good adaptation ATTI Time of Onset of Mother's Feelings of Love Code: 4 weeks after delivery or not yet first 3 weeks after hospital discharge during hospital stay with delivery i.e. right away 1 2 3 4 5 when pregnant ATT2 Time of Onset of Mother's Perception of Baby as Individual Person Code: see ATTl ATT3 Time of Onset of Mother's Perception of Baby's Recognition of Her Code: not yet at 4 weeks after delivery at 3 weeks after delivery at 2 weeks after delivery during first week after delivery 1 2 3 4 5 RECALL2 Mother' Code: Recall of Difficulty of Labor and Delivery very easy easy neither easy nor hard hard very hard mth—‘m 192 «so. am ~ac. «m no“. on coo. um «on. «m 009. «M «on. um «no. um non. hm ~uu. nm .0: ~ .0: a .94 . .c: a .o: a .o: v .o: a .c: a .u: u .u: . «ammo «mm4oI «ocuoI nomNoI ocumol embroI a~noal ”OamoI omen. mmnwo akau man. an ago. am can. um Qua. um nae. um mono um ado. um mac. um no“. um «mu. um .oo o .9: a no; a go: u no: u “a: a “o: w .o: a .o: a an: é cuuon moun- Neono nonn- Oocno nann- ounn. oboe. camaoI n~:«oI omawOb u:~o um man. a” sun. um and. um onw. um com. um can. an mud. um «um. um m:~o mm .o: e .o: v .o: v .o: u .0: a .o: a .0: v .0: u .u: v ho: a «canal nmsooI numool $30“. 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I0 .9: 9 0:«9.I :79: «99. «m .9 9 9999.« 9309 :0«. an .9: 9 0909. ~fio¢ 9509 0:420: 0995 APPENDIX K PEARSON PRODUCT MOMENT CORRELATION COEFFICIENTS OF RESPONSES TO INTERVIEW QUESTIONS AND BACKGROUND VARIABLES, NEONATAL CHARACTER- ISTICS, MATERNAL RESPONSIVENESS IN THE DELIVERY ROOM AND DURING FEEDINGS, AND MOTHER-INFANT ADJUSTMENT ASSESSED FOUR WEEKS FOLLOWING DELIVERY 212 213 APPENDIX K TABLE Kl.--Pearson Product Moment Correlation Coefficients of Responses to Interview Questions and Backgr0und Variables, Neonatal Characteristics, Maternal Responsiveness in Delivery Room and During Feedings, and Mother-Infant Adjustment Assessed Four Weeks Following Delivery. Maternal perception of overall adjustmenta overall healthb total no. symptomsb irritabilityb recall of dif. . total score of labor and mat. resp. delivery during home feeding .3325 -.376l -.3413 .2928 .2999 Maternalgperception of mother-infant reciprocitya b per. resources for child rearingd education irritability -.4024 .2914 -.2559 Maternal perception of infant's adjustmenta bother inventoryb punitivenessb -.2560 -.2780 Maternalgperception of personal adjustmenta b newborn state control concern for baby .2586 -.4541 Onset of maternal feelings of attachmentc c overall healthb onset of recognition of baby as person -.3150 .6178 Onset of maternal recognition of baby as personc stress during pregnancy onset of maternal feelings of attachmentc -.3829 .6178 Onset of mother's perception of baby's recognition of herc income -.2718 Maternal recall of difficulty of labor and deliverye planning of pregnancy total score of mat. responsiveness total score of mat. responsiveness in the delivery room during hospital feeding -.2983 —.3586 -.3218 negative aspect of caregivingb total No. symptomsb maternal perception of overall . adjustmenta -26l5 .2696 .2928 maternal perception of personal adjustmenta -.3043 Note. Only correlations with < .05 are reported. cale from Mother—Infant Adapgation Interview (Kennedy, 1969). cScale from Postpartum Research Inventory (Schaefer & Manheimer, Note 2). dAttachment questions (Robson & Moss, 1970). Total concern score, Survey on Bringing Up Children (Helfer & Schneider, 1975). eRecall questions from Interview Assessment of Mother-Infant Adaptation. APPENDIX L PEARSON PRODUCT MOMENT CORRELATION COEFFICIENTS OF MATERNAL RESPONSIVENESS DURING A FEEDING FOUR WEEKS FOLLOWING DELIVERY AND MEASURES OF MOTHER-INFANT ADJUST- MENT FOUR WEEKS FOLLOWING DELIVERY 2l4 APPENDIX L TABLE L1.--Pearson Product Moment Correlation Coefficients of Maternal Responsiveness during a Feeding Four Weeks Following Delivery and Measures of Mother-Infant Adjustment Four Weeks Following Delivery. Total score of maternal responsiveness during feeding; ignore babya overall healtha baby responsiveness during feeding -.3937 .2995 .3683 maternal perception of overall adjustmentb .2999 Note. 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