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Electronic Version CORE Metadata, citation and similar papers at core.ac.uk Provided by Wolverhampton Intellectual Repository and E-theses Sandie Sandbrook Love or Protection? Defining and measuring maternal-fetal attachment from the woman’s perspective. Volume One Sandra Sandbrook BA (Joint Hons.), RN, RM, ADM, MTD, Cert. Ed (FE) A thesis submitted in partial fulfilment of the requirements of the University of Wolverhampton for the degree of Doctor of Philosophy December 2009 The right of Sandra Patricia Sandbrook to be identified as the author of this work is asserted in accordance with ss.77 and 78 of the Copyright, Designs and Patents Act 1988. At this date copyright is owned by the author. Signature: …………………………………………………… Date: ………………………………………………………… 1 Sandie Sandbrook Abstract Existing commonly used maternal-fetal attachment instruments have not been thoroughly tested for reliability and validity; criticism can be levelled for a variety of problems ranging from lack of reliability due to an inadequate underpinning framework to facilitate objective interpretation to limited generalizability due to the sample. The aim of this study is to acknowledge the centrality of the mother, to use the experiences of pregnant women to generate a definition of maternal- fetal attachment and ultimately create a tool that will act as a reliable, valid and simple measurement. A mixed method framework utilising a sequential exploratory strategy has allowed qualitative exploration of the phenomenon under investigation followed by quantitative testing of the emerging theory on a much larger and different sample. Phase 1 involved face to face open structured interviews on an opportunity sample of 10 (5 primigravid; 5 multiparous) women in the final trimester of pregnancy followed by 3 focus groups targeting specific groups – primigravid women (6 participants); multiparous women (7 participants) and teenagers (4 participants). Data analysis was through constant comparative methodology. A multidimensional, psycho-biological definition of attachment was generated from the women’s own perception of their attachment to their fetus. This was used as a framework to design a questionnaire for the measurement of maternal-fetal attachment. Phase 2 involved the validation of the questionnaire and further testing of the definition. Cohort 1 tested for reliability with 200 participants within their second or third trimester of pregnancy. Following modification of the questionnaire, Cohort 2 a sample of 150 women within the final trimester of pregnancy tested the tool for internal reliability and validity. The generated Maternal-Fetal Attachment Tool (MFAT) following rigorous testing proved both reliable and valid. Maternal fetal attachment is founded in psycho-biological theory and is a complex multi-dimensional construct. Central to the definition is the woman’s need to protect her fetus, attachment develops as the fetus becomes more tangible, it is facilitated through the woman’s intergenerational experience of attachment and through appropriate social support. Maternal-fetal attachment facilitates behavioural change to ensure a favourable intra-uterine environment. 2 Sandie Sandbrook Contents Volume 1 Abstract 2 Introduction and Overview 12 Chapter 1: The History of the Attachment Concept 20 Chapter 2: The Psycho-biological Basis of Attachment 36 Chapter 3: Antenatal Attachment – Maternal-Fetal Attachment 52 3.1: Attachment as a Developmental Process 53 3.2: Intergenerational Attachment 59 3.3: Social Support and Cultural Expectation as a Foundation within the 64 Development of Attachment 3.4: The Importance of Partner Support 72 3.5: Attachment and Previous Experiences of Pregnancy 76 3.6: Prenatal Attachment and High Risk Pregnancy 80 3.7: Antenatal Depression and Attachment 83 Chapter 4: Measurement of Maternal-Fetal Attachment 87 4.1: Cranley’s (1981) Maternal-Fetal Attachment Scale 87 4.2: Condon’s (1993) Maternal Antenatal Attachment Scale 91 4.3: Muller’s (1993) Prenatal Attachment Inventory 96 3 Sandie Sandbrook Chapter 5: Overview of Research Framework 102 Chapter 6: Phase One: Qualitative Research 111 6.1: Part I – One to One Interviews 114 6.2: Part II – Focus Groups 122 Chapter 7: Results 134 7.1: Data Analyses: Interviews 134 7.2: Data Analyses: Focus Groups 148 7.3: Integration & explanation of the themes to produce key concepts 182 7.4: Model and definition of maternal-fetal attachment 195 Chapter 8: Part III: Developing the Psychometric Tool 198 8.1 : Submission for Ethical Approval 212 Chapter 9: Phase Two: Quantitative Research 213 9.1: Cohort One: Reliability 215 9.2: Cohort Two: Validity 229 Chapter 10: Results 238 10.1: Testing the Tool for Reliability (Cohort One) 238 10.2: Testing the definition of maternal-fetal attachment (Cohort One) 245 10.3: Further development & testing of the Tool: Modification 259 10.4: Testing the Modified Tool for Reliability (Cohort Two) 263 4 Sandie Sandbrook 10.5: Testing the Modified Tool for Validity (Cohort Two) 266 10.6: Testing the definition of maternal-fetal attachment 268 Chapter 11: Discussion 282 11.1: Psycho-biological Theory as a Framework for Antenatal Attachment 288 11.2: Challenging Condon’s framework of adult attachment 295 11.3: Maternal-fetal attachment is characterised by protection, not love 299 11.4: The developmental nature of maternal-fetal attachment 304 11.5: The effects of parity on maternal-fetal attachment 313 11.6: The influences of intergenerational attachment 318 11.7: The importance of partner support 326 11.8: Original Contribution to the theory of maternal-fetal attachment 332 Conclusions 335 Limitations to study 337 Further Research 339 Summary 342 References 346 List of Figures Figure 1: Overview of study 16 5 Sandie Sandbrook Figure 2: Sequential Exploratory Strategy 108 Figure 3: Stages in qualitative data analysis 120 Figure 4: Model of multi-dimensional maternal- fetal attachment 197 Figure 5: Gestation of participants (n = 200) 218 Figure 6: Age of participants (n = 200) 219 Figure 7: Occupation of participants (SOC 2001) (n = 200) 220 Figure 8: Age participants completed full-time education (n = 200) 220 Figure 9: Occupation of participants (SOC 2001) (n = 100) 222 Figure 10: Age participants completed full-time education and graduate status (n = 100) 222 Figure 11: Number of weeks participants pregnant (n = 150) 231 Figure 12: Age of participants (n = 150) 232 Figure 13: Age participants completed full-time education 233 Figure 14: Occupation of participants (SOC 2001) (n = 150) 233 Figure 15: Cattell’s Scree Plot (Round One) 241 Figure 16: Responses to question 4 – When did you first think of the pregnancy as a real little baby – a real little person? (n = 200) 252 Figure 17: Responses to question 5 – Would you describe the main feeling towards the baby as protective? (n = 200) 257 6 Sandie Sandbrook Figure 18: Cattell’s Scree Plot (Round Two) 265 Figure 19: Responses to question 4 – When did you first think of the pregnancy as a real little baby – a real little person? (n = 150) 273 Figure 20: Responses to question 5 – Would you describe the main feeling towards the baby as protective? (n = 150) 278 List of Tables Table 1: Commonly used measures of maternal-fetal attachment 98 Table 2: Participants Biographical Information (Interviews) 118 Table 3: Biographical information of participants (Focus Group 1) 126 Table 4: Biographical information of participants (Focus Group 2) 129 Table 5: Biographical information of participants (Focus Group 3) 132 Table 6: Initial Coding – Concepts identified by primigravid participants 135 Table 7: Initial Coding – Concepts identified by multiparous participants 136 Table 8: Primitive themes – primigravid participants 138 Table 9: Primitive themes – multiparous participants 140 Table 10: Key concepts for primigravid and multiparous participants 142 Table 11: Initial coding: Concepts identified by primigravid participants (Focus Group 1) 149 Table 12: Core analysis: Formation of primitive categories (Focus Group 1) 150 Table 13: Key concepts for participants in Focus Group 1 151 7 Sandie Sandbrook Table 14: Initial coding: Concepts identified by multiparous participants (Focus Group 2) 160 Table 15: Key concepts for participants in Focus Group 2 161 Table 16: Initial coding: Concepts identified by pregnant teenagers (Focus Group 3) 170 Table 17: Core analysis: Merged categories (Focus Group 3) 171 Table 18: Key concepts: Pregnant teenagers 172 Table 19: Integrated key concepts & important themes 185 Table 20: Biographical details of participants in Stage 1 Pilot group 207 Table 21: Biographical details of participants in Stage 2 Pilot group 210 Table 22: Orthogonal factor loading matrix (Round One) 24 1 Table 23: Results of Proportion / Percentage of Agreement 244 Table 24: Descriptive statistics of the results of MFAT scores (n = 200) 247 Table 25: Analysis of variance summary table showing the effect of parity and marital status on MFAT score (n = 200) 249 Table 26: Analysis of variance summary table showing the effect of marital status on MFAT score (n = 200) 250 Table 27: Analysis of variance summary table showing the effect of gestational period on MFAT score (n = 200) 253 Table 28: Orthogonal factor loading matrix (Round Two) 265 Table 29: Descriptive statistics of the results of MFAT scores (n = 150) 269 8 Sandie Sandbrook Table 30: Analysis of variance summary table showing the effect of parity and marital status on MFAT score (n = 150) 270 Table 31: Analysis of variance summary table showing the effect of increasing parity on
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