Mapping Identity and Connection How First-Time Mothers Make Sense of Premature Birth ____________________________________________________________ A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Social Work by Lauren Lindsey Porter University of Canterbury 2017 Table of Contents Table of Contents .............................................................................................................. 1 Acknowledgements ........................................................................................................... 5 Abstract ............................................................................................................................ 6 Chapter I: Introduction ...................................................................................................... 8 I.1 Introduction .......................................................................................................................... 8 I.2 Conception and plan .............................................................................................................. 8 I.3 Aims and significance .......................................................................................................... 12 I.4 Structure of the thesis ......................................................................................................... 13 I.5 Conclusion ........................................................................................................................... 16 Chapter II: Background and Context ................................................................................ 18 II.1 Introduction ....................................................................................................................... 18 II.2 A snapshot of premature birth in New Zealand ................................................................... 19 II.3 The statistical picture ......................................................................................................... 21 II.3.1 Premature birth around the world ...................................................................................... 21 II.3.2 Worldwide low-risk prematurity ......................................................................................... 23 II.3.3 The New Zealand picture .................................................................................................... 24 II.3.3.1 Low risk and late preterm birth in New Zealand ........................................................................ 26 II.3.3.2 New Zealand in comparison with other nations ........................................................................ 27 II.3.4 Context of ethnicity and socioeconomic status ................................................................... 28 II.3.4.1 Ethnicity and socioeconomic issues in New Zealand ................................................................. 28 II.3.4.1.1 Long term study of birth outcomes and ethnicity in New Zealand .................................... 29 II.4 Policies regarding prematurity ............................................................................................ 33 II.4.1 Worldwide policy regarding prematurity ............................................................................ 33 II.4.2 Policy in New Zealand ......................................................................................................... 35 II.4.3 Infant and family rights in New Zealand ............................................................................. 40 II.4.4 Legal frameworks and policies ............................................................................................ 44 II.5 Neonatal social work in New Zealand and around the world .............................................. 46 II.5.1 Social work in the New Zealand NICUs ............................................................................... 49 II.6 Conclusion .......................................................................................................................... 52 Chapter III: Literature Review .......................................................................................... 54 III.1 Introduction ...................................................................................................................... 54 III.2 Terminology ...................................................................................................................... 56 III.3 Mothers in connection to their infants: Developing a relationship ..................................... 57 III.3.1 Prematurity ........................................................................................................................ 57 III.3.1.1 Prematurity: Infant experience ................................................................................................. 58 III.3.1.2 Prematurity: Maternal experience ............................................................................................ 59 III.3.1.2.1 Prematurity: Mothers and resolution of the diagnosis ..................................................... 60 III.3.1.2.2 Prematurity: Mothers and grief ........................................................................................ 61 III.3.2 Low risk prematurity .......................................................................................................... 61 III.3.2.1 Low risk prematurity: Background ............................................................................................ 62 III.3.2.2 Low-risk prematurity: The infant experience ............................................................................ 62 III.3.2.3 The unique profile of low-risk prematurity ............................................................................... 63 III.3.2.4 Low risk prematurity: The maternal experience ....................................................................... 64 III.3.2.4.1 The unique profile of mothers of low-risk premature infants ........................................... 65 III.3.2.5 Low risk prematurity in conclusion ........................................................................................... 65 III.3.3 The impact of prematurity on the developing mother-infant relationship ........................ 66 1 III.3.3.1 Relational risk factors ................................................................................................................ 66 III.3.3.2 The relational backdrop ............................................................................................................ 67 III.3.3.3 The science of mother-infant bonding ...................................................................................... 67 III.3.3.3.1 The science of touch .......................................................................................................... 69 III.3.3.3.2 How they respond to stress: The science of stress and vulnerability ............................... 70 III.3.3.3.2.1 The context of stress ................................................................................................. 71 III.3.3.3.2.2 How the environment impacts biology: The science of epigenetics ......................... 72 III.3.3.3.2.3 The context of stress and earthquakes ..................................................................... 73 III.3.4 Mothers in connection with their infants: Summary ......................................................... 74 III.4 Mothers in relation to themselves ..................................................................................... 75 III.4.1 First time mothers .............................................................................................................. 75 III.4.2 Becoming a mother of a premature infant & maternal identity within the NICU .............. 76 III.4.2.1 Maternal identity and liminality ................................................................................................ 77 III.4.2.2 Maternal identity and claiming of the baby .............................................................................. 78 III.4.2.3 Maternal identity in other medical contexts ............................................................................ 78 III.4.3 The physiological process of becoming a mother .............................................................. 79 III.4.3.1 Stress for Mothers in NICU ....................................................................................................... 80 III.4.3.1.1 Response to stress through experiential avoidance ......................................................... 80 III.4.3.1.2 Hidden contextual factors of stress ................................................................................... 81 III.4.3.1.3 The stress of separation .................................................................................................... 82 III.4.3.1.4 Separation and its future implications .............................................................................. 83 III.4.3.1.5 Stress in summary ............................................................................................................. 84 III.5 Mothers in relationship with others: Medical and NICU contexts ...................................... 84 III.5.1 Mothers interacting with nurses ........................................................................................ 85 III.5.1.1 Mothers and nurses: Dyads and triads ....................................................................................