Infant Behavior and Development

Infant Behavior & Development 35 (2012) 1–11
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Infant Behavior and Development
What helps the mother of a preterm infant become securely attached,
responsive and well-adjusted?
Tracey Evans a,∗ , Koa Whittingham b,a,c , Roslyn Boyd b,c
a
School of Psychology, Faculty of Social and Behavioural Sciences, The University of Queensland, Brisbane, Australia
Queensland Cerebral Palsy and Rehabilitation Research Centre, The School of Medicine, Faculty of Health Sciences, The University of Queensland, Brisbane,
Australia
c
Queensland Children’s Medical Research Institute, Faculty of Health Sciences, The University of Queensland, Brisbane, Australia
b
a r t i c l e
i n f o
Article history:
Received 12 July 2011
Received in revised form
28 September 2011
Accepted 18 October 2011
Keywords:
Preterm infant
Maternal attachment
Maternal psychological symptoms
Maternal responsiveness
a b s t r a c t
Objective: To investigate the relationship between the predictor variables of experiential
avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and postpartum support, and the criterion variables of maternal attachment, maternal
psychological symptoms and maternal responsiveness, after controlling for birth weight.
Design: A quantitative survey study.
Method: The participants were 127 mothers of preterm infants (delivery prior to
37 weeks gestation, <24 months corrected age) recruited through parent support
organisations. The web-based survey included measures of: demographics, postpartum
support and prenatal expectations (compared to postnatal experience)—all designed
for this study, as well as maternal attachment, (MPAS) maternal responsiveness
(MIRI), experiential avoidance (AAQ), maternal psychological symptoms (DASS-21)
and relationship satisfaction (RQI). Three standard multiple regression analyses were
conducted.
Results: The combined effects of experiential avoidance, relationship satisfaction, prenatal
expectations (compared to postnatal experience) and postpartum support accounted for
a significant 21% of variance in maternal attachment, Fch (4,121) = 8.01, p < .001, a significant 38% of variance in maternal psychological symptoms Fch (4,121) = 18.38, p < .001, and
a significant 11% of variance in maternal responsiveness, Fch (4,121) = 3.78, p = .013 after
controlling for birth weight.
Conclusion: The four predictor variables predicted maternal attachment, psychological symptoms and responsiveness after controlling for birth weight, with experiential
avoidance being the most important predictor, followed by prenatal expectations
(compared to postnatal experience), relationship satisfaction, then postpartum support. This has implications for designing interventions to optimise attachment and
responsiveness, and minimise psychological symptoms, in mothers of infants born
preterm.
© 2011 Elsevier Inc. All rights reserved.
∗ Corresponding author at: Queensland Cerebral Palsy and Rehabilitation Research Centre, The University of Queensland, Level 7, Building 6, Royal
Brisbane and Women’s Hospital, Herston, Brisbane 4029, Australia. Tel.: +61 7 3636 5361.
E-mail address: [email protected] (T. Evans).
0163-6383/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.infbeh.2011.10.002
2
T. Evans et al. / Infant Behavior & Development 35 (2012) 1–11
1. Introduction
1.1. Preterm birth
In Western societies premature births account for approximately 5–9% of all live births (Greco et al., 2005). Preterm
birth is associated with an elevated risk of neonatal complications that can cause significant mortality or morbidity (Laws &
Hilder, 2008). The survival of preterm infants is promoted by admission to a Neonatal Intensive Care Unit (NICU) (Goldberg,
Perrotta, & Minde, 1986; Goldenberg & Rouse, 1998). The intense medical environment of the NICU can be difficult for the
parents of preterm infants and the medical condition of the infant can enforce the separation of the parent from their infant.
Parents may find themselves adopting a passive role as health professionals manage the day to day care of their infant and
may find themselves experiencing feelings of guilt, helplessness and anxiety (Hughes, McCollum, Sheftel, & Sanchez, 1994;
Miles, Funk, & Casper, 1992; Zeanah, Canger, & Jones, 1984).
Preterm birth can have health and developmental consequences for infants not only immediately following the birth
but also in the long-term (Aylward, Pfeiffer, Wright, & Verhulst, 1989; Clark, Woodward, Horwood, & Moor, 2008; Greco
et al., 2005; Laws & Hilder, 2008; Lorenz, Wooliever, Jetton, & Paneth, 1998; McCormack, McCarton, Tonascia, & BrooksGunn, 1993). With preterm infant survival rates increasing (Goldenberg & Rouse, 1998) there will be a greater number of
parents experiencing the difficulties adjusting to parenthood in the NICU environment, as well as the ongoing health and
developmental problems more common in the very preterm infant.
Mothers of infants born preterm are at risk for attachment difficulties (Amankwaa, Pickler, & Boonmee, 2007; Borghini
et al., 2006; Nagata, Nagai, Sobajima, Ando, & Honjo, 2004; Tideman, Nilsson, Smith, & Stjernqvist, 2002), increased psychological symptoms (Davis, Edwards, Mohay, & Wollin, 2003; Ellestad et al., 2007; Muller-Nix et al., 2004; Poehlmann & Fiese,
2001), and decreased responsiveness (Amankwaa et al., 2007; Feely, Gottlieb, & Zelkowitz, 2005; Landry, Smith, Swank,
Assel, & Vellet, 2001; Zelkowitz, Bardin, & Papageorgiou, 2007).
1.2. Attachment
Attachment is a reciprocal bond between parent and infant (Bowlby, 1988). The way in which these bonds develop
and are organised in infancy has a key role in determining mental health in adulthood. Insecure attachment patterns are
more likely if the mother is less responsive (Bowlby, 1958; Mills-Koonce, Gariepy, Sutton, & Cox, 2008; Van Ijzendoorn,
Goldberg, Kroonenberg, & Frankel, 1992) or has increased psychological symptoms (Ainsworth, Blehar, Waters, & Wall,
1978; Anisfeld, Casper, Nozyce, & Cunningham, 1990; Bowlby, 1988; Mills-Koonce et al., 2008; Van Ijzendoorn et al.,
1992).
Mothers and preterm infants are at risk of attachment difficulties (Borghini et al., 2006; Forcada-Guex, Borghini,
Pierrehumbert, Ansermet, & Muller-Nix, 2010; Tideman et al., 2002) because preterm birth disrupts normal physical contact
between the mother and the infant (Amankwaa et al., 2007) and mothers may withdraw from their preterm infant due
to distress (Miles, Holditch-Davis, & Burchinal, 1999). This may inhibit the mother’s caregiving behavioural system, as her
desire and ability to provide protection for her preterm infant is interrupted. This can affect the mother’s attachment representations and the child’s attachment patterns (George & Solomon, 2008). Borghini et al. (2006) found at 6months only 20%
of mothers with preterm infants had a secure attachment representation compared to 53% for the term comparison group.
At the 18-month follow-up, the figures were 30% and 57%, respectively.
1.3. Maternal psychological symptoms
Preterm birth is a risk factor for a mother developing postnatal depression (Psychosocial Paediatrics Committee, 2004)
and increased psychological symptoms (Davis et al., 2003; Ellestad et al., 2007; Muller-Nix et al., 2004; Poehlmann & Fiese,
2001), with preterm birth accounting for 24% of the total variance in depression (Blumberg, 1980). This increased risk is
likely due to a combination of factors including the elevated infant risk of mortality and morbidity (Laws & Hilder, 2008),
the enforced separation of the parent from their infant, an extended hospital stay and costs (Kaufman & Fairchild, 2004)
and the crisis atmosphere of the NICU (Zeanah et al., 1984). Increased maternal psychological symptoms are a risk factor for
attachment difficulties and decreased maternal responsiveness (Muller-Nix et al., 2004; Nagata et al., 2004; Poehlmann &
Fiese, 2001).
1.4. Maternal responsiveness
Maternal responsiveness or sensitivity is a sequence of synchronous mutual exchanges or expressions between the
mother and her infant (Landry et al., 2001). Infancy is a particularly critical time where mothers need to respond in a
sensitive and warm manner as this provides a strong basis for the child’s later development including the development of
secure attachment patterns (Ainsworth et al., 1978).
A preterm birth can also have a negative impact on maternal responsiveness because the behavioural cues of a preterm
infant may be less noticeable and more difficult to understand (Poehlmann & Fiese, 2001). Eckerman, Hsu, Molitor, Leung,
T. Evans et al. / Infant Behavior & Development 35 (2012) 1–11
3
and Goldstein (1999) found only 33% of very low birth weight (VLBW) and 21% of low birth weight (LBW) infants (n = 47)
showed strong positive arousal cues and weak negative arousal cues in a standardised peekaboo game compared to 69% of
full-term infants in the comparison group (n = 32). Over 61% of the preterm infants failed to show a full smile compared to
less than 16% of full-term infants.
Responsiveness may also be disrupted by maternal psychological symptoms (Amankwaa et al., 2007; Feely et al., 2005;
Landry et al., 2001; Zelkowitz et al., 2007) for which mothers of infants born preterm are at risk (Davis et al., 2003; Ellestad
et al., 2007; Muller-Nix et al., 2004; Poehlmann & Fiese, 2001). Three studies (Feely et al., 2005; Zelkowitz et al., 2007;
Zelkowitz, Papageorgiou, Bardin, & Wang, 2009) using different sample groups and different time measurement periods of
two weeks, nine months and 24 months, showed that mother’s of preterm infants with high levels of anxiety displayed low
levels of maternal responsiveness when mother–infant interaction was observed.
In order to effectively intervene it is important to identify predictors in the relationship between prematurity and maternal attachment, maternal psychological symptoms and maternal responsiveness. One potential predictor from a psychosocial
perspective is experiential avoidance. Experiential avoidance is a person’s unwillingness to experience certain private experiences, for example, emotions, images, memories, thoughts and bodily sensations (Hayes, Wilson, Gifford, Follette, & Strosahl,
1996). The person takes action to alter the form, frequency or contexts in which the experiences occur, even when the avoidance can cause behavioural harm (Hayes et al., 1996). Increased levels of experiential avoidance can lead to increased levels
of depression, anxiety, psychopathology and trauma (Greco et al., 2005; Marcks & Woods, 2005; Reddy, Pickett, & Orcutt,
2006; Sloan, 2004; Spira et al., 2007). Greco et al. (2005) examined the responses of sixty-six mothers of preterm infants who
completed the Parental Stressor Scale (PSS), Parenting Stress Index-Short Form, Post traumatic Stress Checklist for Civilians
and the Acceptance and Action Questionnaire (AAQ) when their infants were aged between 3 and 36 months-of-age. They
found maternal experiential avoidance partially mediated the relationship between NICU stress and maternal well-being
after discharge, with a positive correlation between experiential avoidance and maternal stress and trauma symptoms (Greco
et al., 2005).
From a behavioural systems perspective, marital satisfaction may also be a predictor as research has shown marital satisfaction to increase maternal sensitivity and attachment (Belsky, Crnic, & Gable, 1995; Feldman, Weller, Sirota, & Eidelman,
2003). In addition, mothers reported as depressed expressed a decrease in marital satisfaction (Cicchetti, Rogosch, & Toth,
1998). Further, preterm birth can impact upon relationship satisfaction (Belsky, 1985; Zelkowitz et al., 2007). Zelkowitz et al.
(2007) found that for both mothers and fathers the quality of the marital relationship was significantly, negatively related
to anxiety and positively related to parental responsiveness.
Another possible predictor arises from the psychosocial association between prenatal expectations and a negative transition to parenthood, when the mother had underestimated the personal impact of the birth of the infant (Feldman & Nash,
1984) or the mother’s experience was negative compared to her prenatal expectations (Harwood, McLean, & Durkin, 2007). A
preterm birth is likely to be completely different to the positive, romanticized expectations held during pregnancy (Feldman
& Nash, 1984).
Again from a behavioural systems perspective, postpartum support is a potential predictor of maternal attachment,
responsiveness and adjustment. Postpartum support refers to all assistance received by the mother in the postpartum period
(Logsdon, McBride, & Birkimer, 1994). It is one of the most important predictors of postpartum depression and maternal
responsiveness in mothers of newborn infants (Beck, 2001) including mothers of infants born preterm (Younger, Kendell, &
Pickler, 1997). Further, postpartum support may play a key role in assisting mothers of infants born preterm in achieving
mastery in parenting tasks.
1.5. The current study
The aim of this study was to test four potential predictors of maternal attachment, maternal psychological symptoms
and maternal responsiveness. Four potential predictors that may be modifiable by intervention were chosen, experiential
avoidance, relationship satisfaction, prenatal expectations (as compared to postnatal experience) and postpartum support. It
was hypothesised that after controlling for birth weight, these predictors would predict the quality of maternal attachment,
psychological symptoms and responsiveness. Specifically, as experiential avoidance increased, maternal psychological symptoms would increase and the quality of maternal attachment and responsiveness would decrease; as relationship satisfaction
decreased, the quality of maternal attachment and responsiveness would decrease and maternal psychological symptoms
would increase; as the difference between prenatal expectations (compared to postnatal experience) increased, maternal
psychological symptoms would increase and the quality of maternal attachment and responsiveness would decrease; and
as postpartum support decreased, the quality of maternal attachment and responsiveness would decrease and maternal
psychological symptoms would increase.
Giving birth to a preterm infant can have a negative impact on maternal attachment, maternal psychological symptoms
and maternal responsiveness. These negative effects can have both short- and long-term implications for both the mother
and the child, and on the relationship that exists between them. It is important therefore to investigate factors that may
improve the mother’s psychological symptoms, responsiveness and attachment to potentially decrease the negative effects
for the mother–infant dyad.
4
T. Evans et al. / Infant Behavior & Development 35 (2012) 1–11
Table 1
Demographics of mother and infant in the preterm sample (n = 127).
Variable (mother)
M
SD
Age (years)
Ethnicity (%)
Caucasian
European
Asian
Marital status (%)
Married
De facto
Education (%)
University postgraduate
University undergraduate
Trade/apprenticeship
High school grade 12
High school grade 10 2
Less than grade 10
Income (%)
Less than $25,000
$25,000–50,000
$50,000–70,000
$70,000–100,000
Over $100,000
Employment status (%)
Employed full-time
Employed part-time
Home duties
Unemployed
History of preterm births, n (%) yes
History of miscarriages, n (%) yes
32.47
7.63
Variable (infant)
Gender, n (%) of male
Gestational age at birth (weeks)
Birth weight, n (%)
<1000 (g)
>1000–<1500 (g)
>1500–<2500 (g)
>2500 (g)
Birth order
First born
Second born
Third born or later
Twins, n (%)
Duration of hospitalisation (days)
Number
117 (93%)
8 (6%)
1 (1%)
102 (80%)
25 (20%)
29 (23%)
43 (34%)
31 (24%)
10 (8%)
9 (7%)
5 (4%)
2 (1%)
9 (7%)
31 (24%)
41 (32%)
43 (34%)
18 (14%)
33 (26%)
76 (60%)
0 (0%)
20 (16%)
21 (17%)
M
SD
30.40
3.53
Number
74 (54%)
36 (26%)
34 (25%)
55 (40%)
13 (9%)
82 (66%)
24 (19%)
19 (15%)
22 (16%)
58
6.14
2. Method
2.1. Participants
The study included 127 mothers who had given birth to preterm infants (gestational age < 37 weeks, M = 30.40, SD = 3.53).
They were eligible for the study if their child/children were less than 24 months corrected age, to ensure the preterm birth
was relatively recent when recalling the experience in the self-report sections of the questionnaire. In addition, they had to
be married or in a defacto relationship so they could complete the Relationship Satisfaction measure. They were recruited
via preterm parent support groups within Australia, for example, the Preterm Infants’ Parents’ Association in Queensland,
and also by word-of-mouth. Participant characteristics are displayed in Table 1.
2.2. Measures
2.2.1. Demographics questionnaire
The demographics questionnaire was designed for the purposes of this study and included basic demographic information,
details of birth and hospital stay as well as baby characteristics. No participants were excluded on information given for
other diagnoses or significant health complications.
T. Evans et al. / Infant Behavior & Development 35 (2012) 1–11
5
2.2.2. Postpartum support questionnaire
The researchers designed the postpartum support questionnaire for the purposes of this study as one did not previously
exist. Questions were scored on a five-point Likert scale from ‘1 strongly disagree’ to ‘5 strongly agree’, with a score range
of 9–45 for the total score. It included questions on how easy or difficult the hospital environment and staff made it for the
mother to visit her baby, and the amount of emotional and practical support the participant received from their partner,
family and friends in the postpartum period. Internal consistency for this study was high, ˛ = .81.
2.2.3. Prenatal expectations (compared to postnatal experience) questionnaire
The researchers of this study designed the prenatal expectations (compared to postnatal experience) questionnaire to
determine the difference between the participant’s prenatal expectations of their experience with their baby, to their actual
experience with their baby following the preterm delivery. Questions were scored on a five-point Likert scale from ‘1 strongly
disagree’ to ‘5 strongly agree’. Prenatal and postnatal item scores were added together separately, and then the prenatal
scores were subtracted from the postnatal scores producing a score range for the total score of −40 to 40. This resulted in a
‘difference’ score, with negative scores reflecting a large difference and positive scores reflecting a small difference between
prenatal expectations and postnatal experiences. Internal consistency for this study was high for both prenatal expectations
˛ = .89 and postnatal experience ˛ = .87.
2.2.4. Maternal postnatal attachment scale (Condon & Corkingdale, 1998)
This self-report scale quantitatively measures a mother’s emotional response to her infant by assessing the intensity
and frequency of her subjective experiences in four indicators of attachment. These indicators are pleasure in proximity,
tolerance, need-gratification and protection, and knowledge acquisition. The scale consists of 19 self-report items scored
on a five-point scale, with 1 indicating low attachment and 5 indicating high attachment. Scores for each item are added
together to form an attachment score ranging from 19 to 95, with higher scores indicating higher attachment levels. The
scale has high internal consistency ˛ = .78, ˛ = .79 and ˛ = .78 at four weeks, 4 months, and 8 months, respectively (Condon
& Corkingdale, 1998). Test–retest reliability is also high with Pearson’s correlation coefficient reported at .86. The scale
was found to be a valid measure of attachment as it was significantly positively related to the AQS, which is a behavioural
indicator of caregiver–infant attachment. Internal consistency for this study was high, .79.
2.2.5. Maternal infant responsiveness instrument (MIRI; Amankwaa & Pickler, 2007)
This instrument is a 22-item self-report questionnaire measuring maternal responsiveness to infant cues. Specifically, it
measures the mother’s recognition of her own responses, the mother’s recognition of her infant’s responses to her, and any
difficulties she notices in responsiveness. It is scored on a five-point Likert scale from ‘1 strongly agree’ to ‘5 strongly disagree’,
with a score range of 22–110. Face and content validity were established using advanced practice nurse practitioners and
maternal child nursing experts (Amankwaa & Pickler, 2007). The scale has good internal consistency ˛ = .86 (Amankwaa &
Pickler, 2007) and ˛ = .83 (Drake, Humenick, Amankwaa, Younger, & Roux, 2007). Internal consistency for this study was
high, ˛ = .84.
2.2.6. The acceptance and action questionnaire (AAQ; Hayes et al., 2004)
The AAQ is a nine-item standard measure of experiential avoidance. Each item is scored on a 7-point Likert scale from
‘1 never true’ to ‘7 always true’, with a score range of 16–112. It focuses on five main areas: taking action when inhibitory
thoughts or feelings are being experienced, the presence of anxiety, worry or negative evaluations of private events and the
control of these, the ability to distance yourself from the actual content of negative evaluations, using worry or day-dreaming
to regulate behaviour, and using negative comparisons to cope with your life. The questionnaire is a good measure of experiential avoidance with good internal consistency ˛ = .70, a test–retest reliability of .64, and several significant correlations
with related constructs, including thought suppression and social desirability indicating high construct validity (Hayes et al.,
2004). Internal consistency for this study was high, ˛ = .71.
2.2.7. The depression anxiety stress scale-21 (DASS-21; Lovibond & Lovibond, 1995)
The DASS-21 is the reduced version of the DASS-42 (Lovibond & Lovibond, 1995). It contains 21 self-report items reflecting
the frequency or severity of the participant’s experiences with depression, anxiety and stress over the past week. Each item
is rated on a four-point Likert Scale from ‘0 Did not apply to me at all’ to ‘3 Applied to me very much, or most of the time’,
with a score range of 0–63. The DASS-21 has been shown to have high internal consistency ˛ = .83, ˛ = .78 and ˛ = .87 for
depression, anxiety and stress, respectively (Norton, 2007). The scale has high convergent validity with other measures of
similar constructs: r = .76 between the DASS depression scale and the BDI, r = .74 between the DASS anxiety scale and the
Beck Anxiety Scale and r = .74 between the DASS stress scale and the Positive and Negative Affect Schedule (Gloster et al.,
2008). Internal consistency for this study was high, ˛ = .93.
2.2.8. Relationship quality index questionnaire (RQI; Norton, 1983)
This six-item questionnaire has been adapted from the quality marriage index (Norton, 1983), and contains evaluative
variables of relationship satisfaction. Each item is measured on a 7-point Likert scale from ‘1 very strongly disagree’ to ‘7
very strongly agree’, with a score range of 6–45. Responses are added together with low scores representing less relationship
6
T. Evans et al. / Infant Behavior & Development 35 (2012) 1–11
Table 2
Descriptive statistics and correlations between MA, MPS and MR, and BW, EA, RS, PE and PS.
MA
MPS
MR
BW
EA
RS
PE
PS
M
SD
M
BW
EA
RS
PE
PS
81.05
33.50
98.17
2.34
56.48
36.07
14.61
36.54
7.82
10.50
9.48
.96
11.89
10.08
9.77
6.50
1
1
1
−.08
−.01
.02
1
−.39***
.49***
−.33***
.01
1
.18*
−.41***
.09
−.03
−.26*
1
−.28*
.34***
−.09
−.26
.23*
−.14
1
.15
−.32***
.12
−.25
−.29***
.35***
−.15
1
MA: maternal attachment; MPS: maternal psychological symptoms; MR: maternal responsiveness; BW: birth weight; EA: experiential avoidance; RS:
relationship satisfaction; PE: prenatal expectations (compared to postnatal experience); PS: postpartum support.
*
p < .05.
***
p < .001.
satisfaction and high scores representing greater relationship satisfaction. The median internal consistency for the six items
is ˛ = .76 (Norton, 1983). Convergent and discriminant validity was significant at the p < .01 level with the DAS and the
Relationship Satisfaction Questionnaire (Heyman, Sayers, & Bellack, 1994). Internal consistency for this study was high,
˛ = .97.
2.3. Procedure
Ethics clearance was obtained from the University of Queensland, School of Psychology, ethics clearance number: 10PSYCH-4-72-JM. A web-based questionnaire was created and uploaded onto a website specially created for the study. Emails
were distributed to 20 preterm support organisations, requesting their help in the recruitment of mother’s of preterm infants
by distributing an information letter to parents. The information letter invited the mothers to participate in the study by
completing the web-based questionnaire. The web-site address was also included in the letter as well as the researchers
contact details for any further information. A web-based distribution method was chosen to maximise participant convenience. The questionnaire took participants approximately 20 min to complete. Participants were informed their responses
would be anonymous and would include questions relating to their expectations before the preterm birth, their experiences during hospitalisation, coping strategies, their feelings, their spousal relationship, and their current feelings about
parenting.
2.4. Analysis
Three hierarchical multiple regression analyses were conducted, with birth weight entered first to control for the severity
of the prematurity, and then experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal
experience) and postpartum support entered next as the predictor variables. Maternal attachment, maternal psychological
symptoms and maternal responsiveness were entered separately as the criterion variables. The analysis was conducted
using Statistical Package for the Social Sciences (SPSS) 17.00.
3. Results
The assumptions were found not to be violated. The pattern of missing data was random and formed less than 5% of the
data set. Where participants omitted a single response on a questionnaire, mean substitution was performed by inserting
that participant’s mean score for that questionnaire as a conservative procedure for obtaining a value (Tabachnick & Fidell,
2007). Logarithmic transformations to account for skewness and kurtosis did not change the interpretation of the data, nor
did the removal of outliers and therefore the original data are reported.
3.1. Hierarchical regression one with maternal attachment as the criterion variable
There were significant correlations between the predictor variables of experiential avoidance, relationship satisfaction
and prenatal expectations (compared to postnatal experience), and the criterion variable maternal attachment. Table 2
shows the descriptive statistics for correlations between the variables.
Results of the analysis of regression at step 1 showed F (1,125) = .75, p = .388, indicating a non-significant 6% (−2% adjusted)
of variance in maternal attachment was due to birth weight. At step 2 the analysis showed Fch (4,121) = 8.01, p < .001, indicating a further significant 21% (18% adjusted) of variance in maternal attachment was due to the inclusion of the combined
effects of experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and
postpartum support. At step 2 with all the predictors in the analysis, it showed F (5,121) = 6.59, p < .001, indicating a significant amount of variance in maternal attachment was due to the combined effects of birth weight, experiential avoidance,
relationship satisfaction, prenatal expectations (compared to postnatal experience) and postpartum support. Experiential
T. Evans et al. / Infant Behavior & Development 35 (2012) 1–11
7
Table 3
Hierarchical multiple regression statistics with BW, EA, RS, PE and PS as predictor variables and MA, MPS and MR as the criterion variables at step 1 and 2.
MA
B
ˇ
sr2
BW
EA
RS
PE
PS
S1
S2
−1.19
−.22
.06
−.19
−.06
−.15
−.33***
.08
−.24*
−.05
.02
.09
.00
.05
.00
MPS
B
BW
EA
RS
PE
PS
S1
S2
MR
BW
EA
RS
PE
PS
S1
S2
.16
.30
−.27
.24
−.15
B
.28
−.26
−.01
−.00
.06
ˇ
sr2
.02
.34***
−.26*
.22*
−.09
.00
.10
.06
.04
.01
ˇ
sr2
.03
−.32*
−.01
−.00
.04
.00
.09
.00
.00
.00
R
R2
Adj R2
R2 ch
Intercept
.08
.46
.01
.21
.00
.18
.21***
98.82
R
R2
Adj R2
R2 ch
Intercept
.01
.62
.00
.38
−.01
.35
.38***
27.77
R
R2
Adj R2
R2 ch
Intercept
.02
.33
.00
.11
−.01
.08
.11*
110.39
MA: maternal attachment; MPS: maternal psychological symptoms; MR: maternal responsiveness; BW: birth weight; EA: experiential avoidance; RS:
relationship satisfaction; PE: prenatal expectations (compared to postnatal experience); PS: postpartum support; S1: step 1; S2: step 2.
*
p < .05.
***
p < .001.
avoidance had a significant 9% unique contribution to the variance for maternal attachment, t (127) = −3.80, p < .001. Prenatal expectations (compared to postnatal experience) had a significant 5% unique contribution to the variance for maternal
attachment t (127) = −2.70, p = .008. Birth weight t (127) = −1.67, p = .098, relationship satisfaction t (127) = .87, p = .384 and
postpartum support t (127) = −.50, p = .617, did not have a significant unique contribution to the variance for maternal
attachment. There was no additional shared variance.
The size and direction of the relationships indicates higher levels of experiential avoidance and a negative difference
between prenatal expectations (compared to postnatal experience) are associated with lower levels of maternal attachment.
The 95% confidence intervals were calculated for birth weight (−2.600 to .223), experiential avoidance (−.332 to −.105),
relationship satisfaction (−.075 to .194), prenatal expectations (compared to postnatal experience) (−.328 to −.050) and
postpartum support (−.276 to .164), showing experiential avoidance and prenatal expectations (compared to postnatal
experience) to have significant ˇ weights.
The relative weights for each predictor were calculated to indicate the relative importance of each predictor. It was found
birth weight had a weighting of 4%, experiential avoidance 60%, relationship satisfaction 6% prenatal expectations (compared
to postnatal experience) 30%, and postpartum support 0%. Table 3 shows the unstandardised regression coefficients (B), the
standardised regression coefficients (ˇ), the squared semi-partial correlations (sr2 ), R2 , adjusted R2 , R2 ch and intercept.
3.2. Hierarchical regression two with maternal psychological symptoms as the criterion variable
There were significant correlations between the predictor variables of experiential avoidance, relationship satisfaction,
prenatal expectations (compared to postnatal experience) and postpartum support, and the criterion variable maternal
psychological symptoms. Table 2 shows the descriptive statistics for correlations between the variables.
Results of the analysis of regression at step 1 showed F (1,125) = .01, p = .914, indicating 0% (−8% adjusted) of variance
in maternal psychological symptoms was due to birth weight. At step 2 the analysis showed Fch (4,121) = 18.38, p < .001,
indicating a further significant 38% (35% adjusted) of variance in maternal psychological symptoms was due to the inclusion
of the combined effects of experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal
experience) and postpartum support. At step 2 with all the predictors in the analysis, it showed F (5,121) = 14.71, p < .001,
indicating a significant amount of variance in maternal psychological symptoms was due to the combined effects of birth
weight, experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and
postpartum support. Experiential avoidance had a significant 10% unique contribution to the variance for maternal psychological symptoms, t (127) = 4.43, p < .001. Relationship satisfaction had a significant 6% unique contribution to the variance
for maternal psychological symptoms, t (127) = −3.31, p = .001. Prenatal expectations (compared to postnatal experience)
8
T. Evans et al. / Infant Behavior & Development 35 (2012) 1–11
had a significant 4% unique contribution to the variance for maternal psychological symptoms, t (127) = 2.81, p = .006. Birth
weight t (127) = .19, p = .851 and postpartum support t (127) = −1.13, p = .259 did not have a significant unique contribution
to the variance for maternal psychological symptoms. There was no additional shared variance.
The size and direction of the relationship indicates high levels of experiential avoidance, low levels of relationship satisfaction and a negative difference between prenatal expectations (compared to postnatal experience) are associated with
higher levels of maternal psychological symptoms. The 95% confidence intervals were calculated for birth weight (−1.524 to
1.846), experiential avoidance (.168 to .439), relationship satisfaction (−.430 to −.108), prenatal expectations (compared to
postnatal experience) (.069 to .400) and postpartum support (−.413 to .112), showing all the variables except for postpartum support to have significant ˇ weights. The relative weights for each predictor were calculated to indicate the relative
importance of each predictor. It was found birth weight had a weighting of 0%, experiential avoidance 44%, relationship satisfaction 28%, prenatal expectations (compared to postnatal experience) 20% and postpartum support 8%. Table 3 shows the
unstandardised regression coefficients (B), the standardised regression coefficients (ˇ), the squared semi-partial correlations
(sr2 ), R2 , adjusted R2 , R2 ch and intercept.
3.3. Hierarchical regression three with maternal responsiveness as the criterion variable
There was a significant correlation between the predictor variable experiential avoidance and the criterion variable
maternal responsiveness. Table 2 shows the descriptive statistics for correlations between the variables.
Results of the analysis of regression at step 1 showed F (1,125) = .04, p = .847, indicating 0% (−1% adjusted) of variance
in maternal responsiveness was due to birth weight. At step 2 the analysis showed Fch (4,121) = 3.78, p = .013, indicating
further a significant 11% (8% adjusted) of the variance in maternal responsiveness was due to the inclusion of the combined
effects of experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and
postpartum support. At step 2 with all the predictors in the analysis, it showed F (5,121) = 3.04, p = .13, indicating a significant
amount of variance in maternal responsiveness was due to the combined effects of birth weight, experiential avoidance,
relationship satisfaction, prenatal expectations (compared to postnatal experience) and postpartum support. Experiential
avoidance had a significant 9% unique contribution to the variance for maternal responsiveness, t (127) = −3.48, p = .001.
Birth weight t (127) = .30, p = .763, relationship satisfaction t (127) = −.12, p = .907, prenatal expectations (compared to postnatal experience), t (127) = −.02, p = .984 and postpartum support, t (127) = .40, p = .694 did not have a significant unique
contribution to the variance for maternal responsiveness. There was no additional shared variance.
The size and direction of the relationship indicates low levels of experiential avoidance are associated with higher levels
of maternal responsiveness. The 95% confidence intervals were calculated for birth weight (−1.541 to 2.098), experiential
avoidance (−.404 to −.111), relationship satisfaction (−.184 to .163), prenatal expectations (compared to postnatal experience) (−.180 to .177) and postpartum support (−.227 to .340), showing only experiential avoidance to have a significant ˇ
weight.
The relative weights for each predictor were calculated to indicate the relative importance of each predictor. It was found
birth weight had a weighting of 0%, experiential avoidance 96%, relationship satisfaction 0%, prenatal expectations (compared
to postnatal experience) 0% and postpartum support 4%. Table 3 shows the unstandardised regression coefficients (B), the
standardised regression coefficients (ˇ), the squared semi-partial correlations (sr2 ), R2 , adjusted R2 , R2 ch and intercept.
4. Discussion
This study found after controlling for birth weight, the combined effects of experiential avoidance, relationship satisfaction, prenatal expectations (compared to postnatal experience) and postpartum support accounted for a significant amount
of variance in maternal attachment, maternal psychological symptoms and maternal responsiveness. This is consistent with
previous research in mothers of infants born preterm (Amankwaa et al., 2007; Davis et al., 2003; Ellestad et al., 2007; Feely
et al., 2005; Muller-Nix et al., 2004; Nagata et al., 2004; Poehlmann & Fiese, 2001; Zelkowitz et al., 2007, 2009).
Experiential avoidance was found to be a significant unique contributor to maternal attachment, maternal psychological
symptoms and maternal responsiveness. Previous research suggests that preterm birth is a stressor for the mother of the
preterm infant (Nagata et al., 2004; Poehlmann & Fiese, 2001; Zeanah et al., 1984) The results of this study suggest that
mothers who attempt to cope with this stress by engaging in experiential avoidance may put themselves at risk of increased
psychological symptoms, consistent with previous research (Greco et al., 2005; Marcks & Woods, 2005; Reddy et al., 2006;
Sloan, 2004; Spira et al., 2007). Further, this study suggests that they also may put themselves at risk of attachment difficulties
and decreased responsiveness to their infant. To the author’s knowledge this is the first study to demonstrate a relationship
between experiential avoidance, attachment and responsiveness. This relationship makes sense. A mother’s experiential
avoidance attempts around cognitions and emotions regarding the preterm birth may decrease the mother’s sensitivity to
infant cues, thus decreasing maternal responsiveness and impacting on the ability to form a secure bond with her infant.
Relationship satisfaction was found to be a significant unique contributor to maternal psychological symptoms only.
This is consistent with previous research establishing a relationship between relationship satisfaction and psychological
symptoms (Cicchetti et al., 1998; Zelkowitz et al., 2007). A positive marital relationship acted as a buffer in the stressful
situation of a preterm birth.
T. Evans et al. / Infant Behavior & Development 35 (2012) 1–11
9
Prenatal expectations (compared to postnatal experience) were also found to be a significant unique contributor to
maternal attachment and maternal psychological symptoms. Consistent with previous research (Harwood et al., 2007)
mothers experienced a better outcome in terms of attachment and psychological symptoms if their prenatal expectations
were consistent with their postnatal experiences.
This research has important implications for interventions to support mothers of preterm infants. Interventions to prevent
problems with maternal attachment, maternal psychological symptoms and maternal responsiveness could be implemented
whilst the infant is in the NICU. Mothers could be screened for experiential avoidance and relationship difficulties with interventions implemented to improve the marital relationship and decrease experiential avoidance. A brief behavioural marital
therapy intervention and Acceptance and Commitment Therapy (ACT) could be utilised for this purpose. ACT is a cognitivebehavioural intervention that targets experiential avoidance as a key mechanism of change. Further research including
a randomised controlled trial of such interventions to establish efficacy in the prevention of psychological symptoms,
attachment difficulties and decreased responsiveness in mother of infants born preterm should be conducted.
Another implication of this research would be the inclusion of information on preterm birth in standard antenatal care to
provide mothers with some expectation and knowledge of the implications of a preterm birth. A correct balance needs to be
found here between alarming low-risk expectant mothers and providing appropriate preparation to women who will go on
to have a preterm birth. The information should be presented in matter of fact, positive light that normalises the experience
of preterm birth. As this study found no significant results for postpartum support, it is not a recommendation of this paper
to address this area as mother’s of preterm infants indicated they felt adequately supported by the hospital staff and the
hospital environment. It is likely that significant results were not found for postpartum support because efforts are made by
hospital staff in the existing NICU environment to support parents well.
A limitation of this study was that the results relied solely on maternal self-report measures, potentially allowing for
response bias and shared method variance. In addition, this study is correlational only, representing a snapshot in time.
Therefore it is impossible to draw definite conclusions about causality. Also the results may not be generalizable to mothers
of preterm infants as there is a possible self-selection bias due to the sample being recruited through parent support organisations via the web. This sample also reported to be of a high socioeconomic status. Future research taking a longitudinal
approach would be beneficial. A further limitation was the absence of a child attachment measure to assess the attachment
of the child to the mother. It is not possible from this study to predict whether the attachment of the mother to the infant also
reflected the attachment of the infant to the mother. Future research could utilise Ainsworth’s Strange Situation paradigm
when the infant was 12 months-of-age to assess the attachment pattern of the infant to the mother.
5. Conclusion
A preterm birth impacts negatively on maternal attachment, maternal psychological symptoms and maternal responsiveness. After controlling for birth weight, this study has identified experiential avoidance, relationship satisfaction and
prenatal expectations (compared to postnatal experience) as predictors of maternal attachment, maternal psychological
symptoms and maternal responsiveness. This suggests that mothers of infants born preterm could be better supported by
providing Acceptance and Commitment Therapy and behavioural marital therapy in the NICU and in ensuring appropriate
prenatal expectations are present in antenatal care. This could potentially improve the mother’s attachment and responsiveness to her infant, and decrease the negative psychological symptoms she may experience. Future research could focus on
exploring the most effective methods of delivering these interventions to the mother whilst she is still caring for her preterm
infant and establishing the efficacy of such interventions. The ultimate aim of these interventions would be to improve the
relationship between preterm infants and their mothers, therefore promoting better outcomes for the mother–infant dyads.
Acknowledgements
We acknowledge the mothers who participated in our study, and the following preterm baby support groups: Feather
Weight Club, Preterm Infant’s Parents Association (PIPA) (QLD), Central Queensland Premmies, Life’s Little Treasures, L’il
Aussie Prems, Bub Born Early, Bonnie Babes Foundation and The Bub Hub.
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