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UBC Theses and Dissertations

Effects of hospital experience on postpartum feelings and attitudes of women Bradley, Christine Felecia 1976

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T H E E F F E C T S O F H O S P I T A L E X P E R I E N C E O N P O S T P A R T U M F E E L I N G S A N D A T T I T U D E S O F W O M E N b y C h r i s t i n e F e l e c i a B r a d l e y B . A . ( H o n o u r s ) M c G I U U n i v e r s i t y , M o n t r e a l , P . Q . 1 9 6 8 M . S c . ( A p p l i e d ) M c G i l l U n i v e r s i t y , M o n t r e a l , P . Q . 1970 A T H E S I S T O B E S U B M I T T E D IN P A R T I A L F U L F I L L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F D O C T O R O F P H I L O S O P H Y In t h e D e p a r t m e n t of P s y c h o l o g y W e a c c e p t t h i s t h e s i s a s c o n f o r m i n g to t h e r e q u i r e d s t a n d a r d T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A A u g u s t , 1976 Christine Felecia Bradley, 1976 In p r e s e n t i n g t h i s t h e s i s in p a r t i a l f u l f i l m e n t o f the r e q u i r e m e n t s f o r an advanced degree at the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by the Head o f my Department or by h i s r e p r e s e n t a t i v e s . It i s u n d e r s t o o d that c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department The U n i v e r s i t y o f B r i t i s h Co lumbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 i i A b s t r a c t T h e p u r p o s e o f t h i s i n v e s t i g a t i o n w a s t w o f o l d . F i r s t , t o i n v e s t i g a t e t h e a t t i t u d e s a n d f e e l i n g s o f a g r o u p o f n o r m a l w o m e n e x p e c t i n g t h e i r f i r s t c h i l d . S e c o n d , to e v a l u a t e t h e e f f e c t i v e n e s s o f a f a m i l y c e n t r e d m a t e r n i t y p r o g r a m m e i n p r o m o t i n g a p o s i t i v e f e e l i n g t o w a r d s t h e i n -f a n t a n d i n t e r m s o f p r e p a r i n g t h e m o t h e r s f o r t h e i r n e w r o l e . T h e s u b j e c t s w e r e 9 4 m a r r i e d w o m e n w h o a t t e n d e d p r e n a t a l c l a s s e s w i t h t h e i r h u s b a n d s . T h e y w e r e w h i t e , C a u c a s i a n , w i t h a m e a n a g e o f 27 y e a r s a n d a m e a n l e v e l o f e d u c a t i o n o f 14 a n d o n e h a l f y e a r s . T h e w o m e n w e r e r a i s e d i n N o r t h A m e r i c a o r t h e B r i t i s h C o m m o n w e a l t h . A l l w o m e n d e l i v e r e d a s i n g l e f u l l t e r m i n f a n t a n d e x p e r i e n c e d n o m a j o r • m e d i c a l c o m p l i c a t i o n s o f e i t h e r t h e m s e l v e s o r t h e i r i n f a n t d u r i n g p r e g n a n c y , d e l i v e r y o r t h e p o s t p a r t u m p e r i o d . E a c h w o m a n c o m p l e t e d a s e r i e s o f q u e s t i o n n a i r e s r e l a t i n g t o a t t i t u d e t o w a r d s p r e g n a n c y , l a b o u r a n d d e l i v e r y , c h i l d b i r t h , t h e n e w b a b y a n d t h e h o s p i t a l e x p e r i e n c e . T h e s e m e a s u r e s w e r e c o m p l e t e d a t f o u r p o i n t s i n t i m e ; i n t h e n i n t h m o n t h o f p r e g n a n c y , w h i l e i n h o s p i t a l a n d a f t e r o n e a n d f i v e w e e k s a t h o m e . In a d d i t i o n , she c o m p l e t e d t h e D e p r e s s i o n A d j e c t i v e C h e c k l i s t s , t h e B e c k D e p r e s s i o n I n d e x a n d t h e P l e a s a n t E v e n t s S c h e d u l e i n t h e n i n t h m o n t h o f p r e g n a n c y a n d i n t h e s i x t h w e e k a f t e r d e l i v e r y o f her c h i l d . T h e D e p r e s s i o n A d j e c t i v e C h e c k l i s t w a s a l s o c o m p l e t e d e a c h d a y t h a t t h e w o m a n w a s i n h o s p i t a l . i i i Major comparisons were (a) type of maternity hospital programme experienced — a family centred maternity programme versus a more traditional maternity programme and (b) type of delivery — whether vaginal or caesarian. Multivariate analyses conducted on the set of variables at each time period revealed a significant difference between the two groups of women depending upon which hospital programme they experienced, both while in hospital and after they had been home for one week. Univariate analyses revealed significant difference between the two groups on their responses to the following variables: The women in the family centred maternity programme had a more positive attitude towards their babies while in hospital; considered that they received more experience in how to care for their babies in hospital and perceived that they obtained more help from the hospital in preparing them for their mothering role. There was no difference in attitude towards the baby once the women had been home for one week caring for and interacting with their babies. A repeated measures analysis of variance indicated that there were no differences in the level of depressive affect between the women in the two types of programme over the time periods involved. Multivariate, analyses of the sets of variables at each time period indicated a significant difference between those who had a vaginal delivery and those who had a caesarian section. Those women who had a caesarian section had a less positive attitude towards their labour and i v d e l i v e r y . T h e r e was no difference between these two groups of women in e i ther the i r attitude towards thei r infant o r the i r feel ings of s e l f -confidence. A repeated measures ana lys i s of var iance revealed that those women who had caesar ians were more depressed after the b i r t h of the i r baby than those women who de l ive red the i r baby v a g i n a l l y . Al though the women in the'present study w e r e not c l i n i c a l l y depressed there were s igni f icant co r r e l a t i ons between l e v e l s of dep re s -s i v e affect and other v a r i a b l e s . F o r example , in the ninth month of pregnancy depress ive affect was related to a l e s s pos i t ive att i tude towards pregnancy; in hospi ta l depress ive affect was re la ted to a l e s s pos i t ive attitude towards labour and d e l i v e r y and towards the baby; at s i x weeks postpar tum depress ive affect was re la ted to a l e s s pos i t ive attitude towards the baby. The d i s cus s ion centred around the i m p l i c a t i o n of the f indings f o r hospi ta l p rog rammes and prenata l c l a s s c u r r i c u l a , cu r r en t behav ioura l theories of depress ion f and the myth of materna l i n s t i nc t . V T A B L E O F C O N T E N T S Chapter Page A b s t r a c t i i L i s t of Tables v i i L i s t of F i g u r e s ix G l o s s a r y x Acknowledgements « x i I Introduction and Purpose of S tudy . 1 Review of the l i t e r a tu r e 2, The ro le of emotional and at t i tudinal factors in k obs te t r i c outcome Pos tpar tum d i so rde r s 22 Hospi ta l environment 32 Conclus ions f r o m rev iew. 54 Presen t Study 56 Evaluat ion r e sea rch 57 II Method 62 Se t t i ng . 62 Subjects 64 M e a s u r e s • 67 Procedures ~]k S t a t i s t i c a l a n a l y s e s „ 7c v i Chapter Page III Resul ts . 78 C o m p a r i s o n between hospi ta l p rog rammes yg C o m p a r i s o n between vaginal d e l i v e r y and caesa r i an sec t ion 94 C o r r e l a t i o n coefficients between va r i ab le s ]01 F a c t o r ana lys i s « ] 03 I V D i s c u s s i o n F a c t o r s affecting present study 105 Impl icat ions f rom findings j 08 References 131 Appendix v i i Tab le L I S T O F T A B L E S Page I Dis t r ibu t ion of women in the three major hospi ta ls in Vancouver 65 II Schedule for comple t ion of data, t ime per iod and measures involved „ 68 III A l p h a r e l i a b i l i t y coeff icients f o r attitude ques t ionna i res . 69 I V Pooled wi th in groups c o r r e l a t i o n ma t r i x for the demographic data 79 V Pooled wi th in groups c o r r e l a t i o n ma t r i x for the measures col lec ted in the ninth month of pregnancy 80 VT Means and standard deviat ions of hospi ta l data — hospi ta l p rog ramme 82 VTI Pooled wi th in groups c o r r e l a t i o n ma t r i x for the measures completed whi le in hospi ta l 8^ VIII Pooled wi th in groups c o r r e l a t i o n m a t r i x of the responses to Greenberg ' s Ma te rn i ty Ques t ionnai re 85 IX Means and standard deviat ions of the measures completed af ter one week at home — Hospi ta l p r o g r a m m e . 86 X Pooled wi th in groups c o r r e l a t i o n m a t r i x of the measu re s completed after one week at home 88 X I Pooled wi th in groups c o r r e l a t i o n ma t r i x fo r the measures completed after f ive weeks at home • • • 89 X I I Repeated measures ana lys i s of var iance — leve l of d e p r e s -s i v e affect over t ime — hospi ta l p rog ramme 91 XII I Means and standard deviat ions of the hospi tal data — type of d e l i v e r y 96 v i i i Tab le • Page X I V Means and standard deviat ions of responses to Greenberg ' s matern i ty quest ionnaire - type of d e l i v e r y . 97 X V Repeated measures a n a l y s i s of var iance — l e v e l of depress ive affect o v e r t ime — type of d e l i v e r y . 99 ix L I S T O F F I G U R E S F i g u r e Page 1 Schema for d i so rde r s of mother ing ^3 2 Means of D A C L s co re s at seven points in t ime — Hospi ta l p r o g r a m m e . 92 3 Means of D A C L s c o r e s at seven points i n t ime — Types of d e l i v e r y . 100 4 M c L e a n ' s schema i l l u s t r a t i n g the consequence of ineffective coping techniques. 119 5 Modi f ica t ion of M c L e a n s ' schema i l l u s t r a t ing effect of having a caesa r i an sec t ion 119 G L O S S A R Y grav id g rav id i ty mulipa rous par i ty par tur ient pa r tu r i t ion p r i m i p a r o u s puerpera l pue rpe r ium pregnant pregnancy having borne more than one c h i l d the fact of having borne l i v i n g c h i l d r e n to be i n l abour ch i l db i r t h bear ing a c h i l d f o r the f i r s t t ime accompanying o r ensuing upon c h i l d b i r t h immedia te postpar tum per iod x i A C K N O W L E D G E M E N T S I would l i ke to thank my commit tee fo r the i r support and the i r valued c r i t i c a l comment s . S p e c i a l thanks a r e due to D r . P . O . Davidson , C h a i r m a n of my committee., fo r h is guidance and encourage-ment in a l l aspects of the study, and for h is cons t ruc t ive c r i t i c i s m s and ed i to r i a l comments . I owe much to D r . Ralph Hakst ian f o r h is s t a t i s t i ca l advice and to M s . V i r g i n i a Green fo r he r pers is tent good humour and patience towards a computer neophyte. T h i s study would not have been poss ib le without the cooperat ion of the teachers of the Vancouver Ch i ldb i r t h A s s o c i a t i o n and the L o w e r Main land Chi ldbear ing A s s o c i a t i o n who a l lowed me access to the couples who par t ic ipate in the i r education for ch i ldb i r th c l a s s e s . N o r would the study have been poss ib le without the women who volunteered to par t ic ipate in the study and who completed the many quest ionnaires under somet imes t ry ing c i r c u m s t a n c e s . The ass i s tance of M s . Janet Quinlan and the staff at the Pos tpa r tum Counse l l ing Cent re fo r the i r ass i s tance and helpful comments i s apprec ia ted . A spec ia l thank you to M s . Bernadette M . Ratsoy of S t . P a u l ' s Hospi ta l fo r he r continuing in teres t and encouragement . 1 C H A P T E R I I N T R O D U C T I O N A N D P U R P O S E OF" T H E S T U D Y Stephen H o r s l e y (1972), w r i t i n g in Mode rn P e r s p e c t i v e s in P s y c h o - o b s t e t r i c s , stated that there i s an a l m o s t total lack of sys temat ic attention to tine psychology of n o r m a l pregnancy, and , as a c o r o l l a r y , the re la t ive absence of comprehens ive teamwork which w i l l be seen to be essent ia l fo r the management of the s t r e s ses of no rma l pregnancy and f o r the prevent ion of mother ing breakdown . . . pregnancy r e sea rch i s s t i l l f ragmentary and somet imes m i s d i r e c t e d in i ts f a i l u r e to c o r r e l a t e obs t e t r i c , psycholog ica l and s o c i a l f a c to r s , (p. 292) He maintained that s tandard obs te t r i c textbooks pay l i t t l e a t ten-tion to the psycholog ica l needs of the average w o m a n , and that s tandard textbooks of psych ia t ry contr ibute nothing to the ve ry r ea l p rob l em of the psychologica l management of n o r m a l expectant paren ts . A sys temat ic s e a r c h of the more recent m e d i c a l , nurs ing and psychologica l l i t e ra tu re fo r e m p i r i c a l s tudies into pregnancy and ch i ldb i r th co r robora tes the va l id i ty of H o r s l e y ' s s tatement, and demonstrates the l ack of e m p i r i c a l data and theore t ica l propos i t ions which would guide those doing r e sea rch in this a r e a . The re have been three main a reas of enquiry wh ich a r e concerned a lmos t exc lu s ive ly wi th the study of abnormal condi t ions of pregnancy. 2 The most concentrated a rea has been to de te rmine whether there i s a re la t ion beh/veen emot iona l , at t i tudinal o r psycho log ica l fac tors dur ing the course of pregnancy and obs te t r ic outcome. The second a rea was concerned wi th puerpera l d i s o r d e r s , such as postpar tum depress ion o r pos t -par tum psychoses . The th i rd a rea involved the eff icacy of education fo r ch i l db i r t h both in t e rms of the reduct ion of s t r e s s and in prepara t ion fo r natural c h i l d b i r t h . One a rea that has rece ived l i t t l e e m p i r i c a l attention i s that of the hospi ta l and the type of d e l i v e r y — whether vaginal o r caesa r i an sec t ion — and the i r effects upon the mother and newborn infant. It was in this context that this study was under taken. The present study a rose f r o m two in t e r e s t s . F i r s t , the need f o r an evaluation of the effects of a " f ami ly cent red" mate rn i ty p r o g r a m m e , ini t iated in a Vancouver hospi ta l in November 1971. S e c o n d , the w r i t e r ' s in teres t in the psycholog ica l aspects of pregnancy, ch i l db i r t h and e a r l y parent / infant r e l a t ionsh ips . Ini t ial p rob lems which reflected the d i f f icu l ty in conducting appl ied r e sea rch in the communi ty , included a l ack of funding and a l ack of i n t e r d i s c i p l i n a r y involvement . Both of these fac tors placed cons t ra in ts on the type of data co l lec ted and on the opportunity f o r l o n g - t e r m fo l l ow-up . T y p i c a l of appl ied r e sea rch was the i n a b i l i t y to a s s ign the par t ic ipants randomly to the two hospi ta l p r o g r a m m e s s tud ied . "The p u r p o s e o f t h i s i n v e s t i g a t i o n w a s t w o f o l d . F i r s t , to i n v e s t i g a t e t h e a t t i t u d e s a n d a f f e c t o f a g r o u p o f n o r m a l w o m e n e x p e c t i n g t h e i r f i r s t b a b y t o w a r d t h e i r e x p e r i e n c e o f p r e g n a n c y a n d c h i l d b i r t h a n d t o w a r d t h e e x p e r i e n c e s e n c o u n t e r e d i n t h e h o s p i t a l a n d t h e e a r l y p o s t p a r t u m p e r i o d . S e c o n d , to e v a l u a t e t h e e f f e c t i v e n e s s o f a f a m i l y c e n t r e d m a t e r n i t y p r o -g r a m m e i n p r o m o t i n g a p o s i t i v e f e e l i n g t o w a r d t h e i n f a n t a n d i n t e r m s o f - p r e p a r i n g i t s p a r t i c i p a n t s f o r t h e i r n e w r o l e . A r e v i e w o f t h e l i t e r a t u r e w a s u n d e r t a k e n t o a s c e r t a i n b o t h t h e p r e s e n t s t a t e o f k n o w l e d g e r e g a r d i n g t h e p s y c h o l o g i c a l a s p e c t s o f p r e g n a n c y a n d c h i l d b i r t h a n d to o b t a i n i n f o r m a t i o n c o n c e r n i n g p o s s i b l e m e a s u r e s f o r t h e p r e s e n t s t u d y . T h e r a t i o n a l e f o r s u c h a s t u d y i s b a s e d u p o n two f a c t o r s . O n e i s t h e c o n v e r g e n c e o f l i t e r a t u r e i n v o l v i n g d e v e l o p m e n t a l a n d c o g n i t i v e p s y c h o l o g y , n u t r i t i o n a n d m e n t a l h e a l t h ( M u r p h y a n d C h a n d l e r , 1 9 7 2 ; S t o u v e l ( N o t e 1); B r o n f e n b r e n n e r , 1 9 7 5 ; N a t i o n a l A s s o c i a t i o n f o r M e n t a l H e a l t h , 1 9 7 3 ) i n d i c a t i n g t h a t p r e g n a n c y , c h i l d b i r t h a n d s u b -s e q u e n t m o t h e r h o o d s h o u l d b e t h e f o c u s o f s u s t a i n e d i n t e r d i s c i p l i n a r y r e s e a r c h a n d i n t e r v e n t i o n a c t i o n . T h e s e c o n d i s a p e r s o n a l b e l i e f i n , a n d c o m m i t m e n t t o , t h e i m p o r t a n c e o f t h i s p e r i o d f r o m t h e v i e w p o i n t o f p r e v e n t i o n a n d p r o m o t i o n o f p s y c h o l o g i c a l h e a l t h a n d w e l l b e i n g o f t h e f a m i l y a s a w h o l e . Review of L i t e r a tu re The Role of Emot iona l and At t i tud ina l Fac to r s in Obste t r ic Outcome T a n z e r ( 1 9 G 7 ) stated that most of the e m p i r i c a l work concern ing the in te r re la t ions between reproduct ive and psychologica l functions appeared in the obs te t r i ca l and gynecological l i t e ra tu re ra ther than in the psycholog ica l l i t e r a tu r e , and was concerned with pathological c l i n i c a l condi t ions . She s ta ted , that the more s y s t e m a t i c , theoret ica l and comprehens ive approaches to the re la t ionship of psycholog ica l and reproduct ive functions have been wr i t t en f r o m a F reud i an o r psychoanalyt ic point of v i ew . The reader i s r e f e r r ed to the wr i t i ngs of Deutsch ( 1 9 4 4 / 5 ) , Benedek ( 1 9 5 2 ) , B i b r i n g ( 1 9 5 9 / 1 9 6 1 ) , Wengraf ( 1 9 5 3 ) , and Shereshefsky & Y a r r o w ( 1 9 7 3 ) . These w o r k s a r e vulnerable to such c r i t i c i s m s as unproven theoret ical a s sumpt ions , l ack of sound methodology, l a c k of e m p i r i c a l data and use of c l i n i c a l case h i s to r i e s a lone . G r i m m ( 1 9 6 7 ) wro te one of the f i r s t comprehensive and c r i t i c a l rev iews of tine ro le of c u l t u r a l , s o c i a l and psychologica l f ac to rs in pregnancy and obs te t r ic outcome. She stated that a rev iew of this l i t e r a tu re revealed more a r t i c l e s which desc r ibed general c l i n i c a l impres s ions o r case h i s to r i e s ra ther than e m p i r i c a l r e s e a r c h . G r i m m emphasized the great need f o r r i g o u r in r e sea rch design and method-ology; the need to make the statement of assumptions more exp l i c i t ; 5 the need to define the criteria used; the need to demonstrate the reliability and validity of measures used. McDonald (1968) reviewed the literature published over a period of twenty years concerned with the role of emotional factors on obstetric outcome. He listed the variables that have been studied, although not systematically. These include age, intelligence, marital status, number of pregnancies, social class and race. He also pointed out that most of the studies he reviewed were confined to indigent white patients and that the role of social class and race in the development of psychogenic obstetric complications has yet to be determined. McDonald stated that preliminary reports suggested that a part is played by emotional factors as a determinant of obstetric outcome, but, due to numerous complications, the diverse populations studied and the heter-ogenous methodology involved it is difficult to make definitive statements regarding such a relationship. McDonald discussed three main methodological approaches reflected in the literature. The first involved a comparison of personality char-acteristics of women experiencing a single complication with those of normal pregnancies. The second involved comparison of several com-plications to determine possible personality characteristics specific to a clinical entity. The third approach was derived from conceiving all complications as derivatives of a single common process. According 6 to M c D o n a l d , i t is this la t te r methodological approach that has gene ra l ly produced the best s tud ies . He stated that the bet ter con t ro l l ed s tudies indicate that "psycholog ica l differences we re cons i s ten t ly found between compl i ca t ion samples and n o r m a l samples . . . the common denominator differentiat ing the groups being an increase in anxie ty l e v e l s , r e g a r d -less of the test ins t rument u s e d " . McDona ld c r i t i c i z e d the l i t e r a tu re he reviewed fo r i ts numerous methodological shor t comings and s a i d that such " l imi t a t ions inval idate o r at leas t s e r i o u s l y weaken the c o n -c lus ions de r ived f r o m these s tud ies , and s t r e s s the need for w e l l -designed e x p e r i m e n t s , r igourous appl ica t ion of s t a t i s t i c a l techniques, and a sys temat ic explora t ion of the p s y c h o l o g i c a l , p h y s i o l o g i c a l , s o c i o l o g i c a l and ep idemio log ica l v a r i a b l e s . " A rev iew of the l i t e r a t u r e subsequent to 1968 reveals that his c r i t i c i s m s and suggest ions of the need for w e l l designed studies a r e s t i l l v a l i d . The s tudies involving anxiety and obs te t r ic outcome w i l l be d i s -cussed to i l l u s t r a t e the type of r e sea rch c a r r i e d out in this a r e a . One of the e a r l i e s t sys temat ic s tudies of anxie ty in pregnancy and ch i ldb i r th was c a r r i e d out by K l e i n , Po t t e r and Dyk (1950), who a t -tempted to pred ic t psycholog ica l and phys io log ica l d i s t r e s s f r o m two measures ass igned to the women par t i c ipa t ing in the i r s tudy. K l e i n and col leagues in terviewed 27 p r i m i p a r o u s women at each c l i n i c v i s i t and divided them into two groups . The f i r s t group exper ienced an easy pregnancy and the second group a d i f f icul t p regnancy . Two genera l 7 measures we re used based on (a) favourableness of attitudes towards conception and pregnancy and (b) general s t ab i l i t y in t e rms of neuro t ic s y m p t o m s , coping mechan isms and capaci ty f o r adapting. No d i f f e r -ences we re found in these measures between the two groups of w o m e n . In 1956, Sco t t and Thomson attempted to establ ish whether materna l psycholog ica l c h a r a c t e r i s t i c s investigated dur ing the s ix th month of pregnancy a r e related to the c l i n i c a l nature of labour . They studied 278 p r i m i p a r o u s m a r r i e d w o m e n . Var ious measures w e r e used including a personal h i s t o r y , in te l l igence tes ts , the Mauds ley M e d i c a l Quest ionnaire and i n t e r v i e w s . No o v e r a l l re lat ionship was found be-tween psycholog ica l measures of adjustment and total length of l abour , c l i n i c a l course of l abour , obs te t r ic compl ica t ions o r s e l f con t ro l dur ing l abour . However , i t was found that those women judged to be emot iona l ly wel l -ad jus ted (rated by the psychologis t on a three point sca le ) and who obtained low sco re s on the Mauds ley M e d i c a l Quest ionnaire had a r e l a -t ive ly low incidence of di f f icul t l abour , w h i l e those women who w e r e judged unstable and poor ly adjusted had a more diff icult l a b o u r . D a v i d s , de Vault and Ta lmadge , (1961a; 1961b) studied the p sycho -l o g i c a l adjustment of 48 pregnant women (mean age 25 y e a r s ) dur ing pregnancy and after d e l i v e r y . A battery of psychologica l tes ts , i n -cluding project ive techniques and objective tes ts , was admin i s t e r ed dur ing pregnancy (in the th i rd t r imes t e r ) and again af ter the women had 8 de l ive red thei r babies . On the bas is -of med ica l observat ion and r eco rd ing in the d e l i v e r y r o o m , the mothers we re c l a s s i f i e d acco rd ing to the degree of phys ica l d i f f icul ty involved in labour and d e l i v e r y and whether the ch i ld had any phys i ca l a b n o r m a l i t y , It was found that the women in the abnormal group s c o r e d s igni f icant ly h igher on the T a y l o r Mani fes t A n x i e t y S c a l e ( T a y l o r , 1953) dur ing pregnancy than d id women who l a t e r had n o r m a l d e l i v e r i e s . It was noted that af ter ch i l db i r t h the differences in the anxie ty s co re s between the no rma l and abnormal group w e r e no longer s ign i f i can t . It should be pointed out that not a l l of the 48 women w e r e tested both before and after d e l i v e r y — only 13 in the no rma l group and only seven in the a b n o r m a l group. In addi t ion , no attempt was made to cont ro l f o r the pa r i t y of the w o m e n . T o examine the re la t ionship between materna l anxiety dur ing pregnancy and ch i ldb i r th a b n o r m a l i t y , Davids and de Vaul t (1962) s tudied 50 c l i n i c patients in the th i rd t r i m e s t e r with a bat tery of tests s i m i l a r to that used in the i r 1961 s tudy. A f t e r de l ive ry the patients w e r e c l a s s i f i ed into n o r m a l and abnormal groups based on med ica l r eco rds . Tne compl ica t ions and abnorma l i t i e s reported va r i ed f r o m congenital condit ions to p rematu r i ty and s t i l l - b i r t h . The psycholog ica l data w e r e then examined to see i f the two groups differed on measures of anxiety der ived f r o m d i r e c t and ind i r ec t measures and pro jec t ive 9 techniques. The resu l t s showed that w i th the except ion of the s e l f -rat ing s ca l e a l l anxie ty rat ings w e r e found to be s ign i f i can t ly h ighe r f o r the abnormal g roup . The authors pointed out that they have no informat ion regarding tine causes o r under ly ing reasons f o r the h igh anxiety s c o r e s in the abnormal group and suggested that examina t ion of soc io log ica l , med ica l and h i s t o r i c a l data may be per t inent . G r i m m (1961) c a r r i e d out an inves t iga t ion to de t e rmine (a) whether "there a r e dif ferences i n degree of p s y c h o l o g i c a l tension o v e r the 40 weeks of pregnancy, and (b) whether the degree of tension i s re la ted to aspects of the course of pregnancy, i . e . weight ga in , length of l abour , compl ica t ions dur ing labour and d e l i v e r y and phys i ca l status of the c h i l d . Us ing a shor t bat tery of p ro jec t ive tes t s , G r i m m evaluated 200 women , 40 at each of f ive different s tages of p regnancy . Each group was equated fo r p a r i t y , p rev ious obs t e t r i c c o m p l i c a t i o n s , r a c e , c u l t u r a l background, m a r i t a l s ta tus , r e l i g i o n , age and educa t ion . A n index of tension was computed f r o m the p ro j ec t ive techniques used (the t e r m tension was used "unt i l m o r e in format ion can be gathered as to s p e c i f i c a l l y what the index measures — whether i t be anx ie ty , pent-up h o s t i l i t y , dep res s ive f ee l ings , e t c . " ) . It w a s found that those i n the l a s t half of the las t t r i m e s t e r had s ign i f i can t ly h i g h e r index of tension than did the other g roups . One of the f i r s t p red ic t ive s tudies was c a r r i e d out by Z e m l i c k and 10 Watson (1953). They studied 15 women (of mixed soc ioeconomic status and va r i ed ethnic origin) throughout pregnancy to a s c e r t a i n whether acceptance- re jec t ion of pregnancy and motherhood, degree of anxie ty and tendency to s o m a t i c i z e w e r e p red ic t ive of the mother ' s adjustment dur ing pregnancy and d e l i v e r y and he r re la t ionship wi th the newborn . A s p red ic t ive measures they used se lected T h e m a t i c Appe rcep t ion Tes t ca rds ( T A T ) ( M u r r a y , 1943),a l o c a l l y devised pregnancy attitude sca le and a psychosomat ic symptom inven tory . C r i t e r i a fo r adjust-ment dur ing pregnancy we re based on two measures ; f i r s t , the obs te t r i c i an ' s ra t ing of emotional symptoms and adjustment and second , the frequency, durat ion and intensi ty of psychosomat ic s y m p -toms . Adjus tment at pa r tu r i t ion was measured by the length of t ime in l abour and adjustment dur ing l abour and d e l i v e r y as rated by the ^obs te t r ic ian , and the postpar tum adjustment of mother and c h i l d . Z e m l i c k and Watson found that anx ie ty , psycho log ica l and somat i c s y m p t o m s , and attitudes of re ject ion of pregnancy and motherhood w e r e seen to be pos i t ive ly related to independent c l i n i c a l c r i t e r i a of prenata l and par tur ien t adjustment. A n x i e t y as measured by the T A T was found to be related to adjustment dur ing pregnancy and d e l i v e r y but not to l a t e r s y m p t o m s . Z u c k e r m a n , Nurnbe rge r , G a r d i n e r , Vand ivee r , B a r r e t t , den Bree i j en (1963) tested the hypothesis that somat i c compla in t s dur ing 11 pregnancy and d i f f icu l t ies in c h i l d b i r t h a r e re la ted to anxie ty and c o n -f l i c t s involv ing atti tudes and feel ings towards o the r peop le . A s e r i e s of tests and s t ruc tu red in te rv iews w e r e given to 52 p r i m i p a r o u s w o m e n , who w e r e predominant ly b l ack , of low o r l o w e r / m i d d l e c l a s s b a c k -ground, and of va ry ing m a r i t a l s ta tus . D e l i v e r y r o o m r e c o r d s w e r e rated by a s e n i o r obs te t r i c i an f o r durat ion of l a b o u r and the amount of ana lges ic r e q u i r e d . On ly one s ign i f ican t r e l a t ionsh ip was found — anxie ty dur ing pregnancy, as measured by the A f f e c t A d j e c t i v e Check L i s t ( Z u c k e r m a n , 1960), was d i r e c t l y re la ted to the amount of a n a l -ges ic r equ i red by the patient dur ing the l a b o u r . . . M c D o n a l d , Gunther and C h r i s t o k o s (1963) s tudied 86 whi te m a r r i e d patients f r o m a v e r y low soc ioeconomic c l a s s in an at tempt to de t e r -mine whether obs t e t r i ca l fac tors such as c o m p l i c a t i o n s and length of l abour a r e re la ted to mate rna l anx ie ty . T h e I P A T A n x i e t y S c a l e ( C a t t e l l , 1957) and the Minnesota M u l t i p h a s i c P e r s o n a l i t y Inventory ( M M P I ) (Hathaway & M c K i n l e y , 1951) s c o r e d f o r the r e p r e s s i o n / sens i t i za t ion s ca l e w e r e admin i s t e r ed at the beginning of the t h i rd t r i -m e s t e r . P regnancy , d e l i v e r y room and pos tpar tum r eco rds w e r e used f o r c l a s s i fy ing patients into e i the r the n o r m a l o r s u b n o r m a l g roups . The l i s t of poss ib le abno rma l i t i e s was obtained f r o m two w e l l known obs te t r ic textbooks, and va r i ed w i d e l y ( e . g . , s u b n o r m a l apgar r a t i ng , postpar tum p s y c h o s i s , pue rpe ra l s e p s i s ) . A c c o r d i n g to the 12 au thors , the two groups we re comparab le f o r age, in t e l l igence , pa r i t y and total number of pregnancies . A s ign i f ican t difference between the n o r m a l and abnormal group was found on the anxie ty s c o r e of the I P A T . The abnormal group a l so sco red s ign i f i can t ly h igher on the R e p r e s s i o n -Sens i t i za t ion S c a l e indicat ing that they responded to threatening s i tuat ions us ing in te l lec tua l and obsess iona l defenses w h i l e denia l and r ep re s s ion was used by the n o r m a l g roup . The authors stated that the i r data suggest that "anxiety may be p h y s i o l o g i c a l l y manifested in a wide va r i e ty of abnormal obs te t r ic cond i t i ons" . A s i m i l a r study by Edwards and h is a ssoc ia te ( E d w a r d s , 1970; Edwards and Jones , 1970) resul ted in con t r a ry f ind ings . Us ing an extensive test bat tery inc luding s e l f - r e p o r t m e a s u r e s , p ro jec t ive techniques and rat ings by obse rve r s Edward and Jones inves t iga ted pe rsona l i ty changes assoc ia ted wi th pregnancies and var ious pa tho log i -c a l obs te t r ic condi t ions . They hypothesised that those women who have obs te t r i c compl ica t ions would show more emot ional d is turbance as ref lected by h igher l eve l s of anxie ty dur ing p regnancy . The subjects in the i r study were 53 u n m a r r i e d pregnant w o m e n , most of whom were tested near o r at the beginning of the th i rd t r i m e s t e r of pregnancy. F o l l o w i n g the i n i t i a l admin i s t r a t ion of the test bat tery , a l l the women completed the State A n x i e t y Inventory on a week ly b a s i s , un t i l they entered the hospi ta l fo r d e l i v e r y of the i r baby. W e e k l y rat ings of 13 each woman w e r e made by a n u r s e , s o c i a l w o r k e r and housemother . A f t e r d e l i v e r y a ped ia t r i c i an placed women in e i the r the n o r m a l o r abnorma l group based on the i r pregnancy, d e l i v e r y and pos tpar tum r e c o r d s . F o u r to ten days a f te r d e l i v e r y , the test ba t tery w a s r e a d -m i n i s t e r e d . A c c o r d i n g to Edwards and Jones the r e su l t s fa i l ed to c o n f i r m the i r hypothes is . T h e r e w e r e no di f ferences between the n o r m a l and abnormal groups on four out of the f ive measu re s re la ted to atti tudes towards the pregnancy . T h e r e w e r e no d i f ferences b e -tween the n o r m a l and abnorma l group on the prenata l measu res i n d i c a -t ive of anxie ty o r r ep re s s ivenes s (as measu red by the R e p r e s s i o n / S e n s i t i z a t i o n sca le of the M M P I ) . A m o r e recent study involv ing the re la t ionsh ip of anx ie ty to obs te t r i c outcome was conducted by G o r s u c h and K e y (1974), T h e s e authors state that most s tudies measured anx ie ty e i the r d i r e c t l y o r .. i n d i r e c t l y at one o r two points i n t i m e , du r ing pregnancy , o r at bes t , at two points in t i m e , and usua l ly late i n the pregnancy , o r even pos t -d e l i v e r y . It i s poss ib le , therefore , that the r epor t s of anx ie ty , often obtained r e t ro spec t i ve ly , a r e influenced by the mo the r s ' knowledge of h e r cond i t ion . The authors a l so noted that p rev ious s tudies measured t r a i t - type anxie ty w h i c h , because of i t s g lobal na ture , does not d i s c r i m i n a t e the exact l eve l s of fe l t anxie ty ove r sho r t t ime p e r i o d s . 14 The purpose of Gor such and K e y ' s study was to invest igate p r o -spec t ive ly the re la t ionship of anxiety and l i f e s t r e s s to abno rma l i t i e s of pregnancy, pa r tu r i t ion and the postnatal p e r i o d . They examined the re la t ionship of t ime - spec i f i c anxiety to the development of obs te t r i c abnorma l i t i e s and the re la t ionship of the amount of l i fe changes to the same type of a b n o r m a l i t i e s . The subjects w e r e 118 women attending an obs te t r ic c l i n i c that s e rved low income pat ients . They w e r e of mixed m a r i t a l s ta tus , g rav id i ty and r ace , and ranged in age between 17 and 41 . The authors pointed out that these women a re in a "high r i s k " category as factors such as youth , g r a v i d i t y , r a c e , s ing le status tend to be associa ted wi th a "higher incidence of med i ca l p rob -lems in pregnancy" . A t the f i r s t c l i n i c v i s i t (which va r i ed f r o m the second to eighth month of pregnancy) the women completed the S t a t e / T r a i t A n x i e t y Inventory ( S p i e l b e r g e r , G o r s u c h and Lushene, 1970) f o r both state and t ra i t anx ie ty . A f t e r inspect ion of the med ica l repor ts of the mother and infant the subjects we re d iv ided into p rob lem free p r e g -nancy and d e l i v e r y and those whose pregnancy and d e l i v e r y had one o r more abnorma l i t i e s wi th in the f i r s t twelve h o u r s . State anxie ty m e a s -u res w e r e col la ted on the bas is of l una r month of pregnancy and c o r r e l a -tions we re run between measures of t ra i t anxiety before pregnancy (assessed re t rospec t ive ly at the f i r s t c l i n i c v i s i t ) and the c r i t e r i a of a b n o r m a l i t y . It was found that t ra i t anxiety l eve l s before pregnancy 15 did not differ s ign i f ican t ly f o r the two groups o f w o m e n . H o w e v e r , those women in the abnormal group had s ign i f i can t ly h ighe r states of anxie ty dur ing the th i rd and fourth l u n a r months of pregnancy than d id those women in the n o r m a l g roups . The authors a l so repor ted a s ign i f ican t c o r r e l a t i o n between anxie ty and the number of a b n o r m a l i t i e s . The two groups did not differ throughout the r e s t of the i r p regnancy . G o r s u c h and K e y stated that i t appears that h i g h e r s tates o f anxie ty e a r l y in pregnancy a r e p r ed i c to r s of a b n o r m a l i t i e s du r ing the p regnancy . The authors pointed out that the i r f indings a r e consis tent wi th E d w a r d s (1970) who found no re la t ionship between states of anx ie ty in the l a s t seven weeks of pregnancy and subsequent c o m p l i c a t i o n s . They s u g -gested that future r e s e a r c h invo lv ing such a r e la t ionsh ip be cent red on the states of anxiety dur ing the f i r s t t r i m e s t e r of p regnancy . L u b i n , Ga rdene r , Roth (1975),who used a p redominan t ly whi te middle c l a s s sample of women, repor ted that state anx ie ty as measu red by the Af fec t Ad jec t ive C h e c k l i s t ( A A C L ) ( Z u c k e r m a n and L u b i n , 1965) va r i ed s ign i f ican t ly as a function of t r i m e s t e r . T h e i r s a m p l e cons i s t ed of 88 white women and four negro w o m e n , whose mean age was 27 y e a r s and mean l e v e l of education 14.19 y e a r s . F o r a l l subjects the mean anxie ty s c o r e s of the A A C L taken a t the second t r i m e s t e r w e r e s i g n i f i -can t ly l o w e r than the s c o r e s obtained in the f i r s t and th i rd t r i m e s t e r . In a l l subjects anxiety decreased in the second t r i m e s t e r and rever t ed 16 back to i ts i n i t i a l l e v e l in the th i rd t r i m e s t e r . F r o m this b r i e f se lec ted rev iew of the s tudies invo lv ing anx ie ty and obs te t r ic outcome, i t i s apparent that M c D o n a l d ' s c r i t i c i s m s a r e w e l l founded. T h e r e was s e l d o m con t ro l f o r p a r i t y o r s o c i o e c o n o m i c s ta tus . S m a l l samples of women w e r e used who were often a s s igned to n o r m a l o r abnormal groups wi th no c l ea r - cu t c r i t e r i a of a b n o r m a l i t y . In addi t ion a wide va r i e ty of a b n o r m a l condi t ions were used ranging f r o m congenital condit ions to p r e m a t u r i t y and s t i l l b i r t h . Re l i ance was often placed on pro jec t ive measu res ; there was often a l a c k of • information regarding the r e l i a b i l i t y of m e a s u r i n g ins t ruments u sed , and a l a ck of operat ional def ini t ions regard ing t e rms used; e .g . , easy and d i f f i cu l t p regnanc ies , a b n o r m a l d e l i v e r i e s , no rma l and a b n o r m a l g roups . One of the more s e r i o u s p rob l ems wi th these s tudies that has r ece ived l i t t l e comment i n the l i t e r a t u r e i s the soc ioeconomic status of the population of women s tud ied . The re la t ionsh ip of anxie ty to obs te t r i c outcome i s confounded by the soc ioeconomic status of the w o m e n . The major i ty of s tudies used women f r o m low s o c i o e c o n o m i c c l a s s , and accord ing to S t o v e l (note 1) who rev iewed the l i t e r a t u r e of nu t r i t ion in pregnancy, low soc ioeconomic c l a s s has been re la ted to a poor outcome in pregnancy and p a r t i c u l a r l y to low b i r t h weight infants . 17 Higgins (1975) stated that the re la t ionship between materna l fac tors and infant mor t a l i t y and morb id i ty has rece ived extens ive study and i t has been found that " . . . infants born in pover ty have h igher mor t a l i t y rates because of the low b i r th weight and that age, r ace , and soc ioeconomic status, we re important only insofar as they we re related to b i r t h weight" . S i n g e r , Wes tpha l , N i swander (1968), found that low b i r t h weight i s related to increased inc idence of s t i l l b i r t h , neonatal death, poor infant development, c e r e b r a l pa l sy , mental re tardat ion and lowered in te l l igence . Another , important fac tor that has been over looked in the studies reviewed is tine obs te t r ic h i s to ry of the w o m e n . A c c o r d i n g to S t o v e l , many authors have indicated that subsequent pregnancies tend to repeat themselves in t e rms of outcome, e . g . , p r e m a t u r i t y , d i s a b i l i t y , fetal loss and so o n . A fur ther fac tor not taken into account was the p reg rav id weight of the mother and the amount of weight gain dur ing pregnancy. Higgins stated that there have been numerous studies which showed a high pos i t ive re la t ionship between b i r t h weight and maternal p r eg rav id weight and weight gain dur ing pregnancy. S i n g e r and assoc ia tes in the co l l abora t ive study found a s ignif icant reduction in morb id i ty and an improvement in growth and development in infants f r o m mothers wi th above average weight gain dur ing pregnancy. The conclus ions to be drawn f r o m the foregoing rev iew a r e that no 18 re la t ionsh ip has been es tabl ished between anx ie ty and obs te t r i c ou tcome . W h i l e this question needs to be invest igated fur ther i t r equ i r e s an i n t e r -d i s c i p l i n a r y approach and i s thus beyond the scope of the presen t s tudy . S e v e r a l r e sea rche r s have invest igated the attitude of women toward the i r pregnancy expe r i ence . In one of the e a r l i e s t inves t iga t ions into att i tudes toward pregnancy, H a l l and M o h r (1933) stated that t he i r casua l enqui ry into the attitudes of women expect ing the i r f i r s t baby revealed mental hygiene p rob lems i n i m i c a l to the prospect of succes s fu l c h i l d b e a r i n g . They suggested that " . . .the ra t iona l approach of the expectant mother should include a mental hygiene approach" . S i m i l a r l y , Thompson (1942) d i scussed the case h i s t o r i e s of women in te rv iewed at prenata l c l i n i c s regarding the i r at t i tudes toward pregnancy. He pointed out the necess i ty of paying "attention to the adjustment of the total ind iv idua l and not focusing a l l the attention on the l o w e r ha l f of the t o r so ' ' . ~ an atti tude which p r e v a i l s ove r 30 y e a r s l a t e r . G r i m m (1967) c i t ed the development of the Pregnancy R e s e a r c h Ques t ionnai re by Schaefe r and M a n h e i m e r (1960) which at tempted to e v a l -uate the emotional status of pregnant women as i t re la ted to the course of pregnancy. The authors of this ques t ionnai re co l lec ted data f r o m only 37 19 women and the i r one s ign i f ican t f inding was that women who w e r e fearful about the baby or themselves w h i l e pregnant tended to be . . f e a r f u l , s e l f -b l aming and insecure i n the c a r e of t he i r infants , and to need much r e a s s u r a n c e . " C l i f f o r d (1962) used the Pregnancy R e s e a r c h Ques t ionnai re to invest igate the attitude of pregnant women as a function of the i r m a r i -ta l status and p a r i t y . The three groups of 50 women who w e r e g iven the quest ionnaire w e r e -1. unwed mothers ; 2 . women expect ing the i r f i r s t baby and 3 . women who w e r e expect ing t h e i r second o r s u b s e -quent baby. F i v e of the seven subsca les dea l ing wi th at t i tudes toward pregnancy revealed s igni f icant dif ferences among the means obtained by these three g roups . Unwed women expressed l e s s d e s i r e f o r p r e g -nancy and l e s s mate rna l feel ing than e i the r of the two other g roups ; un-wed women expressed more depress ion and wi thd rawa l and p e r c e i v e d the materna l ro le as being ' l e s s ascendant ' than d id women expect ing the i r f i r s t baby. The women who w e r e expect ing their f i r s t baby expressed grea te r fears f o r the baby, l e s s i r r i t a b i l i t y and a g r e a t e r degree of m a r i t a l happiness than women who had more than one c h i l d . G r i m m and Venet (1966) studied the re la t ionsh ip of emot ional adjustment and atti tudes as measured e a r l y in pregnancy to adjustment 20 in l a t e r pregnancy and the pue rpe r ium as w e l l as to the mothers ' phys i ca l condi t ion . W h i l e a degree of re la t ionship was found between e a r l y emotional and att i tudinal c h a r a c t e r i s t i c s and emotional adjustment l a t e r in the materni ty c y c l e , none was seen between these attitudes and the phys ica l condit ion of e i ther mother and c h i l d . A c c o r d i n g to the au thors , the sample of women appeared to be typical, of the total obs te t r ic population and included white and negro , mixed par i ty , r e l i g i o n , s o c i o -economic status and educat ion, and a wide va r i e ty of cu l t u r a l backgrounds . G r i m m and Venet felt that there may be a confounding of the effect of pa r i ty and age of mother which indicated the need for study of p r i m i p a r a e wi th in a na r row age range. They a l so suggested that s i nce there we re no g r o s s l y pathological condit ions in the s a m p l e , emotional fac tors w i th in the " n o r m a l " range may be too m i n o r to exer t an influence in the deve lop-ment of pathology. Doty (1967) invest igated the effects of s o c i a l c lass and pa r i t y in he r attempt to relate expressed atti tudes in pregnancy to a va r i e ty of maternal c h a r a c t e r i s t i c s . She developed a pregnancy attitude s ca l e and a maternal check l i s t of infant p rob lems concerned wi th genera l hea l th , feeding behaviour , s leeping patterns and amount of c r y i n g . Her sample of 200 women were ass igned to middle and lower c l a s s on the bas i s of the Hol l ingshead Index of S o c i a l P o s i t i o n . The subjects c o m -pleted the attitude s ca l e and the M M P I dur ing the third t r i m e s t e r of 21 pregnancy . When the infant w a s s i x months o l d the mothe r comple ted the mate rna l c h e c k l i s t of p r o b l e m s dev i sed by Doty,and the P a r e n t a l At t i tude R e s e a r c h Instrument (Schaefe r and B e l l , 1958). D o t y ' s r e su l t s indicated that s o c i a l c l a s s s ign i f i can t ly affected the att i tudes re f l ec t ing emot ional d i s tu rbance , phys i ca l symptoms and re jec t ion of p regnancy . The middle c l a s s group endorsed s i g n i f i c a n t l y fewer i t ems ind ica t ing emot ional d is turbance and expressed s i g n i f i c a n t l y l e s s re jec t ion of pregnancy than the l o w e r c l a s s g roup . M i d d l e c l a s s women had s i g n i -f i can t ly more phys i ca l symptoms of pregnancy than d id the l o w e r c l a s s group. Both middle and l o w e r c l a s s mu l t ipa rae expressed s i gn i f i c an t l y g rea te r re jec t ion of pregnancy and s i gn i f i c an t l y l e s s fear of pregnancy and c h i l d b i r t h than did p r i m i p a r a e . L o w e r c l a s s mul t ipa rae expressed s ign i f i can t ly g rea te r re jec t ion of pregnancy and materna l r o l e than d id the o ther g roups . Doty concluded that at t i tudes towards pregnancy va ry as a function of s o c i a l c l a s s m e m b e r s h i p and p rev ious p r egnanc i e s . He ins te in (1967) hypothesized that the m o r e negative the at t i tudes towards pregnancy the more s eve re the p h y s i c a l compl i ca t ions s u r -rounding pregnancy. A var ian t of the P regnancy Resea rch Ques t ionna i re was admin i s t e r ed to 156 pregnant w o m e n , one th i rd of whom w e r e b l a c k . The subjects w e r e c l i n i c patients f r o m low income f a m i l i e s w i t h a median age between 24 and 2 5 . One t h i r d of the group had co l l ege educat ion. One th i rd of the women w e r e seen i n the i r f i r s t fou r months 22 of pregnancy; one th i rd in the i r fifth to s ix th month and one th i rd in the las t three months of pregnancy. The quest ionnaire was given dur ing the f i r s t contact wi th the c l i n i c . The total med ica l data ( involv ing pregnancy, labour and d e l i v e r y , ped ia t r i c and neuro log ica l e x a m i n a -tion of the infant) were grouped into three ca tegor ies by the obs te t r i c ian and s en io r obs te t r ic nu r se , depending on the type of c o m p l i c a t i o n . Only s ix teen of the 272 i tems of the quest ionnaire we re s ign i f i can t ly related to the degree of phys i ca l compl i ca t i ons , thus thei r hypothesis was not c o n f i r m e d . W h i l e the o v e r a l l resu l t s a r e equivocal regard ing the effects of materna l prenatal attitude to obs te t r i c outcome, there i s evidence that attitudes do va ry accord ing to pa r i t y and s o c i a l c l a s s . It would s e e m reasonable therefore to con t ro l f o r such va r i ab l e s in fur ther r e s e a r c h . Pos tpar tum D i s o r d e r s A major l ine of enquiry has concerned i t s e l f wi th puerpera l d i s -o r d e r s such as postpartum psychoses o r postpar tum d e p r e s s i o n . The focus of these invest igat ions has been the psychopathological condi t ion of women resul t ing f r o m the exper ience of pregnancy and c h i l d b i r t h . Pos tpar tum psychos i s was genera l ly defined as psychos is wi th o n -set wi th in s ix months af ter d e l i v e r y , accord ing to Ka i j and N i l s s o n (1972), who stated that psychot ic compl ica t ions in pregnancy o c c u r in 23 one o r two cases pe r 1,000 d e l i v e r i e s and who c i ted s tudies indica t ing that 4-5% of a l l admis s ions of females to mental hospi ta ls a r e due to such i l l n e s s e s . . B a k e r , D o r z a b , W i n o k u r , Cadore t , (1971) defined a pos tpar tum depress ive episode "as a pers i s ten t dep res s ive syndrome las t ing a m i n i m u m of s i x weeks , whose onset was w i t h i n s i x months of the t ime of g iv ing b i r t h " . W h i l e there i s some conf l i c t in the l i t e r a t u r e , the consensus appears to be that d i s o r d e r s occurring in associat ion with ch i ldbea r ing a r e indis t inguishable f r o m those occurring at other times i n t e rms of symptomatogy and prognos is ( R y l e , 1961; C r u i k s h a n k , 1940; S e a g a r , 1960; Brat fos and Haug , 1966; B a k e r , D o r z a b , W i n o k u r , Cadore t , 1971; B r o w n and She reshe f sky , 1972; W i l s t o n , 1972). A f t e r rev iewing many e a r l y s tudies S e a g e r (1960) concluded that there was no evidence fo r spec i f i c puerpera l mental d i s o r d e r s , but that the pue rpe r ium acted as a s t r e s s , p rec ip i t a t ing breakdown in p r e -disposed w o m e n . Todd (1964) c a r r i e d out one of the f i r s t p rospec t ive ep idemio log ica l s tudies and stated that h i s f igures suggested that puerpera l depress ion i s the end resu l t of a long es tabl ished malad jus t -ment, not a spec i f i c d i s o r d e r — and that the pregnancy, confinement and pue rpe r ium a r e the s t r e s s leading to the breakdown. A leading a r t i c l e in the B r i t i s h M e d i c a l J o u r n a l (1966) stated that there i s no good evidence f o r regarding puerpera l psychos i s as d i s t inc t f r o m 2k psychos i s outside the p u e r p e r i u m . In a s i m i l a r ve in , S i l v e r m a n (1968) stated that the view seems uncontested c l i n i c a l l y that mental i l l n e s s assoc ia ted wi th ch i ldbear ing i s no different f r o m mental i l l n e s s u n -re la ted to c h i l d b i r t h . Howeve r , f o r the pregnancy phase, " T h e r e i s a general a i r of d i ssa t i s fac t ion regard ing mental d i s turbances w h i c h o c c u r af ter d e l i v e r y " . Ka i j and N i l s s o n pointed out that, al though in t e re s t ing , the p s y c h o -ses must be regarded, as a s m a l l group of d i seases f r o m a s o c i o -med ica l point of view and of subs tan t ia l ly l e s s s ign i f icance than the m i n o r p s y c h i a t r i c i l l n e s s fo l lowing p regnancy . They noted that i n v e s t i -gations have indicated that neuroses , non-psychot ic d e p r e s s i o n s , as thenic react ions ,e tc . , a r e e x t r e m e l y c o m m o n dur ing the pos tpar tum y e a r . The w o r k of N i l s s o n (1970) and J a c o b s o n , Ka i j and N i l s s o n (1965) indicated that as many as one woman i n four exper iences m o r e o r l e s s incapaci ta t ing neurot ic a n d / o r d e p r e s s i v e symptoms d u r i n g this p e r i o d . These authors fel t that this i m p l i e d that the w e l l b e i n g of the woman i s d is turbed and he r n o r m a l way of functioning i s r e s t r i c t e d . A c c o r d i n g to Ka i j and N i l s s o n " S y s t e m a t i c invest igat ions on i nc idence , e t io logy , p rognos is and symptoms of neuro t ic react ions in pregnancy and p u e r p e r i u m a r e v i r t u a l l y nonexis tent" . Y a l o m , Lunde , M o o s , Hamburg (1968) stated that the o c c u r r e n c e of postpar tum blues i s " . . . s o ubiquitous and os tens ib ly benign that i t has not often been 25 deemed wor thy of s e r i o u s s t u d y . . . except f o r a s e r i e s of uncon t ro l l ed r e t rospec t ive quest ionnaire s t u d i e s . . . the re la t ionsh ip between this syndrome and pe r sona l i ty t r a i t s , p rev ious menta l hea l th , at t i tudes towards pregnancy, compl i ca t ions of pregnancy , mens t rua l o r o ther endocr ine d i s tu rbances , p rev ious pos tpar tum d e p r e s s i o n , s e v e r i t y of l abour have not been p r e v i o u s l y s t u d i e d " . A rev iew of the m o r e recent l i t e r a t u r e invo lv ing pos tpar tum dep re s s ion and "blues" s u p -por ts the va l id i t y of the above s ta tement . . Y a l o m and assoc ia tes stated that because of the l a ck of c o n -sensua l def ini t ion o r object ive s tudies of this s y n d r o m e , the inc idence rates repor ted va ry g rea t ly w i t h es t imates ranging f r o m 5% to 80%. T h e postulated reasons f o r the pos tpar tum "b lues" have been v a r i o u s l y a t t r ibuted to hormonal changes, p sycho log ica l d i f f i c u l t i e s , p h y s i c a l d i s c o m f o r t , and the onset of lac ta t ion ( P i t t 1968). The symptoms that o c c u r in the postpar tum "blues" involve c r y i n g , (the most c h a r -a c t e r i s t i c s ign) , vu lne rab i l i t y to m i n o r rebuffs , tens ion, anx ie ty , i r r i t a b i l i t y and fatigue. ( H a m i l t o n , 1962; Y a l o m , Lunde , M o o s , H a m b u r g , 1968; P i t t , 1968). Y a l o m and assoc ia tes s tudied the degree of depress ion before d e l i v e r y and f o r ten days pos tpar tum in a group of 39 w o m e n , whose average age was 23 y e a r s . A l l but two women we re m a r r i e d and came f r o m a wide va r i e ty of soc ioeconomic backgrounds . Of the total g roup , 26 37 we re whi te , two negro; nine of the women we re expecting the i r f i r s t baby. Depress ion was measured by in t e rv i ews , behaviora l observat ions and psycholog ica l tests . The findings f rom these measures we re co r r e l a t ed wi th data gathered f r o m the personal h i s t o r y and hospi ta l r ecords concern ing labour and d e l i v e r y for each subject . C l i n i c a l data obtained f r o m d a i l y in te rv iews indicated that c r y i n g was not synonymous wi th a feel ing of dep re s s ion . Some of the stated r e a -sons fo r c r y i n g we re as fo l lows : — inc reased vu lnerab i l i ty or h y p e r -sens i t i v i t y to poss ib le re ject ion; poor ly tolerated lonel iness in hospi ta l ; anger d i rec ted at husbands fo r l ack of cons idera t ion o r u n w i l -l ingness to he lp . A mul t ip le c o r r e l a t i o n of .76 was obtained between an average da i ly depress ion s c o r e and seven va r i ab l e s of which the main contr ibut ions we re made by lower pa r i t y , increased length of t ime f r o m l a s t pregnancy, p rev ious postpar tum depress ion and younger age at menarche . Y a l o m and assoc ia tes pointed out that i t has been demonstrated that the more severe postpar tum emotional d is turbance is co r re l a t ed wi th low pa r i t y , and this suggests that the f i r s t pregnancy represents a unique s t r e s s , that " . . . p r i m i p a r a e , unl ike the m u l t i p a r a e , cannot prepare themselves f o r the phys ica l sensations of pregnancy, fo r the personal sensat ion of c r e a t i o n , fo r the d e l i v e r y p r o c e s s , fo r the major phys ica l and emotional changes necessi ta ted by the a s s u m p -tion of motherhood". T h e r e i s , however , conf l ic t ing evidence 27 regard ing the assoc ia t ion of low pa r i ty wi th d e p r e s s i o n . F o r example , T o d d (1964) conducted a prospect ive ep idemio log i ca l study of puerpera l d e p r e s s i o n . A n evaluation of pa r i t y revealed a preponderance of th i rd pregnancies wi th in the depressed g roups . A c c o r d i n g to Todd p r i m i p a r o u s women "seem re l a t i ve ly immune f r o m psycho log ica l d i s -turbances in the p u e r p e r i u m " . Davidson (1972) used a sample of negro women and found that postpar tum blues w e r e s ign i f i can t ly assoc ia ted wi th a g rea te r incidence of m u l t i p a r i t y . C o n c u r r i n g wi th Y a l o m and a s s o c i a t e s , P i t t (1968) stated that although i t i s common knowledge that women often become depressed af ter c h i l d b i r t h , there has been l i t t l e evaluat ion of what this depress ion amounts to. A c c o r d i n g to P i t t , t r ans i to ry tearfulness in the e a r l y p u e r p e r i u m is common and i s genera l ly regarded as a n o r m a l pheno-menon. He quer ies what l i e s between the ex t remes of s eve re puerperal depress ion occurring in no more than one in 500 b i r ths and the " t r i v i a l weepiness of the b lues" . He suggests the concept of "a typ ica l d e p r e s -s i o n " . P i t t surveyed 305 matern i ty patients who we re given a ques t ion-na i re designed to measure anxiety and depress ion around the 28th week of pregnancy and again s i x to eight weeks af ter d e l i v e r y . Ten per cent of the women developed puerpera l dep re s s ion , and of these only one of the women had a c l a s s i c a l dep re s s ion , w h i l e the pattern of symptoms fo r the res t of the group was that of " a t y p i c a l " depress ion — " a 28 m i l d e r var ian t of phys io log ica l depress ion most often seen in younger women o r immatu re p e r s o n a l i t i e s " . It i s c a l l e d a typ ica l dep re s s ion because of the prominence of neurot ic s y m p t o m s , i . e . , a n x i e t y , i r r i t a -b i l i t y and phobias , o r because some features do not co inc ide wi th c l a s s i c a l cases of d e p r e s s i o n . P i t t stated that i t was af ter "the re tu rn home that depress ion was a lways mos t evident , chief ly as tear fu lness , despondence, feel ings of inadequacy and inab i l i t y to cope — p a r t i c u -l a r l y w i th the baby" . The depress ion was n e a r l y a lways accompanied by anxiety o v e r the baby, anxie ty wh ich was not jus t i f i ed by i t s hea l th . In 1973 P i t t decided to examine the inc idence , phenomenology and assoc ia ted features of the " b l u e s " . He in te rv iewed 100 women between the seventh and tenth day pos tpar tum and found that ha l f of these women r could be diagnosed as having the " b l u e s " . Of these 35% o c c u r r e d w i t h -in four days of p a r t u r i t i o n , 26% on the th i rd day. Those women suffer ing the "blues" dif fered f r o m the r e s t of the women only in that they exper ienced more d i f f i cu l ty in b reas t - feed ing . No s ign i f i can t d i f -ferences in attitudes towards pregnancy, exper ience of l abour , baby ' s heal th o r s o c i a l s t r e s s w e r e apparent . S i x of the women who had the "b lues" developed puerpera l dep re s s ion , a state of despondency l a s t ing a month o r m o r e . P i t t stated that the "b lues" i s "a t r i v i a l , f leet ing phenomenon"and should not be confused wi th the ' a t y p i c a l ' o r neuro t ic f o r m of puerpera l d e p r e s s i o n . 29 Pos tpa r tum Adjustment The Gordons (Gordon and Gordon,1959; Gordon and Gordon,1960; G o r d o n , Kapos t inus , Gordon,1965) have shown that pe r sona l and s o c i a l s t r e s s i tems s ign i f ican t ly d i s c r i m i n a t e between n o r m a l m a r r i e d mothers and those who have pos tpar tum emot ional upset . The authors gave a s o c i a l h i s t o r y quest ionnaire to 98 n o r m a l women who had ju s t d e l i v e r e d the i r babies . F o u r months af ter d e l i v e r y the p h y s i c i a n of each woman completed a ra t ing s ca l e as to the degree of emot iona l d i s t u r -bance exper ienced by these women subsequent to d e l i v e r y . The 98 women w e r e compared wi th matern i ty patients who had sought p s y c h i -a t r i c h e l p . The fo l lowing i tems s ign i f i can t ly differentiated tine two groups: emotional p rob lems in the woman ' s background; phys i ca l c o m -l i ca t ions of pregnancy; age of wi fe ; r e l i g i o u s i n t e r m a r r i a g e ; no help ava i l ab le af ter the b i r t h . N i l s s o n and h is a ssoc ia tes ( N i l s s o n , 1970; N i l s s o n and A l m g r e n , 1970) have conducted a s e r i e s of p rospec t ive studies invo lv ing the pos t -natal adjustment of S w e d i s h w o m e n . T h e a i m of these s tudies was th ree -f o l d ; F i r s t , to study the o c c u r r e n c e , nature and prognos is of para p a r turn emot ional i l l n e s s using a p rospec t ive method; second, to invest igate wh ich ae t io log ica l fac tors influence such i l l n e s s ; and t h i r d , to es tab l i sh c h a r a c t e r i s t i c patterns of adaptation in r e l a t ion to the s t r e s s s i tua t ion w h i c h b i r t h e n t a i l s . T h e i r study involved the inves t igat ion of 165 unselected women 30 attending prenatal c l i n i c s fo r the f i r s t t ime dur ing the cu r r en t p r e g -nancy. The women we re in te rv iewed on three occas ions ; af ter the i r f i r s t v i s i t to the c l i n i c , two to three days postpartum and s i x months pos tpar tum. The content of such in te rv iews included p s y c h i a t r i c h i s -to ry , general s o c i a l and envi ronmenta l questions and att i tudes towards the i r cu r r en t pregnancy. A c l i n i c a l evaluat ion was c a r r i e d out and the p s y c h i a t r i c status of the women was noted. A t the f i r s t and th i rd i n t e r -v iew, the women we re given psycho log ica l tests including an a s ses smen t of in te l lec tual and cogni t ive functioning and a personal i ty a s se s smen t . F o u r ques t ionnaires were designed to measure n e u r o t i c i s m , prenatal ident if icat ion and degree of ident i f ica t ion wi th stereotyped feminine and mascu l ine c h a r a c t e r s . M e a s u r e s used by the authors as c r i t e r i a of the women ' s adjustment to c h i l d b i r t h included the occu r r ence of p s y c h i a -t r i c symptoms (before , dur ing and af ter pregnancy); c l i n i c a l s igns of i l l n e s s ; deviat ions in tes ts , att i tudes and sexual adjustment. In P a r t One of the i r study they surveyed psych ia t r i c m o r b i d i t y . On the bas is of reported s y m p t o m s , the extent .of adaptional d i f f icu l t i es dur ing pregnancy and postpar tum was ca l cu la t ed . The p r i n c i p a l m e a -sure in this su rvey was the au thor ' s es t imat ion of the degree of d i s -turbance based upon the se r iousness and number of ind iv idua l p sych ia t -r i c symptoms reported in each p e r i o d . They found that the s igns of mental dis turbance we re of the same magnitude during pregnancy 31 a s du r ing the postpar tum per iod and the o c c u r r e n c e of such s i gns , e . g , l owered mood, affect ive l a b i l i t y , p sychomotor re ta rda t ion ,was high in both p e r i o d s . N i l s s o n and assoc ia te s stated that the high o c c u r -rence of mental symptoms and d is turbances dur ing the pregnancy pe r iod was r emarkab le in view of the genera l be l i e f that p s y c h i a t r i c symptoms o c c u r infrequently dur ing this pe r iod and since, s e v e r a l authors m a i n -tained that mental i l l n e s s i s more c o m m o n after d e l i v e r y . In P a r t Two of the i r s tudy N i l s s o n and assoc ia te s compared the f requencies of subject ive p s y c h i a t r i c symptoms before , -during and af ter pregnancy wi th va r ious background f ac to r s , tests and c l i n i c a l obse rva t ions . Re la t ionsh ips w e r e found between symptoms o c c u r r i n g dur ing pregnancy and the postpar tum pe r iod and such fac to r s as the w o m e n ' s attitude towards pregnancy, re la t ionsh ip w i t h the c h i l d ' s fa ther and envi ronmenta l condi t ions at the t ime of p regnancy . A c c o r d -ing to the authors the high frequency of symptoms dur ing pregnancy often seemed related to unfavourable envi ronmenta l c i r c u m s t a n c e s , w h i l e postpar tum s y m p t o m s , to a great extent, indicated the exis tence of " m o r e deeply seated con f l i c t s " connected w i t h reproduc t ive func t ion -i n g . These conc lus ions w e r e based on the a s soc ia t ion wh ich was found between postpar tum mental symptoms and such fac tors as unsa t i s fac tory e a r l y re la t ions wi th the paren ts , a m o r a l i z i n g atti tude towards sex at the parenta l home, a negative atti tude towards motherhood. 32 T h e r e is l i t t l e e m p i r i c a l r e sea rch into the psycho log ica l aspects of postpar tum adjustment. It i s d i f f icul t therefore to d raw any conclus ions about a poss ib le re la t ionship between postpar tum adjustment and attitude toward the infant. Hosp i ta l Env i ronment A n o t h e r a rea of r e sea rch that has rece ived l i t t l e attention to date and that may influence the postpar tum materna l behaviour of women and the i r e a r l y re la t ionship wi th the i r infantsis the study of the hospi ta l exper ience and i ts effects , i f any , upon the mother and he r infant. A rev iew of the l i t e r a tu re showed only a few objective s tudies , concerned p r i m a r i l y wi th the hospi ta l exper ience of the mother , although there a r e many a r t i c l e s desc r ib ing the ins t iga t ion , phi losophy and advantages of r o o m i n g - i n and f a m i l y centred matern i ty ca r e (Enge la , 1963; Fa l e t t a , 1963; Wooden, 1962a, 1962b; J a c k s o n , 1946; Engelb,1963; T i m b e r l a k e , 1975; Thorns , 1962; Ra tsoy , 1974; H a i r e and H a i r e , 1968; C o x , 1974). Shea, Klatski.n, S J ackson (1952) compared the home adjustment over a per iod of one month post hospi ta l d i scharge of mothers who exper ienced r o o m i n g - i n wi th those women who par t ic ipated in the typ ica l matern i ty w a r d . Al though rooming - in was not defined in the s tudy, typ ica l ly i t involves the s i tuat ion where the newborn infant i s placed in a b a s -s inet in the mother ' s r o o m , usua l ly dur ing the day. A t night the infant i s returned to the cent ra l n u r s e r y . The study involved eleven matched p a i r s of p r i m i p a r a e , equated as c l o s e l y as poss ib le fo r age, education 33 and s o c i o e c o n o m i c c l a s s . F o l l o w - u p v i s i t s w e r e made on the mothers ' f i r s t day home f r o m the hospi ta l and then a r ranged acco rd ing to the mother ' s need. These home v i s i t s w e r e made by a m e m b e r of the r e s e a r c h staff of the r o o m i n g - i n p ro jec t . A general outl ine cove r ing ce r t a in topics was used f o r each v i s i t , and the v i s i t i n g r e s e a r c h e r wro te down he r observat ions a f t e rwards . T o make these observat ions more objec t ive , a ra t ing sca le was devised to code the data . Shea and assoc ia tes stated that because of the s m a l l number of subjects i nvo lved , no s t a t i s t i ca l ana lys i s was done, ( nor were , the data presented in such a way as to a l low one to make s t a t i s t i c a l ana lyses ) . C e r t a i n trends w e r e noted by the au thors , e .g . , the r o o m i n g - i n mothers w e r e rated more competent in handling the i r baby, they fel t more s e l f confident in understanding the i r baby 's needs and behaviors and requ i red fewer nurs ing v i s i t s . (Those in r o o m i n g - i n averaged three v i s i t s ; non- rooming- in , seven v i s i t s . ) Shea and assoc ia tes c o n -cluded that "mothers having r o o m i n g - i n exper ience have g rea t e r f a c i l i t y in handling the baby and more se l f -conf idence in understanding the baby's behaviour" . A second study compar ing r o o m i n g - i n wi th t radi t ional matern i ty w a r d s was c a r r i e d out in Sweden . G r e e n b e r g , Rosenberg and L i n d (1973) randomly ass igned 100 p r i m i p a r o u s women , matched fo r age, s o c i o e c o n o m i c status and education of fathers to e i the r a r o o m i n g - i n 34 f a c i l i t y o r a t rad i t iona l w a r d . The women in the r o o m i n g - i n f a c i l i t y fed the infants on a r e g u l a r schedu le . The infants w e r e brought to the mother 12 to 16 hours af ter b i r t h and remained in the bass ine t in the "room f r o m 9 .00 a . m . to 6 .00 p . m . In the t rad i t iona l w a r d , the mothers saw the infant f o r 20 minutes at each feeding . F a t h e r s in both groups v i s i t ed f o r one hour a day dur ing wh ich t ime the infant was not permi t ted in the r o o m . The authors developed a 50 - i t e m m u l t i -p le choice quest ionnaire wh ich was given to a l l w o m e n . The impor tan t s igni f icant findings f r o m this study w e r e that r o o m i n g - i n mothe r s judged themselves m o r e confident w i t h the infants and i n c a r i n g f o r the infant; could understand one o r m o r e a t t r ibutes of the baby 's c r y ; and developed mate rna l feel ings f a s t e r than those women in the t r a d i -t ional matern i ty w a r d . One s igni f icant feature of the usua l f a m i l y cent red mate rn i ty p r o -g r a m m e not incorpora ted into the above s tudies was the pa r t i c ipa t i on by fa thers . A n e a r l y study compar ing conventional ma te rn i ty sy s t ems w i t h a f a m i l y centred approach was undertaken by M o y e r , C o l l e t t e , and Ludtke (1966). T h e authors stated that i t was d i f f icu l t to define e i the r the conventional matern i ty c a r e p r o g r a m m e o r the f a m i l y centred p rog ramme i n absolute t e rms because of the many va r i a t i ons to be found. The two p rac t i c e s can be d is t inguished in a genera l sense ,however , and the authors c i t ed f ive r e l a t i ve ly d i s t i nc t d i f ferences 35 between the two p rog rammes as appl ied to the hospi tal in wh ich they c a r r i e d out the i r r e s e a r c h . These differences a r e l i s t ed below: Conventional p r o g r a m m e 1. Fa the r not present dur ing d e l i v e r y 2 . Infant housed in cen t ra l nu r se ry 3 . Scheduled feedings 4 . Fa ther present only dur ing regu la r v i s i t i ng hours 5 . Fa the r cannot handle the baby F a m i l y centred p rog ramme 1 . Fa the r present dur ing d e l i v e r y 2 . Infant housed wi th mother 3 . Demand feeding 4 . Fa the r has unres t r i c t ed v i s i t i ng p r i v i l e g e s 5. Fa the r a l lowed to handle the baby In 1964, the hospi ta l in wh ich M o y e r and assoc ia tes c a r r i e d out the r e sea rch changed f r o m a conventional materni ty d e l i v e r y s y s t e m to a f a m i l y centred s y s t e m . The most pronounced difference between the two p r o g r a m m e s was the added emphasis placed on c lose contact among the f a m i l y members dur ing the hosp i t a l i za t ion . The bas i c design of the study was to make a post hoc compar i son of two groups of f a m i l i e s . In one group the mothers had been cared for under the t radi t ional p r o g r a m m e , wh i l e the second group cons is ted of those who 36 entered the hospi ta l af ter the changeover to the f a m i l y cen t red p l a n . F o r t y cases w e r e se lec ted at random f r o m those mothers who d e l i v -e red the i r baby p r i o r to the changeover and 40 cases f r o m those who de l i ve red the i r baby af ter the changeover o c c u r r e d . Ques t ionna i res w e r e then ma i l ed to both groups at the appropr ia te t ime i n t e r v a l s a f t e r hospi ta l d i s c h a r g e . The ques t ionnai res involved i nd i ca to r s of posthospi ta l adjustment and inc luded mothers ' and fa thers ' tension l e v e l in handling the infant; mo the r s ' and fa thers ' i r r i t a b i l i t y l e v e l ; degree of mothers ' postpar tum depress ion ; heal th p r o b l e m s of the infants wh ich might have emot ional e t io logy . E igh ty p e r cent of the ques t ionnai res w e r e re turned f r o m each group of pa ren t s . T h e mos t s ign i f ican t f inding was that.'.88% of mothers in the t rad i t iona l p r o g r a m m e repor ted va ry ing l eve l s of i r r i t a b i l i t y , w h i l e only 53% of those in the f a m i l y centred p r o g r a m m e repor ted the s a m e . M o y e r and a s soc i a t e s concluded by s tat ing that the i r f indings " . . . g i v e s o m e c redence to the assumpt ions under ly ing the f a m i l y centred mate rn i ty c a r e p l a n . H o w -e v e r , cons iderab le r e sea rch s t i l l needs to be done in o r d e r to a s c e r -tain the r e l a t ive value of the va r ious facets of the p r o g r a m m e " . M o y e r ' s study i s r e t rospec t ive and w h i l e the groups in each p r o -g r a m m e appear to be s i m i l a r , there is no in format ion deal ing wi th group compos i t i on . T h e r e was a 20% dropout rate f r o m both g roups . M o y e r argued that h i s f indings give s t rong support to the proponents 37 of f a m i l y centred materni ty c a r e inasmuch as the p r o g r a m m e c o n t r i b -uted to. the emotional adjustment and s t ab i l i ty of the f a m i l y . In fact , there w e r e no differences between the groups repor ted f o r mothers ' postpar tum depress ion as measured on a four point s c a l e . In view of the fact that the study took place re la t ive ly soon af ter the inst igat ion of the new p r o g r a m m e there i s the dist inct p o s s i b i l i t y of a Hawthorne effect. A second and more ambi t ious study of the differential effects of a f a m i l y centred materni ty ca re p r o g r a m m e was c a r r i e d out by J o r d a n between 1969 and 1971 ( Jordan , 1973a, 1973b, 1973c). T h i s study was c a r r i e d out in two hosp i ta l s , one of which offered a f a m i l y centred materni ty p r o g r a m m e and the other a more tradit ional p r o g r a m m e . Two hundred and nine f a m i l i e s par t ic ipa ted in the s tudy. One hundred and eleven f a m i l i e s we re involved wi th the hospital having the f a m i l y centred matern i ty p r o g r a m m e and 98 at the more t rad i t iona l ly or iented hosp i t a l . The women we re d iv ided into pr imiparous and mul t iparous groups . A l l the par t ic ipants w e r e seen f ive t imes by one of two project invest igators as fo l lows : dur ing the ninth month of pregnancy, 24-48 hours after d e l i v e r y of the baby; seven to ten days after d i scharge f r o m the hospi tal and at f ive and eight weeks after d i s cha rge . Each t ime the subjects were seen an appropr ia te set of quest ionnaires we re left to be completed by the husband and w i f e . Data we re analyzed in 38 2 x 2 contingency tables using c h i square as the test of s i g n i f i c a n c e . S ign i f ican t f indings included the fo l lowing : a patient, has a g rea te r degree of t rust and confidence in the nurse when a spec i f i c nurse patient ass ignment i s made; the parents ' confidence is g rea te r and they have l e s s fear of the i r inab i l i ty to ca r e fo r the baby when the hospi ta l environment has offered a va r i e ty of l ea rn ing opportunit ies in the ca re of the baby; the f a m i l y re la t ionship i s s t ronge r when the hospi tal environment permi t s , the parents to be together during the labour ing p rocess and to handle the i r baby as much as they des i re ; a r ea s of c o n -ce rn to the mother a r e expressed more frequently when a va r i e ty of learn ing opportuni t ies a re offered to the mother in the hosp i ta l ; more fathers feel confident in caring fo r the baby, being of g rea te r help wi th the baby and do not object to helping wi th the infant when the couple have par t ic ipa ted in the f a m i l y centred p rogramme; mothers r equ i re l e s s help wi th ins t ruct ion and requ i re l e s s reassurance . Jo rdan made the i m p l i c i t assumpt ion that " r o o m i n g - i n " i s f a m i l y centred matern i ty c a r e . It has been pointed out by H a i r e and H a i r e (1968) that "modi f ied r o o m i n g - i n " i s an impor tant part of f a m i l y c e n -tred materni ty c a r e . These authors stated that rooming- in r equ i r e s the mother to "ca tegor ize h e r s e l f — to designate o r c o m m i t h e r s e l f to a type of ca r e she often knows l i t t l e about". F l e x i b l e r o o m i n g - i n , on the other hand, a l lows the mother ra ther than the hospital to de termine 39 how much t ime she spends w i t h the baby. Jo rdan a l so assumed that the groups in each hosp i ta l w e r e c o m -parable regard ing demographic data when , in fac t , s ign i f i can t d i f -ferences ex is ted between the two groups of p r i m i p a r o u s women in favour of the f a m i l y centred mate rn i ty hosp i t a l . It i s unfortunate that the study was completed wi th a s ample that did not meet the i n i t i a l s e l ec t ion c r i t e r i a . F i f t y pe r cent of those in the t rad i t iona l hospi ta l d id not meet the c r i t e r i a of no prenata l c l a s s e s , thus, confounding the r e su l t s obtained regard ing the eff icacy of f a m i l y cent red c a r e wi th the effects of attending prenatal c l a s s e s . A n o t h e r d i f f icu l ty wi th the study was that J o r d a n ' s method of obtaining tine sample differed f o r the two groups . One group (the f a m i l y cent red materni ty) was approached pe r sona l ly w h i l e the o ther group (traditional-) was r e fe r r ed by the d o c t o r . A c c o r d i n g to Jo rdan different ind iv idua ls conducted the va r ious in t e rv iews which apparent ly resul ted in s l igh t dif ferences i n the manner i n wh ich the in te rv iew data were repor ted , and this may have contr ibuted to d i s to r t ion o r bias in the r e s u l t s . T h e r e was no indica t ion in J o r d a n ' s repor t as to whether the ques t ionnaires were r e l i ab l e in t e rms of e i the r in te rna l cons is tency o r s t a b i l i t y ove r t i m e . S t a t i s t i c a l a n a l y s i s of the data was conducted using the c h i squa re . T h i s resul ted in hundreds of compar i sons being made which led to the ve ry s t rong p o s s i b i l i t y of many Type 1 e r r o r s o c c u r r i n g . R e s e a r c h i s p resen t ly being conducted by K l a u s and Kennel 1 and the i r a ssoc ia tes wh ich re la tes to the hospi ta l env i ronment of the m a -terni ty pat ient . K l a u s and Kenne l l (1970) maintained that behav ioura l s tudies in a l a rge range of a n i m a l spec ies as w e l l as p r e l i m i n a r y s tudies of human materna l behaviour suggested that what happens in the pe r iod immed ia t e ly fo l lowing d e l i v e r y of the baby "may be c r i t i c a l to l a t e r mate rna l behav iour" . S e a s h o r e , L e i f e r , Barne t t and L e i d e r m a n (1973) a g r e e d , c i t i ng s tudies of materna l behaviour in the nonhuman m a m m a l s wh ich suggest "that r e s t r i c t i o n of in terac t ion of the mother and baby in the e a r l y postpar tum per iod influences subsequent mate rna l pe r fo rmance and may , in fact , produce c l e a r l y incompetent m o t h e r i n g . " The authors pointed out that previous studies invo lv ing mate rna l / in fan t separa t ion of the human have concentrated on the effects of long t e r m separa t ion on the development of the infant, paying l i t t l e attention to the question of how the mother i s affected by such a s epa ra t i on . K laus and Kenne l l c i ted a pe rsona l communica t ion f r o m Barne t t , an anthropologis t who searched the Human Rela t ions F i l e (which l i s t s 220 cu l tu res ) f o r var ia t ions i n human materna l behav iour fo l lowing d e l i v e r y of the baby. Barne t t found that a l l soc ie t i e s exhibi t a " r e g u l a r i z e d " way of deal ing wi th b i r t h . In mos t cul turesmother and 41 infant a r e secluded together dur ing the three to seven days af ter b i r t h , unt i l the u m b i l i c a l co rd hea l s . Appa ren t ly "rout ine complete separat ion of mother and infant in the f i r s t days af ter d e l i v e r y ex i s t s only in the high r i s k and premature nu r se r i e s of the W e s t e r n W o r l d " . Klaus and Kennel l stated that In this century both b i r th and death, the two most impor tan t events in the l i fe of an individua 1,have been moved into the hospi ta l and away f r o m the f a m i l y and centur ies of t radi t ions and c u l t u r a l patterns of behaviour . P r a c t i c e s su r round ing both events appear to have been a lmos t w h o l l y de termined by the psychologica l needs, the c o n -venience, the l i m i t e d perspec t ive , and the bias of the dominant members of the hospi ta l cu l tu re (nurse , phys i c i an , and a d m i n i s t r a t o r ) , (p. 1026) Klaus and Kennel l maintained that most no rma l d e l i v e r i e s in the United States a r e associa ted wi th s eve ra l days of what Barnet t c a l l s "depr iva t ion" f o r the mother — "Only mothers who d e l i v e r at home o r r o o m - i n wi th the i r infants exper ience no d e p r i v a t i o n " . W h i l e this i s an overstatement the point i s w e l l taken. ( R o o m i n g - i n , in s tudies m e n -tioned p r e v i o u s l y , seems to be on a da i ly basis ra ther than fu l l t i m e . ) The authors pointed out that the na tu ra l i s t i c a r rangements of r o o m i n g -in procedures may be of immense value fo r the mother and c h i l d . The observat ions made by M c B r y d e (1951) w e r e used by Klaus and Kennel l to support the concept that c lose contact between mother and infant dur ing the i n i t i a l days af ter d e l i v e r y may w e l l fac i l i t a te mother ing behav iour . M c B r y d e reported that when r o o m i n g - i n was made c o m -pu l so ry at. Duke Hospi ta l "the incidence of breas t feeding rose f r o m 35% to 58.5% whi l e telephone ca l l s f rom anxious mothers dur ing the f i r s t weeks after d i scharge decreased by 90%." Klaus and Kenne l l bel ieved that the mothering behaviour of each w o m a n , "her a b i l i t y to tolerate adverse s t r e s s e s , and he r need fo r spec i a l attention differ grea t ly and depend upon a multi tude of f a c t o r s " . F i g u r e 1 i s a modif ica t ion of the schema that they have developed i l l u s t r a t i n g the major influence of mothering behaviour and the resu l t ing poss ib le dis turbances which a r i s e when this behaviour i s d i s o r d e r e d . The d i s o r d e r s range f rom m i l d concerns to the most s eve re — the battered c h i l d s y n d r o m e . Klaus and Kennel l suggested that the range of d i f f i -cu l t ies may be the end resu l t of separa t ion in the newborn p e r i o d . Low b i r th weight and p rematur i ty often involved a prolonged separa t ion between mother and infant. K e n n e l l , T r ause and Klaus (1975) c i ted s tudies showing that premature infants constituted a "d ispropor t iona te ly high number of both battered ch i ld ren (23-31%) and those wi th the " fa i lu re to th r ive" s y n d r o m e " . He i fe r (1975) in his d i scuss ion of ch i l d abuse stated that "The prec ip i ta t ing event may be rea l o r imagined , a b i r th defect, a s o c i a l o r economic d is rupt ion of the f a m i l y , a dif f icul t pregnancy o r d e l i v e r y , o r e a r l y separat ion of mother and c h i l d . " A c c o r d i n g to H e i f e r , abused F i r s t days of l i f e , separat ion of mother and infant Behav ior of doc to rs , nurses , and hospital personnel P r a c t i c e s of hospital Infant Mothe r ' s attachment and earetaking N o r m a l Dis turbed mo the r - ch i l d re la t ions Behav io ra l p rob lems in adopted ch i ld ren Vulnerable • ch i ld syndrome Developmental and emotional problems in highj r i s k infants F a i l u r e to thr ive Bat tered ch i ld syndrome F i g u r e 1. D i s o r d e r s of mother ing: adapted f rom Klaus M . and Kennel l 0:. Mothers separated f rom the i r newborn infants . Pediat C l i n N A m e r 17:1015, 1970. 44 ch i l d r en have a p rematu r i ty rate twice that of the general population and a caesa r i an sec t ion rate much higher than that of the genera l populat ion. (In a personal communica t ion to K e n n e l l , T r a u s e , and Klaus (1975),Hel fer stated that the incidence of c h i l d abuse i s ten t imes g rea te r wi th a caesa r i an sec t ion than wi th vaginal d e l i v e r i e s . ) F indings f r o m the r e sea rch undertaken by Klaus and h i s assoc ia tes have demonstrated that there i s indeed an influence of e a r l y separa t ion on the subsequent re la t ionship between mother and infant. In an e a r l y study K e n n e l l , Gordon , and Klaus (1970) compared the behaviour of mothers who had been separated f r o m the i r p rematu re i n -fants f o r the f i r s t 21 days of l i f e , wi th those mothers who had been a l lowed phys i ca l contact wi th in the f i r s t f ive days . Us ing t ime lapse photography, observat ions were recorded and analyzed for the f i r s t ten minutes of the feeding immed ia t e ly before d i scharge f r o m the h o s p i t a l . Twen ty - f ive ac t i v i t i e s w e r e recorded for each mother including care tak ing s k i l l s and maternal af fect ion. A s igni f icant difference in the percentage of 'en face ' contact and cuddling t ime was seen between the e a r l y and late contact mo the r s . A t a one month fo l low-up i t was found that late contact mothers held the i r babies d i f ferent ly , changed posi t ion l e s s , burped them l e s s and w e r e not as s k i l l f u l in feeding them as those mothers who had had e a r l y con-tact wi th the i r p remature infants . Kennel l and assoc ia tes (1975) d i scussed the follow-up of p remature infants and stated t h a t ' p r e l i m i n a r y data on the kS Stanford Bine t I . Q . of the two groups of c h i l d r e n at 42 months indicated that those in the e a r l y contact group s c o r e d s ign i f i can t ly h igher than those i n the late contact group (mean I . Q . 99 vs 85) . F u r t h e r m o r e , a s i g n i -f icant c o r r e l a t i o n ( co r re l a t ion coeff icient = .71) was found between the I . Q . a t 42 months and the amount of t ime women spent looking at the i r babies dur ing the f i lmed feeding at one month of age" . (It i s u n c l e a r whether this fo l low-up i s of the c h i l d r e n studied by K e n n e l l , Gordon and Klaus (1970).) In 1972 K l a u s , J e r a u l d , K r e g e r , M c A l p i n e , S tef fa , and K e n n e l l c a r r i e d out a study to de termine whether hospi ta l p r ac t i c e s in the United States affected l a t e r mate rna l behaviour of women who had fu l l t e r m as opposed to p remature infants . The sample was 28 p r i m i -parous women (26 negro , 2 white) wi th an average age of 18 y e a r s who had reached grade 10 o r 11 . Of this group nine w e r e m a r r i e d . E a c h mother was placed in one of two study groups depending on the day of d e l i v e r y . A c c o r d i n g to the authors the mean age , soc ioeconomic c l a s s m a r i t a l s ta tus , r ace , p r emed ica t ion , sex of infant and days h o s p i t a l -i zed w e r e "nea r ly i d e n t i c a l " . Four teen mothers had the usual amount of contact w i th the i r infants, i . e . , a g l impse of the baby s h o r t l y af ter b i r t h , b r i e f contact and ident i f ica t ion at s i x to 12 h o u r s , then the usua l feeding scheduled every four h o u r s . In addi t ion to this rout ine , fo r 46 the three days after d e l i v e r y , the 14 mothers in the extended contact group were given the i r nude babies , for one hour wi th in the f i r s t three hours after b i r th and fo r f ive ext ra hours of contact each af ternoon. The mothers returned one month after d e l i v e r y fo r three separate observat ions cons i s t ing of a s tandardized in te rv iew, an observa t ion of maternal per formance dur ing the phys i ca l examination of the infant and a f ie ld study of the mother feeding he r infant. The resu l t s ind ica t -ed a s igni f icant difference in behaviour of the groups of women towards the i r infant, in the area of fondling and face contact. The s c o r e s obtained on in te rv iew questions and observat ions made du r ing the phys ica l examinat ion of the infant a l so indicated s ignif icant differences between the groups . The extended contact mothers we re more r e l u c -tant to leave the i r infants wi th someone e l s e , showed grea te r soothing behaviour i f the infant c r i e d , and engaged in s ign i f ican t ly m o r e eye - to -eye contact wi th and fondling of the infant. In view of these differences i n materna l behaviour at one month, K e n n e l l , J e r a u l d , W o l f e , C h e s l e r , K r e g e r , M c A l p i n e , Steffa and Klaus (1974) conducted a fo l low-up study to see whether these differences pe r s i s t ed after one y e a r . A t this t ime the mothers we re observed by invest igators who we re not f a m i l i a r wi th the mothers , n o r had the observers had contact wi th the mothers dur ing the previous eleven months. The authors d id not say w h e t h e r the invest igators w e r e aware to which group the m o t h e r / infant p a i r belonged. The obse rve r s moni tored mother / infant i n t e r -hi act ion through a two-way m i r r o r in seven separate s i tua t ions . S ign i f i can t differences we re found between the two groups in the i r answers to in terv iew questions and in the i r behaviour dur ing a phys ica l examinat ion of the infant. In the observat ion pe r iod dur ing the phys ica l examinat ion the women in the extended contact group spent a s ign i f ican t ly grea te r total t ime a-ssisting the phys ic i an than did the cont ro l women. The extended contact group a l so spent a s ign i f i can t ly grea te r t ime soothing in response to c r y i n g and were more l i k e l y to k i s s the i r babies than.the con t ro l group. In addit ion there was a s igni f icant difference on the B a y l e y mean developmental index between the two groups of infants — 98 for the infants of the extended contact mothers and 93 f o r the con t ro l group mo the r s . Kenne l l and col leagues c o n -cluded that these apparent ly s t r i k i n g findings need to be rep l ica ted in a l a rge study but that those who ca re fo r infants and mothers should be aware of the poss ib le long t e r m effects of the e a r l y postpar tum p e r i o d . Two y e a r s l a te r f ive mothers we re se lec ted at random f r o m each group and the l ingu i s t i c behaviours of the two groups of mothers we re compared w h i l e speaking to the i r c h i l d r e n . It was found by R i n g l e r , K e n n e l l , J a r v e l l , Navojosky and Klaus (1975) that "the extended contact mothers used twice as many ques t ions , more words p e r p ropos i t i on , fewer contact w o r d s , more adject ives and fewer commands than d id the 48 c o n t r o l s . The authors pointed out that this may have been due to chance se lec t ion and the study should be repeated. They made the addi t ional point that the findings f r o m the above resea rch suggest "that 16 extra hours of contact in the f i r s t three days of l i fe appear to have affected maternal behaviour f o r one y e a r and poss ib ly longer , thus offering support fo r the hypothesis that there is a materna l sens i t ive per iod soon af ter d e l i v e r y . " T h e r e a r e s e v e r a l p rocedura l d i f f icul t ies wi th the above r e sea rch that may have influenced the r e s u l t s . It i s not poss ib le to ru le out expectancy effects on the part of the par t ic ipa t ing mothe r s . F i r s t , i t was not known whether they were aware that they were par t of a r e sea rch study; second , as Klaus pointed out, the mothers may have seen handling the i r baby as a spec i a l p r i v i l e g e , leading to a subsequent change in the i r behaviour . It i s unusual in any hospi ta l to be supplied wi th a heat panel and y o u r naked baby to fondle — a ve ry obt rus ive feature of the s tudy. A l s o , as Klaus mentioned, there was the question of the t ime and amount of contact which was not con t ro l led f o r . In addi t ion , there was no attempt to cont ro l fo r the amount of s t imula t ion per se rece ived by the babies in the contact group — the differences obtained may have been due in some part to the effects of s t imula t ion ra ther than the l ack of separa t ion . L e i f e r , L e i d e r m a n , Barnet t and W i l l i a m s (1972) have conducted 49 s i m i l a r r e sea rch using a different population and more s t r ingent c o n t r o l s . T h e i r sample was 80% white w o m e n . The median education fo r the mother was complet ion of high s c h o o l , and for the father was some col lege educat ion. The median age for both parents was 25-29 and median s o c i a l c l a s s was 111 as measured by the Hol l ingshead Index. The sample consis ted of three groups of mothers; 22 separated mothers of p remature babies , who had v i sua l contact only f o r three to 12 weeks af ter b i r t h ; 22 contact mothers of premature babies who entered the intensive c a r e n u r s e r y two to three days af ter the b i r t h of the infant and handled the infants in the incubator and par t ic ipa ted in n o r -ma l ca r e ac t i v i t i e s as fa r as poss ib le ; and 24 mothers of fu l l t e r m babies . A s s i g n m e n t to the separate and contact group was made on a r a n -dom bas is and the women we re unaware of the existence of the two groups . The separated infants we re given addi t ional handling by the nurses to avoid the p o s s i b i l i t y of differences a r i s i n g due to different ial amounts of e a r l y s t imula t ion ra ther than maternal contact . The f u l l - t e r m mothers w e r e matched as f a r as poss ib le fo r p a r i t y , s o c i a l c l a s s and sex of infant to tine women in the premature group. At tachment behaviours of three groups of women we re compared in t ime - sampled observat ions p r i o r to and one and four weeks af ter the infants ' d i scharge f rom h o s p i t a l . M a t e r -nal attachment behaviour was defined as "the degree to which a mother i s attentive to and maintains phys ica l contact wi th he r infant ." M a j o r 50 f indings f r o m this study w e r e that contact mothers held t h e i r infant i n the vent ra l holding pos i t ion f o r a s ign i f i can t ly greater percentage of the t ime than d id the separa ted mothers at the f i r s t week pos td i scharge p e r i o d . It was a l so found that fu l l t e r m mothers s m i l e d at the i r i n -fants m o r e often and maintained more vent ra l contact wi th them than did mothers of p remature babies w h i l e in h o s p i t a l , and at the one week and one month post d i scha rge t ime p e r i o d s . U s i n g a pa i red c o m p a r i s o n ques t ionnai re f o r the two groups in the above study, S e a s h o r e , L e i f e r , Barne t t , and L e i d e r m a n (1973) examined the atti tudes of se l f -conf idence i n c a r i n g for the infants . It was found that separa t ion resu l ted in l ower self-confidence f o r p r i m i -parous mothers but not fo r mul t iparous m o t h e r s . A c o m p a r i s o n was made of mothers i n i t i a l l y low i n se l f -conf idence and i t was seen that those mothers in the separa t ion group w e r e m o r e l i k e l y to r e m a i n low i n se l f -conf idence unt i l the infant was d i s c h a r g e d . B y one month,how-e v e r , se l f -conf idence of the p r i m i p a r a e had increased to a l e v e l c o m -parable to that of the other m o t h e r s . It was a l s o found, that although p r i m i p a r o u s women in the separa t ion group fe l t s ign i f ican t ly l e s s c o n -fident than did other mo the r s , they w e r e only s l igh t ly l e s s s k i l l f u l at ca re tak ing t a sks . M u l t i p l e r e g r e s s i o n a n a l y s i s indicated that s k i l l never predic ted se l f -conf idence , whereas sel f -confidence fo r i n s t r u -mental tasks such as d i a p e r i n g , feeding and bathing the baby, jus t p r i o r 51 to d i scharge did p red ic t s k i l l one week af ter d i scha rge , thus demon-s t r a t ing that a mother ' s degree of se l f -conf idence does have some bear ing on he r s k i l l in c a r i n g f o r he r infant. A c c o r d i n g to the authors this suggested that modif icat ion in attitudes p r i o r to d i scharge was assoc ia ted wi th subsequent behaviour at one week post d i scharge and a l so suggested the "prepotency" of a s o c i a l s k i l l in d i r ec t i ng o r o rgan iz ing one of the spec i f i c t a sks" . The authors fel t that the i m m e -diate postpar tum per iod may be a t ime when the mother i s p s y c h o l o g i c a l -l y and phys io log ica l ly ready to a s sume the mother ing r o l e . They s u g -gested that a woman who i s uncer ta in of her a b i l i t y to fu l f i l l this ro l e " m a y need the re inforcement and l ea rn ing exper ience" that she i s denied when separated f r o m her infant. F r o m the above data L e i d e r m a n , L e i f e r , ' Seasho re , Barnet t and Grobs te in (1973) and Le ide rman (1974) concluded that denial of contact between a mother and he r infant w i l l influence both materna l attitude and behaviour which i s consis tent wi th the an ima l l i t e ra tu re wh ich shows that delay in contact dur ing the neonatal pe r iod can lead to a d e t e r i o r a -tion of materna l care taking behaviour . They fur ther stated that the finding that ful l t e rm mothers s m i l e more and maintain more ventra l contact wi th the i r infants than do mothers of p remature babies may indicate an "attenuated re la t ionship" between mother and p r e -mature infant. T h i s i s consis tent w i th the data indica t ing that p r e -mature babies a r e more frequently battered by the i r parents than a r e 52 fu l l t e r m babies . L e i d e r m a n and assoc ia tes a l s o stated that the major influence of separat ion seems to be on the maternal s e l f -confidence, suggesting that the immedia te postpartum per iod i s a p a r t i c u l a r l y sens i t ive one fo r the development of appropr ia te mate rna l behaviour . E l even to fifteen months af ter the end of the separat ion p e r i o d , L e i d e r m a n and Seashore (1974) fo l lowed-up the mothers in the above s tud ies . B y the eleven months postdischarge p e r i o d , the only m a t e r -nal behaviours wh ich w e r e differentiated by tine exper imenta l condi t ion of contact o r separat ion we re s m i l i n g and touching. F u l l t e r m mothers s m i l e d at the i r infants more than did mothers of the p remature babies , and mothers in the contact group touched the i r babies more than did the separated group. The conclus ion f r o m this fo l low-up study was that c i r cums tances other than the i n i t i a l separa t ion de te rmined , to a l a rge extent, the behaviour of mothers at t ime of fo l l ow-up . L e i d e r m a n and Seashore pointed out that this emphasized the need f o r "methodological c l a r i t y and the use of more sophis t icated s t a t i s t i ca l techniques cover ing a wide range of fac to rs" before any def ini t ive conclus ions can be drawn regard ing the effect of any s ingle exper imenta l manipulat ion on l a t e r mate rna l behaviour . The authors maintained that the var ia t ions in mothers ' behaviour can be understood more s a t i s f ac to r i l y us ing a l ea rn ing theory model as opposed to an e thological m o d e l . T h i s l a t t e r 53 model would "desc r ibe bonding behaviour as spec ies spec i f i c and r e l a t i v e l y uninfluenced by e i ther p r i o r exper ience of the mothe r , he r expectations o r cu l t u r a l va lue s " . They pointed out that the opportuni ty ex is t s f o r rap id lea rn ing i n the n u r s e r y du r ing the neonatal pe r iod and suggested u t i l i z i n g the n u r s e r y s i tuat ion to encourage spec i f i c kinds of behaviour in parents that may enhance cogni t ive development of the infant on the one hand and f a m i l i a l r e la t ionsh ips on the o ther . In addi t ion to the immedia te exper ien t i a l inf luences in the neonatal n u r s e r y , the authors bel ieved that influences such as s o c i a l c l a s s , sex of infant , and b i r th o r d e r as w e l l as parenta l att i tudes and expectancies a r e among the many fac tors wh ich affect the m a t e r n a l / c h i l d r e l a t i o n s h i p . They concluded that an enlightened view of the impor tance of these e a r l y in terac t ions should lead to an attempt to e n r i c h the " s o c i a l l y s t e r i l e a tmosphere in today's hospi ta l s" thus a l lowing the development of parent / infant re la t ionships in the e a r l y postpar tum d a y s . T h e above r e sea rch i n v o l v i n g mother / in fan t bonding has ; i m p l i - ; ; ••-cat ions f o r the use of ana lges ic and anaesthetic, dur ing l abour and whether the mother i s conscious at the t ime of the b i r t h of he r baby. A l p e r , B r o w n , O s t e i m e r and Scan lon (1975) stated that although many effects of mate rna l ly admin i s t e red drugs on the neonate have been d e s -c r i b e d "the question of the i r s ign i f i cance i s b a s i c a l l y unanswered" . They stated that a comprehens ive long te rm study of the effect of 5 4 materna l medica t ion on mate rna l / in fan t bonding i s needed. A c c o r d i n g to M o s s (1967) this re la t ionship depends on the neonate's r e s p o n s i v e -ness to materna l "cues" , i t a l so depends on the baby 's a b i l i t y to t r i g g e r appropr ia te ca re - t ak ing behaviour f r o m i t s mothe r . A s B r a z e l t o n (1970) s ta ted,"Watching a drugged mother and a depressed infant who must make a 'go T w i th each other should s t imula te us to r e -evaluate the rout ine use of p remed ica t ion and anaesthesia i n pregnancy and d e l i v e r y in the l ight of i ts effect on e a r l y mother / infan t i n t e r a c t i o n " . Conc lus ions f r o m Review In l ight of the numerous methodological d i f f icu l t i es encountered i t i s not poss ib le to draw many major conc lus ions about pregnancy, c h i l d -b i r t h and the e a r l y postpar tum p e r i o d . One conc lus ion that may be d e r i v e d , however , i s that this r e s e a r c h ref lec ts to a great extent the two inherent methodological d i f f icu l t ies of doing appl ied r e s e a r c h . Subjects have to be accepted as a v a i l a b l e , and u sua l l y in ex i s t i ng g roups . Groups a r e p r e fo rmed , and bound to the i r subcul tu re and the t ime and place of the s tudy. A s a r e su l t , ne i ther r andomiza t ion n o r genera l iza t ion -:is:: po s s ib l e . A s C a m p b e l l and Ross (1970) point ou t : S o c i a l r e sea r ch frequently encounters the task of evaluating change produced in nonrandomly se lec ted groups by events wh ich a r e beyond the r e s e a r c h e r ' s con t ro l Because in these s i tua t ions the inves t iga tor has no con t ro l o v e r the ass ignment of ind iv idua ls o r groups to " e x p e r i m e n t a l " and " c o n t r o l " s i tua t ions , the l og i c of the c l a s s i c a l exper iment must be r e -examined in a s e a r c h f o r op t ima l in te rpre ta t ive p rocedures . (p. 110) 55 Given the d i f f icu l ty of randomizat ion in appl ied r e s e a r c h , there a r e inherent p rob lems in the s tudies rev iewed that r e s e a r c h e r s could con t ro l more succes s fu l l y , namely the use of nonstandardized measures , o r l o c a l l y devised measur ing ins t ruments ; there i s a l a ck of opera t iona l definit ions of t e rms used; a l ack of informat ion regard ing the r e l i a b i l i t y and va l id i ty of measures used . It must be mentioned that few measures ex i s t in the a r ea of attitudes towards pregnancy and c h i l d b i r t h . Ano the r di f f icul ty w i th the r e sea rch reviewed i s the frequent r e l i ance oh s ing le measures , e .g . , ra t ings by one ind iv idua l o r s ing le quest ionnaire data , a s c o r e on a depress ion o r anxiety s c a l e . W e b b , C a m p b e l l , S c h w a r t z and S e c h r e s t (1966) pointed out the necess i ty fo r mul t ip le opera t ion i sm and the use of combined measures that avo id the same weaknesses . Other p rob lems include the use of non- represen ta t ive s a m p l e s , e . g . , unwed mothe r s , in r e s e a r c h invo lv ing pregnancy and c h i l d b i r t h and then gene ra l i z ing to a l l w o m e n . It i s felt that some of these d i f f icu l t ies a r i s e because pregnancy and ch i ldb i r th have been c o n -ceptual ized as happening to "women" ra ther than black o r wh i t e , r i c h o r poor , o ld o r young, p r i m i p a r o u s o r mul t iparous w o m e n . M u c h has been wr i t t en on c r o s s c u l t u r a l differences in att i tudes and approaches to d e l i v e r y , and the postpar tum p e r i o d . It i s suggested that we need to acknowledge cu l t u r a l differences a l so and take into account ethnic o r i g i n , r ace , soc ioeconomic c l a s s and concomitants" as w e l l as pa r i t y 56 and age of the women i n v o l v e d . A n o t h e r s e r ious drawback reflected in the pregnancy l i t e r a t u r e i s the l ack of an i n t e r d i s c i p l i n a r y approach to r e sea rch in this a r e a . In fact , one might go so f a r as to say there i s a l ack of commi tmen t to long t e rm p rog rammed r e s e a r c h . A f ina l comment which is not unique but wh ich needs re i t e ra t ing is the emphasis in the l i t e r a tu re on the "abnorma l" aspects of p regnancy and c h i l d b i r t h . How can one make meaningful statements regard ing a b n o r m a l i t y , whether psycho log ica l o r med ica l without regard to the n o r m a l population? A s M e d w a r (1967) points out,"It i s not in fo rmat ive to study var ia t ions of behaviour unless we know beforehand the n o r m f r o m wh ich the var ian ts depar t" . The present study i s appl ied r e sea rch and thus fa l l s h e i r to the d i f f icu l t ies d i scussed above. The ma jo r d i f f icu l ty was the i nab i l i t y to a s s ign women randomly to the two ma jo r independent va r i ab les — hospi ta l matern i ty p rog ramme and type of d e l i v e r y . The re a r e , how-eve r , some aspects of the present study which improve upon prev ious w o r k . F o r example , the total group of women constitute a homogeneous sample of p r i m i p a r o u s w o m e n . It was fe l t necessa ry to con t ro l f o r soc ioeconomic status in view of the re la t ionship between low s o c i o -economic status and obs te t r ic outcome ( c f . , H i g g i n s , 1975; S i n g e r , Westphal and Ni swander , 1968). It was a l so felt necessa ry to con t ro l f o r pa r i ty as r e sea rch indicates that p r i m i p a r a e and mul t ipa rae do in 57 fact d i f fe r in the i r at t i tudes towards pregnancy and c h i l d b i r t h ( E r i c k s o n , 1965; Doty , 1967; T a n z e r , 1967; C l i f f o r d , 1962). A l l women who par t ic ipa ted in the study attended education-for-* c h i l d b i r t h c l a s s e s . A rev iew of the l i t e r a tu r e showed that the ef f icacy •of c h i l d b i r t h c l a s s e s i s equ ivoca l , but there i s evidence to sugges t , that women who par t ic ipa te in prepara t ion f o r ch i ldb i r th d i f fe r f r o m those who do not ( L a p i d u s , 1968, 1969; O l i v e r , 1972; H o o s e r , 1972). S tandard ized measures we re used w h e r e v e r pos s ib l e . W h e r e this was not pos s ib l e , e .g . ,a t t i tude to pregnancy,quest ionnaires w e r e used that had been u t i l i z e d i n a s tudy of a population of women l i v i n g in a major W e s t e r n Canadian c i t y ( Jordan 1973). Pos tpa r tum adjustment was opera t iona l ly defined as a compos i te of affect, behaviour and pos i t ive attitude towards baby(as opposed to a s ing le measure of depress ion) . Eva lua t ion Resea rch Because One present study i s e s sen t i a l ly evaluation r e s e a r c h , i t i s appropr ia te to examine the fundamental differences between this type of r e s e a r c h and exper imenta l r e s e a r c h . W e i s s (1972) pointed out that wh i l e evaluat ion appl ies the methods of s o c i a l s c i e n c e , there a r e some features that d is t inguish evaluat ion r e s e a r c h f r o m other types of s o c i a l r e s e a r c h . F o r example , e v a l u a -tion resea rch- i s used f o r dec i s ion mak ing , the questions cons ide red 58 by an evaluator a r e not h i s / h e r p e r se, r a the r they a r i s e f r o m quest ions that those concerned w i t h dec i s ion making may have and quest ions may a r i s e f r o m the p r o g r a m m e i t s e l f . T h e r e i s a judgmental qua l i ty to evaluat ion r e sea rch that, i s bas ic to evaluat ion and wh ich different ia tes i t f r o m other kinds of r e s e a r c h . Eva lua t ion takes p lace in an ac t ion set t ing where the most important aspect i s what i s going on in the p r o g r a m m e . In evaluat ion the r e s e a r c h requirements often run up against es tabl ished p r o g r a m m e procedure ; there a re often ro le c o n -f l i c t s between s e r v i c e and evaluat ion which typ ica l ly d o not happen in other types of r e s e a r c h . A c c o r d i n g to W e i s s , the purpose of evaluat ion r e s e a r c h i s to m e a -I s u r e the effects of a p r o g r a m m e against i ts ob jec t ives . The usual evaluation hypothesis i s that the p r o g r a m m e i s accompl i sh ing what i t se ts out to do . W e i s s states that exper imenta l design i s the op t ima l r e s e a r c h design to a sce r t a in how w e l l a p a r t i c u l a r p r o g r a m m e ach ieves i ts goa l s . It i s genera l ly agreed that randomiza t ion p rov ides a means f o r con t ro l l ing fo r the influence of extraneous var iab les that cannot be con t ro l l ed d i r e c t l y and i s the soundest bas i s f o r making inferences, c o n -ce rn ing the effects of intervention = (She rwood , M o r r i s , S h e r w o o d , 1975). Sherwood and assoc ia tes stated that an ind iv idua l doing evaluat ion r e s e a r c h i s not a lways ab le to implement a random des ign . S o c i a l in tervent ion does not take p lace i n a c losed l abora to ry w i th in an 59 academic se t t ing , where expe r imen te r s can manipulate both i n t e r v e n -tion and subjec ts . In the opinion of Sherwood and assoc ia t e s , the i n -take po l i c i e s of agencies p rov id ing the s e r v i c e , government regu la t ion ,and f i n a n c i a l , p o l i t i c a l and communi ty p r e s s u r e s a r e l i k e l y to affect dec i s ions concern ing the sample s e l e c t i o n . A s i n most app l ied resea rch , evaluators often w o r k wi th p re fo rmed groups such as school c l a s s r o o m s , hospi ta l wa rds e tc . The authors maintained that the only t ime one can e th i ca l ly randomly a s s ign is when the number of potential m e m b e r s fo r a new p r o g r a m m e i s l a r g e r than the number of openings. They stated that randomizat ion i s usua l ly not poss ib le i f there a re jus t enough appl icants at the beginning of a p r o g r a m m e and wi th p r e v i o u s l y i n i t i a -ted p rog rammes wi th es tabl ished intake p o l i c i e s . If randomiza t ion i s not f eas ib l e , what a r e the options? They cou ld be (a) no appl ied o r evaluat ion r e sea rch ; (b) c r i t i c a l use of q u a s i -exper imenta l des ign , as suggested by Campbe l l and S tan ley (1966); (c) a matching technique, as suggested by Sherwood and assoc ia te s (1975). T h i s th i rd a l te rna t ive w i l l be d i scussed b r i e f ly as i t appears to be a useful technique to use when randomiza t ion i s not p o s s i b l e . A fu l l desc r ip t ion of t he i r method appears in t he i r a r t i c l e . In One context of subject d i f fe rences , Sherwood and h is col leagues argued that randomiza t ion may be viewed as an a l t e rna t ive to match ing , s i nce one of the goals of randomizat ion i s 60 to produce comparab le o r matched g roups . They stated that w h i l e matching as an a l te rna t ive fo r randomizat ion i s viewed as i n f e r i o r i t appears that opposit ion is to the p a r t i c u l a r matching procedures ra ther than matching per s e . They argued that w h i l e the r eg re s s ion to the mean c r i t i que forbids the use of matching on the bas i s of p remeasu res of outcome var iab les i t does not n e c e s s a r i l y forbid matching on the bas i s of other v a r i a b l e s . The bas ic assumption under ly ing thei r mul t iva r i a t e matching p r o -cedure was that,to the extent i t is poss ib le to cons t ruc t subgroups of ind iv idua ls a l i k e on key v a r i a b l e s , " i t i s reasonable to bel ieve that the matching of e x p e r i m e n t a l wi th cont ro ls wi th in these subgroups should lead to the cons t ruc t ion of equivalent exper imenta l and con t ro l g roups" . The authors drew on the bas ic p r e m i s e s of s o c i a l s c i e n c e s and stated that "the assumpt ion i s that an i n d i v i d u a l , h is ideas , a t t i tudes, behaviours , etc. , i s in l a rge par t a product of these e x p e r i -ences and s o c i a l expectations w h i c h impinge upon h i m because he occupies these s o c i a l l y defined ' p o s i t i o n s . . . S o c i a l background var iab les (age, s ex , ethnic aff i l ia t ion) a r e therefore indices of the presumed probab i l i t i e s of s i m i l a r patterns of response in the future". Sherwood and h is assoc ia tes maintained that i t i s poss ib le to a s s e r t that a l a rge segment of the v a r i a b i l i t y in the ind iv idua l ' s responses to and functioning wi th in r ea l l i fe s i tuat ions can be explained by his s o c i a l 61 pos i t i on . " . . .the m o r e ' p o s i t i o n s ' and exper iences an ind iv idua l has in common wi th another i n d i v i d u a l , the g rea te r the p robab i l i ty that they w i l l be l i k e one another w i th respect to other v a r i a b l e s " . They maintained that i f the groups matched on var iab les of this type a r e in fact equivalent , they should manifes t s i m i l a r i t y in response to the pre~ measures of the outcome va r i ab les to be used in the assessment of the in tervent ion . Once the sample se lec t ion procedure as desc r ibed by the authors i s comple ted , the assumpt ion i s that i t has produced equivalent exper imenta l and cont ro l g roups . Tes t ing f o r the effects of i n t e r v e n -tion is then c a r r i e d out in the same way as i f the member s had been randomly a s s igned . The authors pointed out that wh i l e the appl ica t ion of p robab i l i ty based s t a t i s t i c s i s c o n t r o v e r s i a l , poss ib le jus t i f i ca t ion fo r the use of same i s as fo l l ows : p re - in te rven t ion equivalence requ i res that the samples be no more d i s s i m i l a r i n i t i a l l y than "good" random s a m p l e s , and a dec i s ion in this regard requi res the appl ica t ion of a s t a t i s t i c a l test on an "as i f they w e r e random bas i s " ; and i f the degree of pre in tervent ion equivalence is regarded as acceptable , the judgement of post -intervention non-equivalence - the s e a r c h for intervention effect - would s eem to a l low and requi re the same log i c and tests on the same "as if" b a s i s . In the f i r s t instance the question that is asked i s : Is i t reasonable to conclude that these two samples a r e f r o m the same popula -tion? In the second ins tance , the question asked i s : Is i t reasonable to conclude that they a r e no longer f r o m the same popula t ion? (p.222) 62 C H A P T E R II M E T H O D Set t ing Women par t ic ipa t ing in the study de l ive red their babies at one of three major hospi ta ls in Vancouver . One of these hospi ta ls offered a f a m i l y centred materni ty c a r e ' p r o g r a m m e dur ing the immedia te post -par tum pe r iod , whi le the other two hospi ta ls offered a more t radi t ional approach . The f ami ly -cen t r ed matern i ty p r o g r a m m e was ini t ia ted in November 1971 . Its major a i m s we re to provide new parents wi th an opportunity to p rac t i se parenting s k i l l s in a suppor t ive environment and to enhance the development of posi t ive re la t ionships among f a m i l y m e m b e r s . T h e r e a r e s eve ra l a reas of different iat ion between the f a m i l y centred materni ty p rog ramme and the more t radi t ional h o s p i t a l . F i r s t , the spec i f i c nur se /mothe r / in fan t ass ignment wi th i ts ind iv idua l teaching p rogramme which resu l t s in grea te r continuity of ca r e fo r the mother and infant. Second , the g rea te r f l e x i b i l i t y of the postpar tum uni t , the mother i s free to use the superv i sed nu r se ry as she w i s h e s ; she decides when, and fo r how long , the infant should be in the n u r s e r y . The nurse i n i t i a l l y bathes and ca re s fo r the infant in the mother ' s room act ing as a role model fo r the mother . A s the capab i l i t i e s of 63 the mother increase she undertakes grea ter r e spons ib i l i ty and es tabl ishes routines fo r he r se l f and her infant. T h i r d , fa thers a r e encouraged to par t ic ipate in the infant ca r e process and have comple te ly f l ex ib le v i s i t i ng hour s . Wi th the in i t ia t ion of the f a m i l y centred p r o -g ramme seve ra l changes were made in hospi ta l procedures wi th the a i m of s imula t ing the home envi ronment . M o r n i n g temperature taking was e l imina ted ; meal t imes we re changed fo r patient comfor t ; f o r a nominal cos t a husband may eat h i s meals wi th h is w i f e . The pos t -par tum f loor has a lounge where the mothers may v i s i t wi th the i r h u s -bands, watch T V , talk with. the other women and eat the i r m e a l s . Refreshments a r e ava i lab le at a l l t imes fo r both paren ts . In addi t ion there i s a patient l i b r a r y and outside deck f a c i l i t i e s . T h e r e a r e some s i m i l a r i t i e s among the three hospi ta ls in this s tudy. A l l a l lowed husbands to be present throughout l abour and d e l i v -e r y . One t radi t ional hospi ta l emphas ized "demand"' feeding and babies we re bathed in the mother ' s r o o m , i n i t i a l l y by a n u r s e r y nurse and subsequently by the mother under the nurse ' s guidance. T h i s hospi ta l a l so offered indiv idual ized teaching to the mother . The other t radi t ional hospi ta l had a sys t em of scheduled feedings and the "baby bath" was demonstrated to groups of mothers twice a week , at which t imes ins t ruc t ions we re given regarding infant c a r e , feeding e tc . If an individual mother wished to bathe he r own baby she 6k could do so in the n u r s e r y under the guidance of a n u r s e . M o t h e r s in both t rad i t iona l hospi ta l s w e r e a l lowed to keep the i r babies after feeding before re turn ing them to the n u r s e r y and cou ld d iape r them i f they d e s i r e d . Subjects The women in the study w e r e volunteers who w e r e attending educ-at ion f o r ch i ldb i r th c l a s s e s wi th the i r husbands between S e p t e m b e r 1974 and November 1975. These c l a s s e s a r e offered by h/vo p r iva te o r g a n i z a -tions i n Vancouver. A total of 133 p r i m i p a r o u s women volunteered to par t ic ipa te in the s tudy. The d i s t r ibu t ion of these women in each of the three major hospi ta ls in Vancouver and a c o m p a r i s o n wi th a recent s u r v e y involv ing p r i m i p a r o u s w o m e n , c a r r i e d out by the Me t ropo l i t an Heal th S e r v i c e s of G r e a t e r Vancouver (Khai ra t . & C o s t a n z o , 1974, note 2) , i s shown in Tab le I. A c h i square was computed us ing the percentage of those women enter ing the three major hospi ta l s a t both t ime p e r i o d s , this was not 2 s ign i f ican t , x (2) = .222 p_ ^ . . 9 0 , indicat ing that the present s ample i s a representa t ive one in t e rms of the hospi ta ls in wh ich the women gave b i r th to the i r baby. Of the total 133 who volunteered to par t ic ipa te in the s tudy, 15 women had the i r babies in hospi ta ls in c i t i e s other than Vancouver and s i x women did not meet the c r i t e r i o n of d e l i v e r y of a s ing le fu l l t e r m 65 infant (2 sets of twins , 3 premature babies , 1 s t i l l b i r t h ) . A fur ther s i x women did not complete the requ i red number of ques t ionnaires — a drop out rate of 4 . 5 % . The f inal sample cons is ted of 106 women who did meet the se lec t ion c r i t e r i a . (Appendix A ) Tab le I D i s t r i bu t ion of tine Women in the Three M a j o r Hospi ta l s in the C i t y of Vancouver Hosp i ta l ' P resen t study 1974 su rvey N=133 N=-1021 Percentage Percentage A 38 34 !B 30 25 C 21 18 other 11 19 no response 0 4 66 T h e women w e r e w h i t e , Caucasians^ whose age range was f r o m 19 to 37 , w i th a mean of 27 .02 y e a r s and a median of 27 .00 y e a r s . T h e mean number of y e a r s of education was 14.50 — median 1 4 . 8 8 . T h e y had no h i s t o r y of p s y c h i a t r i c d i s o r d e r . T h e women w e r e r a i s e d i n Nor th Amer ica . - : o r the B r i t i s h Commonwea l th . The women w e r e m a r r i e d and expecting t h e i r f i r s t baby. A l l par t ic ipants i n the s tudy l i v e d in the c i ty of Vancouver o r the l o w e r mainland a r e a , and d e l i v e r e d the i r babies in one of the three major hospi ta l s in the me t ropo l i t an a r e a . A . l l women had a s ing le fu l l t e r m infant, and exper ienced no m a j o r med ica l compl ica t ions du r ing pregnancy, d e l i v e r y o r the pos tpar tum per iod of e i ther themselves o r of the i r infants . Deta i led demograph ic data a r e in Appendix ; B . T w e l v e women in the t rad i t iona l hospi ta l set t ing who d e l i v e r e d vagina l ly had r o o m i n g - i n wi th the i r infants . G iven that this was p o s s i -ble only i f you had a p r iva te room f o r wh ich you paid ex t ra pe r day and given the pos s ib i l i t y of s i m i l a r i t i e s between r o o m i n g - i n and f a m i l y centred materni ty c a r e , the data f r o m these women w e r e exc luded f r o m the s t a t i s t i ca l a n a l y s e s . The total number of women used f o r the s t a t i s t i ca l analyses i s therefore 94. Of these women 21*had c a e s a r i a n s ec t i ons . The data f r o m women in both types of p r o g r a m m e w e r e c o m -bined for the analyses invo lv ing the compar i son of vaginal wi th c a e s a r -ian s ec t i on . In view of t h i s , the data f r o m the two women in the caesa r i an sec t ion group who had r o o m i n g - i n wi th in the t r ad i t iona l A l l but two w e r e emergency caesa r i an 67 p r o g r a m m e were not dropped f rom these ana lyse s . The total number of women f o r each group was as fo l lows : F a m i l y centred materni ty p r o g r a m m e vaginal d e l i v e r y 20 caesa r i an sec t ion 6 T r a d i t i o n a l p rog ramme vaginal d e l i v e r y 53 caesa r i an sect ion 13 R o o m i n g - i n caesa r i an sect ion 2 The propor t ion of caesa r i an sect ion (excluding tine two in r o o m i n g -2 in) by type of p rog ramme was not s ign i f ican t , _x^(1) = .13 p_i*» . 5 0 . Nei ther was the propor t ion s igni f icant inc luding the 2 women who had 2 r o o m i n g - i n , x_ (1) = .0112 £ > 50 . M e a s u r e s The schedule f o r complet ion of the var ious quest ionnaires and check l i s t s i s set for th in Tab le II. At t i tude towards pregnancy, l abour , d e l i v e r y and Pie baby quest ionnaires The var ious quest ionnaires deal ing wi th attitudes and feel ings to-wards the pregnancy and ch i ldb i r th exper ience and attitude towards the baby a r e based on those used by Jo rdan in he r study (1973). The f o r -mat of each quest ionnaire was modified s l i g h t l y to conform to a L i k e r t 68 Tab le II S c h e d u l e f o r C o m p l e t i o n o f D a t a T i m e P e r i o d a n d M e a s u r e s I n v o l v e d T i m e P e r i o d M e a s u r e s I P r e n a t a l N i n t h M o n t h D e m o g r a p h i c d a t a q u e s t i o n n a i r e F e e l i n g s a n d a t t i t u d e s t o w a r d s p r e g n a n c y B e c k D e p r e s s i o n I n d e x D e p r e s s i o n a d j e c t i v e c h e c k l i s t ( D A C L ) P l e a s a n t E v e n t s S c h e d u l e II In H o s p i t a l L a b o u r a n d D e l i v e r y Q u e s t i o n n a i r e F e e l i n g s t o w a r d s t h e n e w b a b y q u e s t i o n n a i r e A r e a s o f C o n c e r n D A C L - e a c h G r e e n b e r g ' s M a t e r n i t y Q u e s t i o n n a i r e III A f t e r O n e W e e k a t H o m e F e e l i n g s t o w a r d s b a b y q u e s t i o n n a i r e A r e a s o f C o n c e r n G r e e n b e r g ' s f o l l o w - u p q u e s t i o n n a i r e D A C L I V A f t e r F i v e W e e k s a t H o m e F e e l i n g s t o w a r d s b a b y q u e s t i o n n a i r e A r e a s o f C o n c e r n B e c k D e p r e s s i o n I n d e x P l e a s a n t E v e n t s S c h e d u l e V S i x M o n t h s a f t e r D e l i v e r y A c h e c k w a s m a d e w i t h t h e P o s t p a r t u m C o u n s e l l i n g C e n t r e 69 type quest ionnaire in o r d e r to help con t ro l f o r response se t and acquiescence tendencies . (A h igher s c o r e on the ques t ionnai re ind ica tes a m o r e pos i t ive a t t i tude . ) A l p h a r e l i a b i l i t y coeff ic ients ( W i n e r , 1962) w e r e computed as shown in Tab le III. The r e l i a b i l i t y coeff ic ients i n -dicate that each ques t ionnai re has in te rna l cons i s tency and homogenei ty . T a b l e III A l p h a R e l i a b i l i t y Coeff ic ients f o r At t i tude Ques t ionnai res Name N N A l p h a of quest ions of subjects At t i tude to pregnancy 40 133 .91 At t i tude to l abour and d e l i v e r y 31 121* .93 At t i tude towards Baby T i m e l 28 . 121 .80 At t i tude towards Baby T i m e 2 38 121 .94 At t i tude towards Baby T i m e 3 33 121 .90 N = 121 excludes the s i x women who did not complete the s tudy and the s i x women who d id not meet the c r i t e r i a f o r s e l e c t i o n . 70 A r e a s of Conce rn The women a l so completed a check l i s t of p rob lem a r e a s f o r both themselves and the i r infants at three points in t ime; in h o s p i t a l , a f te r one week at home and af ter f ive weeks at home (Jordan; T973).The p u r -pose of these c h e c k l i s t s was to l e a r n of the p rob lems the w o m e n exper ienced at these three t ime po in t s . Tine total number of p r o b l e m s was the f igure used i n the a n a l y s i s . Hospi ta l Expe r i ence and One Week F o l l o w - u p Greenberg (1973) and his a ssoc ia tes devised a ques t ionnai re to l e a r n how the new mother pe rce ived h e r exper ience w h i l e in h o s p i t a l . They used it in a s i m i l a r r e s e a r c h study and ce r t a in i t ems w e r e found to differentiate groups of women randomly ass igned to r o o m i n g - i n o r t radi t ional w a r d s . Al though the complete quest ionnaires w e r e a d m i n -i s t e r e d , some questions w e r e not appropr ia te f o r the proposed s t a t i s t i c a l ana lyses , although they w i l l be used f o r desc r ip t i ve pu rposes . T h e r e f o r e , only re levant i tems sca leab le in the L i k e r t fo rmat re la t ing to the h o s p i -tal exper ience we re used in the s t a t i s t i c a l ana ly se s . S i m i l a r l y s c a l e -able i tems we re se lec ted f r o m the fo l low-up ques t ionna i re . T h e s e quest ionnaires a r e in Appendices C and D . The h igher s c o r e r e f l ec t s the more pos i t ive statement. ' 71 Depres s ive Af fec t T w o measures of depress ive affect w e r e chosen that a r e w i d e l y used i n the c l i n i c a l se t t ing . In addi t ion an es t imate of behav ioura l a c t i v i t y was obtained f r o m the w o m e n , (a) The Beck D e p r e s s i o n Index (Beck , 1961; 1967; 1970). T h i s i s a c l i n i c a l l y de r ived inven tory c o n -cerned wi th the c h a r a c t e r i s t i c s , att i tudes and symptoms of depressed ind iv idua l s . It cons i s t s of 21 ca tegor ies deal ing wi th a f fec t ive , behav ioura l , cogni t ive and somat i c s y m p t o m s . Each ca tegory contains graded se l f -eva lua t ive statements ranging f r o m z e r o to th ree . T h e h igher the s c o r e obtained, the more depressed the i n d i v i d u a l . A l t h o u g h the Beck confounds state and t ra i t dep re s s ion , a cco rd ing to B e c k e r (1974) i t i s sens i t ive to change and apparent ly d i s c r i m i n a t e s d e p r e s s i o n f r o m anx ie ty . A n a l y s i s has shown good r e l i a b i l i t y using the c r i t e r i a of in te rna l cons is tency and s t ab i l i t y and i t has been shown to be v a l i d i n fac tor ana ly t i c s tud ies . (Cropley, & W e c k o w i c z , 1966; Pichot ,& L e m p e r i e r e , 1964). Mean sca le s c o r e s f o r the category of no d e p r e s -s i o n , m i l d , moderate and severe depress ion a r e 1 0 . 9 , 1 8 . 7 , 2 5 . 4 and 3 0 . 0 r e spec t ive ly , (b) The Depres s ion Ad jec t i ve C h e c k l i s t s ( L u b i n , 1965). T h i s i s a measure of state depress ion acco rd ing to L u b i n and cons i s t s of 32 ad jec t ives , 22 indicat ing depres s ive mood and ten i n -dica t ing non-depress ive mood . T h i s ins t rument has the advantage of being b r i e f and has a l ternate f o r m s f o r the purpose of repeated m e a s u r e s . 72 The sca l e s have good s p l i t half r e l i a b i l i t y and i n t e r co r r e l a t e h i g h l y , and " d i s c r i m i n a t e between n o r m a l s , nondepress ive p s y c h i a t r i c patients and diagnosed depress i v e s " . The h igher the s c o r e obtained on the D A C L the more depressed the i n d i v i d u a l . A raw s c o r e of 15 would indicate that a person i s m i l d l y depressed . A s would be expected, the Beck Depress ion Index and Depres s ion Ad jec t ive C h e c k l i s t a r e s ign i f ican t ly but not highly co r r e l a t ed wi th each o ther . In the present s tudy, the co r r e l a t i ons between these two m e a -su re s in the ninth month of pregnancy and s ix weeks postpar tum w e r e £ = . 4 4 8 £ < . 0 1 and r = .478 p_<i.01 r e spec t i ve ly . Behav iour T h e Pleasant Events Schedule devised by M a c P h i l l a m y and Lewinsohn (1971) was used . The authors stated that the schedule was designed to e l i c i t events that people have enjoyed o v e r the past month . The ins t rument cons i s t s of 320 events and ac t i v i t i e s and has been used by Lewinsohn and his col leagues in the i r s tudies of the a s soc ia t ion between depress ive mood and ac t iv i t i e s (Lewinsohn , L i b e t , 1972; Lewinsohn , G r a f , -1973). In the present study the women comple ted only P a r t A of the Schedule responding to the question "How often have these events o c c u r r e d ? " . The total a c t i v i t y s c o r e i s indicated by the. number of i tems checked . 73 Hospi ta l Data Sheets for Mothe r and Infant These w e r e factual informat ion sheets ( Jo rdan , 1973) completed by the mother and included such i tems as length of labour , type of anaes -thet ic , type of feeding, and sex of infant. S i x months af ter d e l i v e r y a check was made with the Pos tpar tum Counse l l ing Cent re to ve r i fy whether any women in the study had sought a s s i s t ance f r o m the cen t r e . T o a sce r t a in whether the groups of women in each hospi ta l w e r e s i m i l a r regard ing the measures completed wi th in the prenatal p e r i o d , they w e r e compared on (a) the demographic data and (b) the i r responses to the quest ionnaires involving attitude to pregnancy, depress ive affect and total a c t i v i t y . One-way mul t iva r i a t e ana lys i s of var iance of the set of demographic va r i ab les (age, education of wi fe , income of w i f e , education of husband, income of husband) revealed no s ignif icant difference among those women enter ing the three major hospi ta ls ( .Likelihood rat io c r i t e r i o n , lamba = .966, F (10,196) = .34 £ ^ . 5 0 ) . The means and standard deviat ions of the demographic data fo r the total sample a r e shown in Appendix E . T h e r e was no s ignif icant difference among the three groups of women in the set of var iab les re la t ing to the prenatal p e r i o d ' (att i tude towards pregnancy, depress ive affect o r the amount of behaviour engaged i n ' ) (A = .963 , F ( 8 , 1 9 6 ) = .88 £ ^ .50). The means and standard deviat ions of. these data a r e in 74 Appendix F . It was fe l t , therefore , that the women in the three hosp i ta l s w e r e comparab le in t e r m s of both demographic data and data co l l ec ted dur ing the ninth month of pregnancy . The data f r o m those women who de l i ve red the i r babies in hospi ta ls offering the m o r e t r a d i -t ional mate rn i ty exper ience we re combined f o r subsequent s t a t i s t i c a l a n a l y s e s . P r o c e d u r e The educat ion-foi—childbir th c l a s s e s w e r e v is i ted at the penul t imate c l a s s . The groups w e r e told that I was s tudying the n o r m a l w o m a n , expecting he r f i r s t baby, and h e r feel ings and attitudes toward p r e g -nancy, c h i l d b i r t h , the hospi ta l and e a r l y postpar tum expe r i ence . The group was a l so in fo rmed of the c r i t e r i a f o r se lec t ion and w e r e told that they would r ece ive a copy of the resu l t s of the study when c o m p l e t e d . Those women who volunteered s igned a consent f o r m and w e r e g iven the f i r s t set of ques t ionnai res in a s tamped addressed envelope, to be c o m -pleted and re tu rned . Upon receipt of the f i r s t set , the second and s u b -sequent sets of ques t ionnai res w e r e m a i l e d to the women at the a p p r o -p p n a t e t i m e . 2 At the t ime of the nationwide postal s t r i k e in Canada , 21st of Oc tobe r to-ear ly December 1975, the ques t ionnai res w e r e p icked up and de l i ve red by hand. 75 A l e t t e r was a l so sent to the phys ic ian whose patients we re involved i n the s tudy, de sc r ib ing the study and inv i t ing questions a n d / o r comments . (Appendix G) S t a t i s t i c a l A n a l y s e s A l l analyses w e r e c a r r i e d out i n the computing centre at the U n i v e r s i t y of B r i t i s h C o l u m b i a , Vancouver , B . C . The independent va r i ab les were (a) type of hospital p r o g r a m m e and (b) type of d e l i v e r y exper ienced (whether vaginal o r caesa r i an ) . S e v e r a l types of analyses were c a r r i e d out. 1 . Dif ferences between the groups on the set of dependent va r i ab les at each t ime per iod were analyzed us ing Hote l l ings T^ technique f o r two s a m p l e s . F o r each t ime pe r iod the hypothesis was that the groups came f r o m a population wi th a common mean vec to r . If the hypothesis w e r e rejected mul t ip le compar i sons were made us ing the "simultaneous c o n -fidence i n t e r v a l " to de termine wh ich indiv idual dependent va r i ab le means w e r e s igni f icant ( M o r r i s o n , 1967). The conserva t ive feature of this method of mul t ip le compar i sons used may w e l l resu l t in an increase in Type 11 e r r o r . W h i l e this more s t r ingent approach prevents the p o s s i b i l i t y of over in terpre ta t ion of one's data i t a l so prevents the generat ion of poss ible hypotheses. 76 2. To ascertain the effectiveness of the family centred maternity care programme several specific comparisons between this programme and the traditional programme were carried out using univariate analysis of variance. These specific dependent variables were as follows: a) Amount of self confidence regarding child care in hospital and after having been home for one week. b) Responses to questions involving the amount of experience gained in hospital in caring for the new baby. c) Responses to questions regarding the amount of help received in hospital to prepare one for the role of motherhood. d) Attitude towards the baby while in hospital, after one week at home and after five weeks at home. 3 . Women who had vaginal delivery were compared with those who had caesarian section on their feelings of self confidence regarding child care and their attitude towards the baby while in hospital, after one week at home and after five weeks at home, using univariate analyses of variance. 4. A repeated measures analysis of variance was conducted on the levels of depressive affect over time for both the independent variables, i .e . , type of programme and type of delivery. 77 5. In o r d e r to a sce r t a in the re la t ionship between the measures co l l ec t ed , tine pooled wi th in groups c o r r e l a t i o n mat r ices fo r the sample (N=94) f o r each point in t ime we re examined . The pooled wi th in groups ma t r ix was chosen in view of the s igni f icant differences between the var ious groups on ce r t a in m e a s u r e s . T h i s ma t r ix of c o r r e l a t i o n s is not inflated by these d i f fe rences . Al though c o r r e l a t i o n coefficients among a la rge number of v a r i -ables a r e suspect in view of the fact that spur ious co r re l a t ions o c c u r by chance, p rovid ing one evaluates, them caut ious ly such re la t ionships a r e valuable f r o m a heu r i s t i c point of v i e w . The pooled wi th in groups c o r -re la t ion ma t r ix fo r a l l va r iab les was examined with this in m i n d . The spec i f i c va r iab les that w e r e looked at in t e rms of their re la t ionship to others we re as fo l lows : method of feeding (whether breas t o r bottle feeding^ number of days spent in hospi ta l ; number of days spent " r o o m i n g - i n " wi th the baby. 6. A p r i n c i p a l components fac tor ana lys i s with a v a r i m a x rotat ion was c a r r i e d out using the major variables in the study. ( S e v e r a l v a r i -ables w e r e omit ted because of the s m a l l n e s s of the s a m p l e . ) 78 C H A P T E R III R E S U L T S The desc r ip t ive s ta t i s t i cs fo r the total sample regard ing length of l abour , sex of infant, type of anasthesia, etc. , a r e in Appendix H . C o m p a r i s o n Between Hospi ta l P r o g r a m m e s  T i m e 1 ~ Prena ta l data completed in the ninth month of pregnancy To a sce r t a in whether the groups who par t ic ipated in the two h o s p i -tal p rog rammes we re comparable wi th respect to the i r demographic c h a r a c t e r i s t i c s and responses to the quest ionnaires and c h e c k l i s t s a d _ 2 m in i s t e r ed at the ninth month of pregnancy, Hote l l ings T s t a t i s t i c a l technique was conducted. The re was no difference between the means f o r e i ther set of v a r i a b l e s , F (5, 66) = . 28 p_> . 50; F ( 4 , 6 7 ) = .34 p > . 5 0 . These data a r e shown in Appendix I and Appendix J r e s p e c t i v e l y . The means f o r the Beck Depress ion Index and D A C L indicate that the two groups of women a r e wi th in the n o r m a l l i m i t s in te rms of the i r d e p r e s -s ive affect. The range of s co re s on the D A C L and Beck Depres s ion Index for both groups , however , indicate that there a r e some Women who might be ca l l ed m i l d l y depressed . The pooled wi th in groups co r r e l a t i on ma t r i ce s of these data for the total sample a r e in Tables I V a n d V respec t ive ly . 79 Table I V Pooled wi th in groups c o r r e l a t i o n ma t r i x for the demographic data. N = 93 * A g e of Y e a r s of Income Y e a r s of Income Wife Educat ion of Wi fe Educat ion of - ; - Wife ..—' Husband Husband A g e of 1.000 .432*** .152 .112 .341*** Wife Y e a r s of .209** .364*** .125 Education -Wife Income of .069 .070 Wife Y e a rs of .117 Educat ion -Husband Income of Husband *** p « £ . 0 1 ** p < . 0 5 * one set of quest ionnaires fo r this t ime per iod was los t dur ing the m a i l s t r i k e . 80 Tab le V Pooled wi th in groups co r r e l a t i on ma t r ix fo r the measures co l lec ted in the ninth month of pregnancy. N - 93* At t i tude to Beck Depress ion D A C L Pleasant Pregnancy Index Events Schedule At t i tude to Pregnancy 1 . GOO - .022 -.325*** - .031 Beck Depres s ion Index .448*** .081 D A C L - .103 Pleasant Events Schedule p < . 0 1 * one set of ques t ionnaires for this t ime per iod was los t dur ing the m a i l s t r i k e 81 T i m e II - Hospi ta l data The responses of the women on the var ious measures at this point in t ime were analyzed in two p a r t s . The f i r s t ana lys i s of the hosp i ta l data involved a compar i son of the two groups on the fol lowing set of va r i ab les ; attitude to labour and d e l i v e r y , attitude to the baby, a reas of concern in hospi ta l and amount of depress ive affect exper ienced each day. The means and standard deviat ions fo r these data a r e in Tab le V I . Hote l l ings T 2 revealed a s ignif icant difference between the two groups of women as a function of the hospi tal p r o g r a m m e exper ienced, F ( 7 , 6 5 ) = 3 . 002. S imul taneous mul t ip le compar i sons revealed no differences in the means of the individual v a r i a b l e s . Subsequent un ivar ia te ana lys i s of va r iance indicated that the va r i ab les contr ibut ing most to the o v e r a l l differences we re attitude to baby, F ( 1 , 7 1 ) = 4.179 p_<£ .045 , and the n u m -b e r of p r o b l e m s , F (1,17) = 7 . 9 1 7 p_<<:.006. Those women who had par t ic ipated in the f a m i l y centred matern i ty p rogramme appeared to have a more pos i t ive attitude to the i r baby in hospital and a l so reported more problems than those women in the t radi t ional p r o g r a m m e . It should be noted that the women who par t ic ipa ted in the f a m i l y centred materni ty p rog ramme in Jo rdan ' s study reported more p rob lems than d id those in the t radi t ional p r o g r a m m e . It may we l l be that the spec i f i c nurse ass ignment and educational phi losophy of this type of p r o g r a m m e provides an atmosphere conducive to the ve rba l i z ing of p r o b l e m s . 82 Tab le V I Means and standard deviat ion of the hospi tal data F a m i l y Cent red Mate rn i ty P r o -g r a m m e N=20 Mean S D T r a d i t i o n a l P r o g r a m m e N = 53 Mean S D At t i tude to l abour and d e l i v e r y At t i tude to baby A r e a s of concern 146.85 131.85 11 .60 12.83 13.92 5 .46 147.06 125.02 8 .23 13.79 12.28 4 .20 D A C L T i m e One 46 .20 4 . 8 5 45 . 19 5 .04 D A C L T i m e Two 46 .80 6 .25 46.77 7 .95 D A C L T i m e T h r e e 50.65 8.84 49 .85 10.10 D A C L T i m e F o u r 50.90 9 .96 48 .68 8.63 83 The pooled wi th in groups c o r r e l a t i o n ma t r i x for the total s ample f o r these data i s in Table VI I . The second major ana lys i s of the hospi ta l data was c a r r i e d out on the responses to Greenberg ' s matern i ty ques t ionnai re . Hote l l ings T 2 shows no difference between the means of the two groups on this set of v a r i a b l e s , F (15,57) = .964 p_>.50. These data a r e in Appendix K . W h i l e Greenberg and associate: had reported s ign i f ican t diffei— ences between women in the i r study this may have been due to the cu l tu ra l differences in studying a Swed i sh sample o r to the s t a t i s t i c a l techniques employed to analyze the responses to the i r ques t ionnai res which may have resul ted in Type I e r r o r s . The present study used mul t iva r i a t e techniques to con t ro l f o r this and the f indings do not s u p -por t those of Greenberg and h is associa te . . The pooled wi th in c o r r e l a t i o n m a t r i x fo r the responses of the total sample fo r the above data i s in Tab le VIII . T i m e 111 - A f t e r one week at home When the women had'been home fo r one week they completed the attitude to baby ques t ion, a reas of conce rn , D A C L and Greenbe rg ' s fo l low-up ques t ionna i re . Hote l l ings T 2 revealed a s ign i f ican t di f ference between the two groups on this set of v a r i a b l e s , F (10,62) = 3 . 6 2 , £.<£..0008. The means and s tandard deviat ions fo r these measures a r e shown in Table I X . S imul taneous mul t ip le compar i sons ,howeve r , 84 Tab le VII Pooled wi th in groups co r r e l a t i on ma t r i x fo r those measures completed wh i l e in hosp i t a l . N = 94 At t i tude At t i tude A r e a s D A C L D A C L D A C L D A C L to labour to o f "> and Baby Conce rn T i m e 1 T i m e 2 T i m e 3 T i m e 4 d e l i v e r y At t i tude 1.000 .431*** .177 to labour and D e l i v e r y At t i tude - . 1 1 3 to Baby A r e a s of Concern D A C L T i m e 1 - .161 - . 1 0 5 - . 0 7 2 - 2 7 7 * * * - . 1 3 7 - . 1 7 2 .015 - .247*** .095 .182 .167 .012 .710*** .300*** .378*** D A C L .405*** .359*** T i m e 2 D A C L .313*** T i m e 3 D A C L T i m e 4 *** p «£..01 p «C.02 Table VIII Pooled within groups correlation matrix of the responses to Greenberg's Maternity Questionnaire N=94 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) Self confidence 1.000 ,a40* .197 .143 ..220* .377*** .239* .158 ; .631***.083 .046 .-.172 -.084 .019 .075 (1) re: child care . Perception of amount ' .131 .155 .127 .180 .173 -.046 .320*** .090 .003 .022 .013 -.039 -.008 of help needed at home (3) Happiness in hospital - .084 .055 .137 .130 -.004 .150 .081 -.083 .052 .090 .144 .240* (4) Present energy level • ..143 .180 .222* -.037 .134 .020 .073 .159 -.038 .096 .053 (5) Absence of anxiety .194 .085 -.065 .109 .027 .107 -.040 -.035 -.014 -.153 regarding responsi-bility for baby (6) Confidence regarding .328*** .488*** .522***.272*** . 137 . 095 . 032 . 202 . 067 role of motherhood (7) Present feelings of .275*** .294***.323*** . 130 .117 -.150 .162 -.156 gladness vs. depression (8) Maternal feeling to baby .231* .362*** .254** -.001 .004 . 231* -.018 (9) Competence re childcare .277*** .172 -.078 (10)Immediacy of understanding .118 -.118 .000 .006 baby's needs 008 .125 .018 - . 128 (11)Lack of restriction in ' .086 - 093 usual activities .048 -.151 (12)Energy level after -.022 .160 .080 delivery (13y\mount of help from -.085 356** nursing personnel (14) Fee!ings of gladness/vs 210* depression after delivery (15) Amount of help received from hospital personnel ***p<:.01 * * p 4 .02 * p < . 0 5 CO \J1 86 Table EK Means and standard deviat ions of the Measu re s completed after one week at home F a m i l y Centred T r a d i t i o n a l Ma te rn i t y P r o - P r o g r a m m e a r a m m e N = 20 N = 53 Mean At t i tude to Baby 163.25 A r e a s of Concern 11 .50 Se l f -Conf idence 3 .50 regarding ch i l d ca r e Ease of adjustment 3 .50 f r o m Hosp i ta l Expe r i ence received 3 .50 in Hospi ta l P repa ra t ion for 3 .70 mother ing ro le Immediacy of 3 .95 understanding infant Cer ta in ty regarding 3 .40 ch i l d c a r e Amoun t of 3 .30 help needed D A C L 48 .55 S D Mean S D 18.67 160.45 18.28 8.59 8.58 6.78 .89 3 .47 . 7 7 . 1.15 3 .06 1.00 .83 2 .60 .97 .98 2 .96 1.07 .94 3 .62 1.15 .99 2 .92 .92 .73 3 .17 .73 8 .05 48 .55 7 .24 87 indicated no differences between the indiv idual means . T h e subsequent un ivar ia te a n a l y s i s of var iance indicated that two va r i ab l e s contr ibut ing most to the o v e r a l l differences were the amount of help rece ived f r o m the hospi ta l in p repar ing fo r the mother ing r o l e , F (1 ,71) = 7 .18 £.£•009, and the amount of exper ience gained w h i l e in hosp i ta l in taking ca re of the baby F (1 ,71 )= 1 3.43 p_ 0004 . The pooled wi th in c o r r e l a t i o n ma t r ix fo r the above data fo r the total sample i s in Tab le X . T i m e I V - A f t e r f ive weeks at home A f t e r the women had been home for f ive weeks they comple ted the fol lowing measures : attitude towards baby; a reas of c o n c e r n , Beck Depress ion Index; the D A C L ; P leasant Events Schedu le . Hote l l ings 2 T revealed no differences between the two groups on this set of v a r i a b l e s , F (5,67) = .654 p_> . 50 . The means and s tandard deviat ions f o r these measures a r e in Appendix L . The pooled wi th in co r r e l a t i on ma t r i x of these data fo r the total sample i s in Table X I . T i m e V - S i x months after d e l i v e r y A check wi th the Pos tpar tum Counse l l ing Centre of G r e a t e r Vancouver , indicated that,based on thei r r e c o r d s , no women in the p r e -sent study had sought the ass i s tance of the centre wi th in s i x months af ter the b i r th of the i r baby. Table X Pooled wi th groups co r r e l a t i on mat r ix of the measures completed after one week at home (1) At t i tude to Baby (2) A r e a s of Conce rn (3) S e l f confidence re c h i l d c a r e (4) Ease of adjustment f r o m hospi ta l (5) Expe r i ence rece ived in hospi ta l r e : c a r e of baby (6) P repa ra t ion for mothering ro le (7) Length of t ime to understand infant (1) (2) (3) (4) (5) (5) (7) (8) (9) (10) 1.000 -.253** .534*** .490*** .274***. .257** ..364** .452*** .303*** .057 - .072 -.337*** - .062 - .096 - .013 - . 0 9 0 - .141 .286* .455*** .405*** .416*** .270*** .558*** .354*** .077 .330*** .289*** ,.410*** .453*** .345*** - . 0 5 9 .794*** .336*** .362*** .139 .075 ,287*** ,318*** .175 ' .007 188 .106 .067 (8) Cer ta in ty re ch i l dca re (9) Amoun t of help needed (10) D A C L * * * p < .01 ** p ^ . 0 2 .424*** .021 .089 89 Table X I Pooled wi th in groups c o r r e l a t i o n ma t r i x for the measures completed af ter f i v e weeks at home. N = 94 At t i tude A r e a s of Beck D A C L Pleasant to Baby Concern Depress ion Events Index Schedule At t i tude to Baby 1 .000 393 - . 1 6 8 .243** .218* A r e a s of Concern 198 148 - .061 Beck Depress ion Index ,478*** .026 D A C L - . 1 9 8 Pleasant Events Schedule *** p - C . 0 2 p<*1.05 90 A c r o s s T i m e - Depres s ive Affec t The s u m m a r y of the repeated measures ana lys i s of va r i ance f o r depres s ive affect i s presented in Tab l e X I I . A s can be seen , w h i l e there is not a s igni f icant difference between the two groups in t e r m s of depress ive affect , there i s a s igni f icant difference in the l e v e l of d e p r e s -s i v e affect reported ove r trie t ime per iod invo lved . These di f ferences o v e r t ime a r e i l l u s t r a t ed in F i g u r e 2 . Note that the l e v e l of dep re s s ive affect peaks at day 3 fo r those women in the t radi t ional hosp i ta l and day 4 f o r those in the f a m i l y centred mate rn i ty p r o g r a m m e . B y the s i x th week pos tpar tum, the leve l of depress ive affect has re turned to the prenata l l eve l f o r both groups . The peaking at the th i rd and fourth day p a r a l l e l s tine repor t s i n the c l i n i c a l l i t e r a tu re of 3 day " b l u e s " , four day "blues" o r " m i l k blues" (P i t t , 1973; B a k e r , 1967). Eva lua t ion of the effectiveness of the f a m i l y cent red ma te rn i ty p r o g r a m m e  compared wi th the t radi t ional p r o g r a m m e U s i n g ana lys i s of var iance three spec i f i c va r i ab les w e r e ana lyzed i n o r d e r to a s se s s the effectiveness of the f a m i l y centred ma te rn i ty p r o g r a m m e . a . S e l f confidence T h e r e was no difference in the l eve l of s e l f confidence of mothers bet-ween the two hospi ta l p rog rammes e i the r w h i l e in hospi ta l o r a f te r one week at home wi th the baby, F(1 ,71)= .733 p_> .30 and F(1 ,71)= .018 p_> .80 . 91 Table X I I Repeated measures ana lys i s of var iance — leve l of depress ive affect over t ime S o u r c e dfs J 2 _ Mean Hospi ta l E r r o r T i m e T i m e / h o s p i t a l E r r o r 1 1 71 6 6 426 6254.24 -CL1 .CO 3 . 8 0 < L 1 . 0 0 .001 .536 ,001 ,987 TIME PERIOD Figure 2. Means of DACL scores at seven points in t ime: Compar ison between hospital programs. 93 b. Exper i ence gained in hospi ta l in how to ca re for the baby The responses of the women in the two p r o g r a m m e s to Greenbe rg ' s F o l l o w - u p quest ionnaire involv ing the amount of exper ience gained i n hospital in ca r ing for the new baby were ana lyzed . A highly s ignif icant difference was found between the hospi ta l p rog rammes in the amount of exper ience r e c e i v e d , in favour of those women in the f a m i l y centred matern i ty p r o g r a m m e , F_ (1,71) = 13.42 p <. .0004. c . Amount of help rece ived f rom the hospi tal to prepare the mother for the mother ing ro le  A highly s ignif icant difference was found between the two groups of women in the amount of help they rece ived f rom the hospi ta l to prepare them for the ro le of motherhood. Those women in the f ami ly centred matern i ty p rogramme perce ived that they obtained more help for th i s ro l e than did those in the t r ad i t iona l p r o g r a m m e , F (1,71) = 7 .18 p <C .009 . d . Att i tude towards baby whi le in the hosp i t a l , after one week at home and after five weeks at home  A s the attitude towards baby quest ionnaires were not designed for a repeated measures ana lys i s of v a r i a n c e , one-way ana lys i s of va r i ance was used to analyze the data. The resu l t s indicate a s igni f icant d i f -ference in attitude towards baby between the two groups . The women in the f ami ly centred materni ty p rog ramme had a more pos i t ive attitude towards the i r baby whi le they were in hosp i t a l , F_ (1,71) = 4 .179 p < . 045 . Af t e r the women had been home for one week and in terac t ing wi th and 94 c a r i n g f o r the i r infante there w e r e no differences in the i r atti tude toward the infant, nor we re there any differences after f ive weeks at home, F" (1,71) = .334 £ > , 5 0 and F (1,71) = 2 .19 £ > - . 1 4 3 r e s p e c t i v e l y . C o m p a r i s o n Between vaginal D e l i v e r i e s and Caesa r i an Sec t ions F o r the fo l lowing analyses the data we re pooled a c r o s s hospi ta l and the independent va r i ab le was type of d e l i v e r y experienced — vaginal o r caesa r i an s e c t i o n . The data we re analyzed in exactly the same manner as we re the data fo r hospi ta l p r o g r a m m e s . T i me 1 - prenatal data (completed in the ninth month of pregnancy) To a sce r t a in whether the two groups we re comparable wi th respect to both the i r demographic c h a r a c t e r i s t i c s and responses to the ques t ion-na i res and check l i s t s in the ninth month of pregnancy, the data w e r e 2 analyzed using Hote l l ings T . T h e r e was no difference between the means f o r e i ther set of data, F" (5,87) = 0.52 p_> .50 and F (4,88) = 1 .44 p_>.20 in that o r d e r . The means and standard deviations f o r these two analyses a r e in Appendix M and N re spec t ive ly . Whi l e the means for the measures of depress ion fo r both groups indicate that the two groups of women a r e wi th in the no rma l l i m i t in te rms of their dep res s ive affect, the range of s co re s on the D A C L and Beck f o r both groups indicate that there a r e some women wi th in both groups who might be cons idered to be m i l d l y depressed at this t i m e . 95 T i m e II - Hospi ta l data 2 Hote l l ings T showed that there was a s ignif icant difference between the two groups of women in the i r responses to the quest ionnaires c o m -pleted w h i l e in hosp i t a l , F (7 .86) = 4 .43 p_ .0003 . T h e means and s tandard deviat ions fo r this set of va r iab les a r e shown in Tab le X I I I . The mul t ip le compar i son using s imul taneous confidence in t e rva l s indicated that there we re s ign i f ican t ly different group means for two va r i ab l e s — attitude toward labour and d e l i v e r y and l eve l of depress ive affect on the f i r s t day pos tpar tum. Those women who had a caesa r i an sec t ion e x -p ressed a l e ss pos i t ive attitude toward the i r labour and d e l i v e r y exper ience and exper ienced m o r e depress ive affect the f i r s t day pos tpar tum than d id women who de l ive red the i r babies vag ina l l y . The means and standard deviat ions fo r responses to Greenbe rg ' s quest ionnaire a r e in Tab le X I V . Hote l l ings T 2 demonstrated a s igni f icant difference between tine responses of women as a function of the i r d e l i v e r y exper ience , on this set of v a r i a b l e s , F (15,78) — 2.05 p_<<.02, although tine mul t ip le compar i son indicated no difference between the va r ious group means of the ind iv idua l v a r i a b l e s . Subsequent un iva r i a t e a n a l y s i s of var iance indicated that women who had caesar ians w e r e l e s s happy in the hosp i t a l , had l ess energy and w e r e more depressed after the d e l i v e r y than we re those women who had vaginal d e l i v e r i e s , F (1,92) = 5.57 p<.02; F (1 ,92) = 3 .96 £ - < . 0 5 ; F (1 ,92) = 8.44 £ , ^ . 0 0 5 r e spec t i ve ly . 96 Table XI I I Means and s tandard deviat ions of the hospital data Vaginal D e l i v e r y N = 73 At t i tude to Labour and D e l i v e r y At t i tude to Baby A r e a s of Concern D A C L T i m e One D A C L T i m e Two D A C L T i m e Three D A C L T i m e F o u r Mean 147.00 126.89 9 .15 45 .47 46 .78 50.07 49 .29 S D 13.45 13.02 4 .78 4 .98 7 .48 9.72 9 .00 Caesa r i an Sec t ion N = 21 Mean S D 120.14 47 .88 122.14 8.52 50.95 51 .38 53.86 51 .48 15.89 5 .10 7 .08 10.10 9 .66 9 .12 97 Table X I V Means and standard deviat ion of responses to Greenbe rg ' s quest ionnaire Vaginal . C a e s a r i a n D e l i v e r y Sec t ion N -= 73 N = 21 Mean S D Mean S D S e l f Confidence 3 .30 regarding c h i l d c a r e Percep t ion of help 3 .73 needed at home Happiness in Hospi ta l 4 .03 Presen t energy l eve l 2 .18 A b s e n c e of anxie ty regard ing 1.44 repons ib i l i ty of baby Confidence regard ing the 4 .42 ro le of motherhood Presen t feel ings of gladness 4 .27 versus depress ion Mate rna l feel ing to baby 4.11 Competence regarding c h i l d c a r e 3 .33 Immediacy of understanding 2 .05 baby's needs L a c k of r e s t r i c t i on in 2 .70 usual ac t iv i t i e s Ene rgy l e v e l after d e l i v e r y 2 .66 Amoun t of help f r o m 2.41 nurs ing personnel Fee l ings of gladness versus 4 .74 depress ion af ter d e l i v e r y Amoun t of help rece ived 3 .14 f r o m hospi ta l personnel .78 3 .24 .84 .64 .90 .53 .80 .92 1.11 .73 1.15 3 .33 3 .62 2 .05 1 .48 4 .48 3.81 3 .62 3 .24 2 .19 1.05 2.61 1.56 1.38 .81 2 .33 .69 4 .09 .90 2 .90 .94 .91 .86 .97 .60 .75 1 .03 1 .22 .83 1 .50 .92 .74 .91 1 .41 1.18 98 T i m e 111 - A f t e r one week at home When the women had been home f o r one week they comple ted the atti tude towards baby ques t ionna i re , a r ea s of c o n c e r n , D A C L and Greenbe rg ' s fo l low-up ques t ionna i re . H o t e l l i n g s conducted on these data revea led that there w e r e no differences between the two groups of women on this set of data, F (10,83) = 1.13 £ ^ . . 5 0 . T h e means and s tandard devia t ions f o r these measures a r e i n Appendix O . T i m e I V - af ter f ive weeks a t home When the women had been home f o r f ive weeks they comple ted the fo l lowing measures ; attitude towards baby; a r e a s of c o n c e r n , B e c k Dep re s s ion Index; D A C L ; P l easan t Events S c h e d u l e . U s i n g Hote l l ings T ^ , the a n a l y s i s of this set of va r i ab l e s demonstrated that there w e r e no differences between those women who had vagina l d e l i v e r i e s and those who had c a e s a r i a n sec t ion , F (5,88) = .80 £ « s i . 5 0 . T h e means and s tandard deviat ions f o r these data a r e i n Appendix P . A c r o s s T i m e T o compare the two groups in t e rms of depress ive affect o v e r the t ime pe r iod invo lved , a repeated measures ana lys i s of va r i ance was c a r -r i e d out. T h i s indicated a s igni f icant difference in l e v e l of d e p r e s s i v e affect between the groups in t e rms of type of d e l i v e r y , and o v e r t i m e . Those women who had caesa r i an sec t ions repor ted a g r e a t e r degree of depres s ive affect than d id those who had vaginal d e l i v e r i e s . The s u m -m a r y table fo r this ana lys i s i s shown in Tab le X V . These di f ferences 99 a r e i l l u s t r a t ed g raph ica l ly in F i g u r e 3 . It should be noted that both groups peak at day three and that the mean leve l of the depress ion affect of the caesa r i an group increases between the f i r s t week and fifth week at home, more than the mean leve l of depress ive affect f o r the vaginal group over the same t ime p e r i o d . It should be pointed out that the means of both groups a r e s t i l l wi th in the range obtained dur ing the prenatal p e r i o d . Tab le X V Repeated measures ana lys i s of var iance Leve l of depress ive affect over t ime S u m m a r y table S o u r c e dfs _F £ Mean 1 7921.34 .001 D e l i v e r y 1 6.92 .010 E r r o r 92 T i m e 6 3 .13 .005 T i m e / d e l i v e r y 6 1 .62 .140 E r r o r 552 S p e c i f i c Compar i sons a . S e l f confidence In view of Sheashore ' s f indings of less s e l f confidence in mothers who had been separated f r o m the i r infant, the s e l f confidence of the women was analyzed accord ing to type of d e l i v e r y . T h e r e w e r e no differences in the leve ls of s e l f confidence between vaginal d e l i v e r y o r caesa r i an sect ion e i ther wh i l e in the hospi ta l o r af ter one week at o l ! I I I _. I _ J 1 2 3 4 5 6 7 prenatal time 1 time 2 time 3 time 4 2 weeks 6 weeks i 1 i i i i Hospi ta l Postpartum TIME PERIOD Figure 3. Means of DACL scores at seven points in t ime: Compar ison between types of del iver ies. 101 h o m e . F (1 ,92 )= .098 £ > . 7 5 5 a n d F (1,92) = 2 .664 £ . > . 109 r e s p e c t i v e l y . b. At t i tude towards baby in hosp i t a l , af ter one week at home and af ter f ive weeks at home  A s the quest ionnaires w e r e not designed fo r repeated measurement , differences in attitudes towards the baby as a function of the type of d e l i v e r y exper ienced, we re ana lyzed using . ana lyses of v a r i a n c e . T h e r e w e r e no differences between these two groups at any of tine t ime points measu red . F (1,92) = 2 .056 £ > . 1 5 7 ; F (1,92) = 3.131 £ > . 0 8 ; F (1,92) = 2 .59 £ ; > . 1 1 3 . The pooled wi th in groups c o r r e l a t i o n m a t r i x fo r a l l the va r i ab l e s in the study was examined to a s c e r t a i n the re la t ionship between (a) method of feeding — whether b reas t o r bot t le , (b) number of days spent i n hospi ta l and (c) number of days rooming in wi th infant to o ther v a r i a b l e s i n the s tudy. (a) Bot t le feeding s ign i f i can t ly re lated to the fo l lowing v a r i a b l e s : r P b i _ P _ the amount of ac t iv i ty engaged in at the ninth month - . 3 5 5 .01 the amount of ac t iv i ty engaged in s i x weeks - . 251 .02 pos tpar tum the amount of exper ience that the women fe l t - . 2 5 4 .02 they had rece ived w h i l e in hospi ta l in c a r i n g f o r the i r baby 102 rpb i s e l f confidence wh i l e in hospi ta l - . 2 4 3 .02 feel ing of competence w h i l e in hospi ta l - . 2 7 5 .01 feel ings of gladness w h i l e i n hospi ta l - . 2 4 5 .02 mother ' s percept ion of not needing help at home - . 2 3 3 .05 D A C L after one week at home .213 .05 attitude towards baby at s i x weeks postpartum - . 2 5 4 .02 (b) Number of days spent in hospi ta l after the b i r th of the i s s ign i f ican t ly related to the fol lowing va r i ab le s : baby r P age of baby at d i scharge . 746 .01 feel ings of happiness in the hospi ta l .218 .05 energy l eve l in hospi ta l - . 2 3 9 .05 amount of help received f r o m nurs ing . 287 .01 personnel (c) Number of days spent r o o m i n g - i n wi th infant was s ign i f i can t ly r e -lated to the fo l lowing v a r i a b l e s : bathing baby attitude towards baby feel ings of se l f confidence in hospi ta l feel ings of competence w h i l e in hospi tal feel ings of confidence af ter one week at home _ n _ p, .499 .01 .241 .05 .227 .05 .227 .05 . 257 .02 103 r -J2. ease of adjustment f r o m hospi ta l to home .261 .. 02 amount of exper ience rece ived wh i l e in hospi ta l .479 .01 amount of help rece ived f r o m the hospi ta l .390 .01 i m m e d i a c y of understanding the infant 's needs .239 .05 cer ta in ty regarding c h i l d ca r e .265 .02 l e s s help needed at home .214 .05 F a c t o r A n a l y s i s F o r heu r i s t i c purposes the data obtained f r o m trie women we re s u b -jec ted to a fac tor ana lys i s procedure in o r d e r to a sce r t a in wh ich variables c lu s t e r together. The resul ts should be interpreted caut ious ly in view of the r e l a t i ve ly s m a l l sample involved (N=93). The factor ana lys i s p r o c e -dure used was a p r i n c i p a l components technique wi th a v a r i m a x rotation. F o u r eigen values were grea te r than unity so four fac tors we re e x t r a c -ted . The fac tors and the i r loadings a r e presented in Appendix Q . Items wi th loadings grea te r than .40 w e r e used to identify the meaning of each f ac to r . The f i r s t fac tor was labe l led the hospi tal exper ience f ac to r . It included the fol lowing va r i ab les wi th loadings greater than .40.' S e l f confidence w h i l e in the hosp i t a l , ease of adjustment f r o m hospi ta l to home, exper ience received wh i l e in hosp i t a l , help rece ived f r o m the 104 hospi ta l in preparat ion for the mothering r o l e , i m m e d i a c y of unde r -standing the infants' needs. L e s s help needed at home and certainty-regarding ch i l dca re when f i r s t at home a l so loaded h ighly on this 3 f ac to r . In addi t ion , number of days spent " r o o m i n g - i n " wi th the i n -fant and attitude towards the baby a l so loaded highly on this f ac to r . The second fac tor included demographic va r i ab le s such as the age and education of the mother and education of the fa ther . The most highly loaded i tems on the th i rd fac tor were energy l e v e l and feel ings of gladness whi le in hosp i t a l . Depres s ive affect, bottle feeding and longer length of labour loaded in the negative d i r ec t ion o n this f ac to r . At t i tude towards labour and d e l i v e r y loaded ve ry h ighly on the fourth fac to r . It was designated thus on the ques t ionnai re . In fact , the only women who had " r o o m i n g - i n " we re the women in the f a m i l y centred p r o g r a m m e and the two women w i t h caesa r i an sect ions who had r o o m i n g - i n in the t radi t ional hosp i t a l . 105 C H A P T E R I V D I S C U S S I O N In the t e rms of Runkel and M c G r a t h (1973), this s tudy i s b a s i c a l l y a natura l f i e ld exper iment . Obv ious ly i t was i m p o s s i b l e to a s s i g n women randomly e i the r to hospi ta l exper ience o r type of d e l i v e r y . T h i s l eaves the p o s s i b i l i t y of unknown s a m p l i n g b iases v e r y much to the f o r e . W h i l e the present study has the advantage of being re levant in the " r e a l " w o r l d , i t has a l l the l i m i t a t i o n s of appl ied r e s e a r c h and unknown s a m p l i n g b iases w i l l l i m i t the gene ra l i z ab i l i t y of the r e s u l t s . W h i l e this i s typica l of evaluat ive r e s e a r c h , i t should be noted that " a p p r o x i -mate ly 80% of our (psychology) r e sea rch i s pe r fo rmed on the 3 p e r cent of the population c u r r e n t l y enro l l ed in co l l ege" wi th an o v e r - r e p r e s e n t a -tion of male subjects ( S c h u l t z , 1969). T h e uncontrol led s a m p l i n g factors of the present study involve the choice of prenatal c l a s s e s by the par t ic ipants i n the study; the s e l f se lec t ion of those who chose to par t ic ipa te and the p o s s i b i l i t y of s e l e c -t ion fac tors operat ing i n the hosp i ta l w h i c h the women at tended. In add i t ion , there is the inherent p rob l em of differences between volunteers and those who chose not to volunteer . Rosenthal (1965) has s u m m a r i z e d some of the r e sea rch on this p r o b l e m . It should be noted that a l l data in this study involved s e l f - r e p o r t measures wi th the l im i t a t i ons of such m e a s u r e s , i . e . , a l l f o r m s of s e l f -106 • . •• repor t a r e suscept ib le to reac t ive b i a s . F i r s t , the subject knows that she i s the focus of r e sea rch ; second, the respondent may w e l l change in the attitude being measured because of'the measurement pe r se; t h i r d , subject ive repor ts a r e vulnerable to ce r t a in types of response se ts as w e l l as the "guinea p i g " effect (Webb, C a m p b e l l , S c h w a r t z , S e c h r e s t , 1966). The re a r e some advantages to the use of s e l f - r e p o r t however . One gets a more d i r e c t measure of ind iv idua l feel ings of the women involved ra ther than the interpreta t ions of what the women w e r e e x p e r i e n c i n g and fee l ing . A s Nunnalty (1975) concluded , "genera l ly tine most v a l i d , e conomica l , somet imes the on ly , way to l e a r n about a persons ' sent iments i s s i m p l y to ask h i m " . A n o t h e r important advan-tage of s e l f - r e p o r t measures i s that they a r e not as ob t rus ive as other techniques. Al though i t would have been useful to have employed other measu re s , such as behavioural observa t ions , pee r r e p o r t s , and input f r o m nu r se s , the present data a r e not as contaminated by reac t ive effects and expectancy effects as they might have been had these var ious other measures been u t i l i z e d . The women who par t ic ipated in the study w e r e w e l l educated, and f r o m intact f a m i l y s i tua t ions . They we re a w e l l motivated group who paid to attend prenatal c l a s ses and whose drop-out rate f r o m the present 107 study was very s m a l l (4.5%). It was not poss ib le to con t ro l the t ime at w h i c h the women comple ted the ques t ionnai res although a ve ry c lo se con t ro l was kept in t e r m s of the date of r ece ip t . A n o t h e r fac tor wh ich may affect the study was the i n a b i l i t y to c o n t r o l changes o c c u r r i n g wi th in each hospi ta l ove r the dura t ion of the study; however , f r o m d i s c u s s i o n wi th hospi ta l staffs and the women in the s tudy, J i t was my understanding that the hospi tal envi ronment r emained f a i r l y s table ove r the 16 month t ime per iod of the s tudy. Before d i scuss ing the imp l i ca t i ons of the findings of the present s tudy , i t should be pointed out that although only the o v e r a l l m u l t i v a r i a t e F" was s igni f icant in s e v e r a l of the ana lyses , i t i s not uncommon "to find that no s ingle p a i r w i s e difference between any two group means is s i g n i -f icant" ( H a r r i s , 1975). T h i s l ack of s igni f icant p a i r w i s e d i f ferences may be a ref lec t ion of the s m a l l but accumula t ive effects of the f a m i l y cent red mate rn i ty p r o g r a m m e . It may a l so suggest that the effects of such a p r o g r a m m e a r e more global and thus not amenable to the more s p e c i f i c measu res used in the s tudy. It had been planned o r i g i n a l l y to compare those women who had rece ived anaesthetic wi th those women who d id not to see i f there w e r e any difference in the i r attitude toward the i r baby w h i l e in h o s p i t a l . Upon a n a l y s i s of the date,however, i t was found that 93% of the women 108 r ece ived some type of anaesthet ic , (Appendix H) thus mak ing such a c o m p a r i s o n i m p o s s i b l e . It v/as noted that 40% of those women in the f a m i l y cent red matern i ty p r o g r a m m e had r ece ived an ep idu ra l anaes -thetic compared wi th 80% of the women in the t rad i t iona l p r o g r a m m e . 2 T h i s i s a s igni f icant d i f ference , x (1) = 11 .38 .001 . It i s therefore poss ib le that the more pos i t ive attitude of the women i n the f a m i l y cent red matern i ty ca re toward the i r baby in hosp i ta l i s confounded wi th the use of anaesthet ic . Inspection of the pooled wi th in groups c o r r e l a t i o n m a t r i x , however , revealed a c o r r e l a t i o n of only —.05 ind ica t ing an absence of assoc ia t ion between attitude toward baby and use of anaesthetic. Impl ica t ions F r o m M a j o r F ind ings — Hospi ta l P r o g r a m m e Hofer (1975) stated that in the United S ta t e s , the r e s e a r c h of e a r l y paren t /ch i ld re la t ionships has been entwined in a s o c i a l movement involv ing obs te t r i c c a r e . Quest ions a r e being asked such as "Shou ld med ica l and nurs ing p r a c t i s e , hospi ta l des ign , obs t e t r i c and ped ia t r i c procedures be a l t e red on the bas i s of r e s e a r c h evidence now a v a i l a b l e " . H a i r e and H a i r e (1968) stated that "The hospi ta l r i t ua l that su r rounds ch i ldb i r th in the Uni ted States does much to des t roy that cohes ive effect that c h i l d b i r t h should have on the f o r m i n g f a m i l y uni t and thwarts na ture ' s n o r m a l plan f o r the ch i ldbea r ing e x p e r i e n c e " . They stated that " f ami ly centred matern i ty c a r e would do much to c o r r e c t 109 the f laws in our concept of conventional matern i ty c a r e " and the i r book desc r ibed how to implement such a p r o g r a m m e . The f indings f r o m the present study indicate that the type of h o s -pi ta l p r o g r a m m e in which a woman spends he r f i r s t pos tpar tum days does make a difference in t e rms of a more pos i t ive attitude towards he r new baby, and in te rms of the amount of exper ience she rece ives in how to take c a r e of a new baby and in the amount of help that she rece ives in hospi ta l to p repare he r fo r the mother ing r o l e . T h i s study complements the w o r k done by Klaus and his col leagues inasmuch as they found s igni f icant differences in behaviour of p r i m i p a r o u s mothers towards the i r f u l l - t e r m infants as a function of the amount of contact they exper ienced i n hosp i t a l . It was found in the present study that the women who par t ic ipated in the f a m i l y centred matern i ty p r o g r a m m e and thus determined the amount of contact wi th the i r infants had a more pos i t ive atti tude towards the baby wh i l e i n hospi ta l than d id women in a t radi t ional p rog ramme in which nurs ing po l i cy dictated when the mother should have the baby. Once women had been home fo r one Week, handling and in teract ing wi th the i r babies , these differences disappeared. The fact that the women w e r e a w e l l educated, w e l l motivated group may have se rved to w o r k against f inding longer t e r m differences between the two hospi tal p r o g r a m m e s . no The fact that there w e r e no differences in the l e v e l of s e l f c o n f i -dence of the women in both p rog rammes suggests that this m o r e p o s i -t ive attitude towards the baby was not related to the feel ings of confidence and competence gained w h i l e c a r i n g fo r the i r baby by those in the f a m i l y centred materni ty p r o g r a m m e . The components of the f a m i l y centred p r o g r a m m e that relate to this more pos i t ive atti tude r e m a i n to be determined e m p i r i c a l l y . It i s poss ib le that the spec i f i c nu r se /mo the r / baby ass ignment has-an effect on the mother ' s attitude towards he r baby. It may be that being responsib le fo r and c a r i n g fo r her own infant dur ing this t ime resu l t s in a more pos i t ive attitude on the par t of the mother in the f a m i l y centred p r o g r a m m e . T h i s would be predic ted fo r example , by Bern ' s theory of s e l f percept ion (Bern , 1970). Suppor t fo r the benefits of f a m i l y centred matern i ty ca re comes f r o m the s igni f icant co r r e l a t i ons between attitude towards baby and the amount of help rece ived f r o m the hospi ta l and the amount of exper ience gained w h i l e in hospi ta l c a r i n g f o r the baby. In add i t ion , the s igni f icant co r r e l a t i ons between var iab les such as feel ings of s e l f confidence and competence, ease of adjustment f r o m hospi ta l to home, for example , and the number of days spent " r o o m i n g - i n " wi th the in fan tas opposed to the number of days spent in hospi ta l per se) is support fo r the pos i t ive effects of the f a m i l y centred matern i ty p r o g r a m m e . 111 The resul ts of the factor ana lys i s indicate that attitude toward labour and d e l i v e r y was unrelated to the hospi tal exper ience f ac to r . T h i s i m p l i e s that the percept ion of the hospital exper ience was unrelated to whether the women had a good o r poor de l i ve ry exper ience . The type of hospi ta l p rogramme exper ienced appeared to have l i m i t e d l o n g - t e r m effect on o v e r a l l postpar tum adjustment of the women in the s tudy. A t s ix weeks postpartum there were no differences between the women in the two p rog rammes in te rms of depress ive affect, behaviour o r attitude toward baby. Type of d e l i v e r y — Vaginal Compared to C a e s a r i a n Sec t ion It should be noted that the difference in attitude toward baby whi l e in hospital only held f o r the compar i son of women in the two hospi ta l p r o g r a m m e s . T h e r e was no difference when compar i sons w e r e made between the women in t e rms of the i r d e l i v e r y exper ience . T h e r e we re no differences in attitudes toward baby at the three t ime points measured between those women who had had vaginal d e l i v e r i e s and those who had had cae sa r i an sec t ions . T h i s f inding i s the ant i thes is of what might have been predic ted given the r e sea rch conducted by Klaus and a s soc i a t e s . Women who undergo a caesa r ian sect ion usua l ly suffer more "depr iva t ion 1 1 (to use Barne t t ' s te rminology) of their infant than do those women having a vaginal d e l i v e r y . In addi t ion , there i s the operat ive procedure i t s e l f and the fact that they have had major s u r g e r y . 112 The resul ts of the fac tor ana lys i s suggest that in fact a pos i t ive attitude towards the baby is unrelated to whether the women had a pos i t ive exper ience dur ing labour and d e l i v e r y . P o s s i b l y the p rocedures involved wi th caesa r ian sect ions enable women to accept such depr iva t ion more eas i ly and perhaps mothers may accept the depr iva t ion of the i r infant, given the need fo r intensive c a r e , more read i ly than those who have vaginal d e l i v e r y . Bot t le feeding A finding that should be interpreted caut ious ly was the s igni f icant negative re la t ionship between bottle feeding and other va r i ab les such as the amount of experience, women fel t that they had rece ived w h i l e in tine hosp i t a l , the feel ings of s e l f confidence and competence and attitude toward the baby at s i x weeks pos tpar tum. T h i s is an in teres t ing f inding in l ight of the emphasis on breastfeeding in l o c a l women (85% of present sample breas t fed the i r baby; 75% of Kha i r a t & Costanzo (1974) sample breastfed thei r babies).. It may w e l l be that the women who breastfeed the i r babies rece ived more attention i n i t i a l l y f r o m the nurs ing staff in o r d e r that the mother and c h i l d have a good beginning. T h i s in turn may be related to the amount of pe rce ived exper ience being gained i n hosp i t a l . The fact that bottle feeding re la tes to l e ss s e l f confidence and competence i s perhaps explainable in l ight of the emphasis in the media 113 and prenata l c l a s s e s on the pos i t ive aspects of b reas t feeding f o r both mother and c h i l d . The women who bottle feed the i r baby feel m o r e depressed and have l e s s confidence in t he i r own a b i l i t i e s , in addi t ion to going against the ' n o r m ' of the i r peer g roup . D e p r e s s i v e Af fec t F r i e d m a n (1974) suggested that the t e rm depres s ion be employed in three w a y s . F i r s t as an affect, second as a c l i n i c a l state and th i rd as a c h a r a c t e r s t y l e . He stated that although this i s not a new way of c o n -cep tua l iz ing depress ion i t has been ra ther neglected un t i l now. F r i e d m a n maintained that l i k e anx ie ty , depress ion can r e f e r both to a bas ic fee l ing and a more defined c l i n i c a l s ta te . Dep re s s ive affect r e fe r s to a b a s i c fee l ing of sadness w h i c h i s par t of the f a b r i c i n l i f e and wh ich i s noted in states of g r i e f and pe r iod of d isappointment . C l i n i c a l d e p r e s s i o n , on the other hand, re fe r s to a complex of symptoms inc luding the affect of depress ion and a l so . .o ther affects such as anx ie ty , gu i l t , h o s t i l i t y as w e l l as mot iva t iona l , vegetative and cogni t ive d i s t u rbances " . M i l l e r ' s (1975) rev iew of the psycho log ica l def ic i t s in depress ion showed that such def ic i t s depend l a r g e l y on s e v e r i t y of depress ion ra the r than type of dep re s s ion , and that depressed subjects in n o r m a l populat ions a r e genera l ly cha rac t e r i zed by def ic i t s s i m i l a r in nature but s m a l l e r in degree to those of depressed pat ients . The repeated measures ana lys i s of the dep re s s ive affect indicated 114 that there was no difference ove r t ime between the group of women who de l i ve red vag ina l ly . T h i s f inding supports c l i n i c a l obse rva t ions , (and previous s tudies of postpartum depress ion a n d / o r blues) insofar as the l eve l of depress ive affect peaks on the th i rd and fourth day. The present data are consis tent wi th the argument fo r a ho rmona l bas i s fo r depressive, affect dur ing this t ime per iod as the peaking was demonstra ted in a l l groups (vaginal and caesa r i an wi th in each hospi ta l p r o g r a m m e ) . The women who had exper ienced a cae sa r i an s e c t i o n w e r e s i g n i f i -cant ly more depressed than those who had vaginal d e l i v e r i e s . G iven that there we re no s igni f icant differences between the two groups i n i t i a l -l y F (1,92) = 3 .535 p_^>.063, this suggests that having a baby by caesai— ian sec t ion i s a l e s s pos i t ive exper ience than having a baby vag ina l l y . T h i s i s supported in the present study by the f inding that these women a l so had a s ign i f ican t ly l e ss pos i t ive attitude toward the i r l abour and d e l i v e r y exper ience than those who de l ive red v a g i n a l l y . It i s unfortunate that a l o n g - t e r m fo l low-up was not feas ible in o r d e r to obtain more i n -format ion regarding the l e v e l of depress ive affect of women who had caesa r i an s ec t i on . It i s poss ib le that the inc rease in l eve l of d e p r e s -s i v e affect seen at s i x weeks postpartum in this group was the beg in -ning of a continuing t r end . 115 W h i l e the present s ample of women w e r e not c l i n i c a l l y depressed there a r e some s igni f icant co r r e l a t i ons between amount of d e p r e s s i v e affect as measured by the D A C L and other va r i ab l e s a t each t ime p e r i o d . F o r example , in the ninth month of pregnancy d e p r e s s i v e a f -fect was re la ted to a l e s s pos i t ive attitude towards pregnancy; in hospi ta l dep res s ive affect was related to l e s s pos i t ive atti tude towards l abour and to d e l i v e r y and towards the baby. A t the s i x w e e k s ' pos tpar tum pe r iod dep res s ive affect was again related to l e s s pos i t ive atti tude towards the baby. In add i t ion , the leve l of depress ive affect was p o s i t i v e l y re la ted to bottle feeding and to the number of p r o b l e m s encountered by the women dur ing the i r f i r s t week at home. The pos i t ive re la t ionsh ip be t -ween depress ive affect and bottle feeding to s o m e extent suppor ts the f indings of P i t t (1973) who stated that women who had the "b lues" di f fered f r o m those who d id not only in that they exper ienced m o r e d i f f i cu l ty in breas t feeding. T h e responses to Greenbe rg ' s hosp i ta l ma te rn i ty quest ionnaire indicated that the mother ' s fee l ings of depress ion re la ted to l e s s s e l f confidence i n c a r i n g f o r the baby; l e s s energy w h i l e in hospi ta l ; l e s s confidence regard ing the ro le of motherhood and an inc reased length of t ime taken to understand the need of the baby. The above re la t ionship between dep res s ive affect and o ther v a r i -ables i:S. consis tent wi th s eve ra l psycho log ica l theories of d e p r e s s i o n . 116 B e c k (1967, 1971, 1974) postulated a cogni t ive theory of depress ion in w h i c h depress ion i s seen as a resu l t of a t r i ad of cogni t ive d i s t u r -bances wh ich predispose an indiv idual to var ious fo rms of thought and behavioura l c h a r a c t e r i s t i c s of dep re s s ion . The components of this t r iad a r e "a negative view of the future, of the environment and of h i m -s e l f " . It could be maintained that the women who exper ience dep re s -s ive affect therefore tend to see thei r exper iences in a l e s s pos i t ive l igh t , have a l e ss pos i t ive attitude towards the i r baby and see t h e m -se lves as less able to ca re for the baby competent ly . The present f indings a r e a l so consis tent wi th the behavioura l theories of depress ion of Cos t e l lo (1972), Lewinsohn and his. assoc ia tes (1976) and S e l i g m a n and his assoc ia tes (1976). C o s t e l l o ' s (1972) theory of depress ion would suggest that the women who had caesa r i an sect ions were depressed because "the re inforcement effectiveness of a l l the components of a chain of behaviours is c o n t i n -gent upon the complet ion of the chain at e i ther an over t o r cove r t l e v e l " . Caesa r i ans did not complete the chain of c h i l d b i r t h f o r which they had tra ined . Lewinsohn (1976) pointed out that the concept of re inforcement i s cen t ra l to the ana lys i s "of dysphor ia and the other events wh ich a r e frequently encountered among persons diagnosed as dep re s sed" , and to the development and maintenance of the depres s ive s y n d r o m e . 117 A c c o r d i n g to Lewinsohn , the behavioural model "focuses on the effects which a reduction in the rate of response contingent pos i t ive r e i n f o r c e -ment i s assumed to have on the behaviour of the i n d i v i d u a l " . T h i s r e -duction can o c c u r in three w a y s . F i r s t , events contingent on behaviour may not be r e i n f o r c i n g . Second , events wh ich a r e r e in fo rc ing may become unavai lable and t h i r d , the indiv idual i s unable to e l i c i t r e i n -fo rc ing behaviour because of the l ack of s k i l l . A c c o r d i n g to Lewinsohn (1974) the total amount of response contingent posi t ive re inforcement i s a function of three v a r i a b l e s . 1 . The number of potential ly re in forc ing events o r a c t i v i t i e s . 2 . A v a i l a b i l i t y of r e in fo rce r s in the envi ronment . 3 . The ins t rumenta l behaviour of the ind iv idua l — the extent to wh ich he possesses the s k i l l s to e l i c i t re inforcement f r o m the envi ronment . Lewinsohn pointed out that the behavioural theory would p red ic t d e p r e s -s ion for an indiv idual who achieved a goal fo r which he has worked hard i f tine reward turns out to be a weak r e i n f o r c e r . The findings f r o m the study a r e a l so consistent wi th the learned help lessness model postulated by S e l i g m a n (1971) who proposed this concept as a l abora to ry model of depress ion i n humans. In h is op in ion , depress ion is caused by exper ience in which an ind iv idua l ' s responses cannot con t ro l the appropr ia te r e i n f o r c e r s . S e l i g m a n stated that 118 reac t ive depress ion may have i t s roots in the l o s s of con t ro l o v e r g ra t i f i ca t ion and the a l l ev ia t ion of su f fe r ing . A c c o r d i n g to S e l i g m a n (1976) the model c l a i m s that many depressions, a r e caused by u n c o n t r o l -lable s i tuat ions which lead the subject to be l ieve that h i s / h e r responses a r e genera l ly ineffective in obtaining re in forcement . The resu l t s of h is latest study support the above model wh ich c l a i m s that "(a) u n -• C • • • con t ro l l ab le events induce d is tor ted percept ions of r e s p o n s e - r e i n f o r c e -ment independence in non-depressed people wh ich cause per formance def ic i t s p a r a l l e l to those found in na tura l ly o c c u r r i n g depress ion and (b) that exper ience wi th cont ro l lab le events r e v e r s e s the percept ions of this independence and the per formance def ic i t s assoc ia ted wi th both he lp lessness and depress ion ." G iven the l ack of differences in l eve l of dep res s ive affect before the b i r th of the baby, the findings of s ign i f i can t ly more depres s ive af -fect af ter d e l i v e r y suggests that caesa r ian sec t ion was a weak r e i n f o r c e r f o r these women . The women in the present study t ra ined as a team wi th t he i r husbands for the b i r th of the i r baby. T h i s behaviour was not c o m -pleted and the women found that a l l they had learned could not be put to use . The b i r t h of the i r baby was suddenly taken out of the i r c o n t r o l , something fo r which the women we re not p r epa red , and , in add i t ion , there we re the s t ress fu l aspects of s u r g e r y and pos t -opera t ive p r o c e -d u r e s . It r ema ins to be investigated e m p i r i c a l l y whether the women 119 a c t i v e l y see themselves as having l ess c o n t r o l . The l eve l of dep res s ive affect may have increased due to feelings of t i r edness , le thargy e tc . due to the operat ion; o r because the i r husbands could not be present at the d e l i v e r y . M c L e a n (1976) proposed a theory in wh ich depress ion i s seen as the "consequence of ineffective coping techniques used to remedy s i t u a -tional l i fe p r o b l e m s " . F i g u r e 4 is M c L e a n ' s schema to i l l u s t r a t e h i s p ropos i t i on . F i g u r e 4 T i m e 0 ) (2) (3) (4) repeated goal feel ing of anticipations depress ion f ru s t r a t i ons in l i t t l e of ch ron ic symptomatology a va r i e ty of con t ro l over f a i lu re s igni f icant a reas environment F i g u r e 5 i s a modif icat ion of tine above us ing the percept ion of having a caesa r i an sect ion as the ineffect ive coping technique, (courtesy of M c L e a n , 1976). F i g u r e 5 . T i m e (1) expectancy of vaginal d e l i v e r y sha ttered (2) woman re l inquishes con t ro l of b i r th process (3) loss of confidence in a b i l i t y (4) h igher s c o r e s on the D A C L 120 It would be in teres t ing to speculate whether the s ame re la t ionsh ip between depres s ive affect and l e s s pos i t ive att i tude toward pregnancy , toward the baby and to other va r i ab les would be found in a c l i n i c a l l y depressed populat ion. What i s the re la t ionship between dep res s ive affect and d i s o r d e r s of mothe r ing , the mos t severe of which resu l t in c h i l d abuse? Is there a re la t ionsh ip between depress ive affect in p regnancy , c a e s a r i a n sec t ion and c h i l d abuse? T h i s remains to be e m p i r i c a l l y de termined but the present r e sea rch suggests the need for fur ther r e s e a r c h to c l a r i f y such r e l a t ionsh ips . A s He i f e r pointed out the p rec ip i t a t ing event fo r c h i l d abuse may be a d i f f icu l t pregnancy a n d / o r d e l i v e r y ; that abused c h i l d r e n have a caesa r i an sec t ion rate much h igher than that of the general popu-l a t i o n . M c L e a n (1976) asked,"What effect, i f any , does parenta l dep res s ion have on effective parenting? " He stated that although there a r e no e m p i -r i c a l s tudies in the l i t e r a tu r e , informat ion f r o m s e v e r a l sources indicates that effective parenting and absence of dep res s ion a r e r e l a t ed . A c c o r d i n g to M c L e a n , evidence f r o m studies of s e l f r e p o r t , effect of parenta l mode l l ing and s e l f es teem in pre~adolescents suggest two hypotheses regard ing the presence of parental d e p r e s s i o n . F i r s t , that parenta l depress ion may render parents l e s s capable of effective parent ing and second , that parental depress ion prov ides an opportunity fo r c h i l d r e n to 121 a c q u i r e ineffective in te rpersonal coping s t r a teg ies through parenta l m o d e l l i n g . T h e low but consis tent re la t ionships of d e p r e s s i v e affect to such va r i ab le s as confidence in mothering a b i l i t y , i nc reased length of t ime taken to "know" the baby, less s e l f confidence in c a r i n g f o r the baby i n a s ample of women who a re not c l i n i c a l l y depressed suggests the eff icacy of a prevent ive approach . C l i n i c a l Impl ica t ions S e l i g m a n (1976) found that the behavioura l immun iza t i on techniques p rov ided an ea r ly and effective means of prevent ing lea rned he lp lessness in a n i m a l s . T h e r e i s evidence in the psycho log ica l l i t e r a t u r e dea l ing w i t h s t r e s s that such techniques w o r k w e l l f o r humans . Johnson and Leventhal (1974) state that many theories suggest that negative affect i s "a product of d i sc repanc ie s between c u r r e n t exper ience and p r i o r expecta t ion" . Johnson (1973) suggests that inaccura te expec ta -t ions regarding sensat ions produced by noxious s t i m u l i a r e the c r i t i c a l sou rce of negative affective responses . T h u s , Johnson cons ide r s that i f a person accura te ly ant ic ipates how a noxious s t i m u l u s w i l l feel he / she w i l l be less f ea r fu l . She found that accura t e expectat ions about the phys i ca l sensat ions to be exper ienced , reduced the s t r e s s caused by painful s t i m u l i . The resul ts of he r study supported the hypothesis that p repara to ry informat ion wh ich reduced' the incongru i t i es between 122 expected and ac tua l ly exper ienced sensat ions was assoc ia ted wi th l e s s intense emot ional responses dur ing painful s t i m u l i . Johnson and Leventhal (1974) c i te studies of fea r communica t ion suggest ing that " . . .behavioura l p repara t ion , detai led ins t ruc t ions on how and when to ac t , and p r i o r r ehearsa l of spec i f i c ac t ions a r e neces sa ry f o r subjects to sus ta in cont ro l over external th rea t s" . They conclude by s tat ing that the i r studies have shown that " spec i f i c types of in format ion can be used to reduce - a v e r s i v e responses and to s t rengthen effective coping responses . . . " Meichenbaum and T u r k (1976) state that behaviour therapy i s shif t ing i t s emphasis to a coping s k i l l s model and desc r ibe the s t r e s s innoculat ion t ra in ing procedures in wh ich subjects a r e provided wi th a p rospec t ive defense, o r set of s k i l l s , to deal w i t h future s t r e s s fu l s i t ua t ions , us ing cogni t ive manipulat ions such a s i m a g e r y r e h e a r s a l , s e l f ins t ruc t ional t r a in ing , and re laxa t ion t r a in ing techniques . They d i s -cuss s tudies showing the successful app l ica t ion of such innoculat ion t ra in ing in cont ro l of phobias , in te rpersona l anxie ty and con t ro l of anger in the psycholog ica l r e a l m . These p rocedures have a l s o been used i n the phys ica l r e a l m of pain c o n t r o l . T h e y d i s cus s the c l i n i c a l potential of such a prevent ive approach f o r handl ing both phys i ca l and psycho log ica l s t r e s s e s . Lange r , J a n i s and W o l f e r (1975) repor ted on the reduction of psychologica l s t r e s s in s u r g i c a l patients us ing two 123 s t r e s s reduction s t ra teg ies in a f i e ld se t t ing . It was found that the coping dev ice (cognit ive r eappra i sa l of anxiety—provoking events , c a l m i n g s e l f - t a l k and cogni t ive cont ro l ) w h i c h was por t r ayed as a way of con t ro l l i ng one's emotions was m o r e effect ive in reducing pre~and p o s t o p e r a t i v e s t r e s s than the technique of g iv ing p r epa ra to ry c o m m u n i -cat ions about what to expect ,combined wi th r e a s s u r a n c e . K l u s m a n (1975) showed that prenata l anxie ty was reduced in an educa t ion - fo r - ch i ldb i r th c l a s s wh ich used e x e r c i s e s , breathing t ech -niques and gave women a sense of pa r t i c ipa t ing in and con t ro l o v e r the ch i l db i r t h p r o c e s s . A n x i e t y was not reduced in the con t ro l prenata l c l a s s wh ich emphasized baby c a r e and in w h i c h p repara t ion f o r c h i l d -b i r t h was l i m i t e d to informat ion regard ing l a b o u r and d e l i v e r y . In o r d e r to teach coping s k i l l s and to emphas ize the i nd iv idua l ' s a b i l i t y to con t ro l the s i tua t ion , the prenata l c l a s s e s w h i c h the women in the present study attended used s t r e s s innoculat ion techniques . G iven the r e sea rch on pain and anxiety one might p r e d i c t that these c l a s s e s would be effect ive . (There a re ,however , few sys t ema t i c s tudies of the ef-f i c a c y of education f o r ch i l db i r t h c l a s s e s . ) D i s c u s s i o n wi th prenatal c l a s s teachers indica tes that c a e s a r i a n sec t ions a r e regarded as an abnormal aspec t of c h i l d b i r t h and , although mentioned as a p o s s i b i l i t y , they a r e not d i s cus sed in any s i g n i -f icant d e t a i l . Given that the present rate of c a e s a r i a n sec t ion in )2h Vancouver i s approx imate ly 20% and given the p o s s i b i l i t y that the n u m -ber of caesar ians w i l l tend to r i s e in view of the inc reas ing use of fetal moni tor ing equipment, it does not make sense to ignore caesa r i an sec t ions . The present findings of s ign i f ican t ly more depres s ive affect in women who have had caesar ian sect ions together wi th the findings of r e s e a r c h into s t r e s s innoculation and behavioura l immuniza t ion techniques and coping s k i l l s , indicate the need fo r g rea te r attention focused on caesa r i an sec t ion in prenatal c l a s s t r a i n i n g . The Myth of Ma te rna l Instinct Janeway (1971) states the fo l lowing: Women a r e not t ra ined to be mothers in our soc ie ty , o r indeed in any s o c i e t y . . . The ve ry fact that ou r soc ie ty does t ra in ini t ia tes f o r m a l l y f o r most jobs . . .makes woman ' s ro le a r c h a i c and a typ ica l in that women s t i l l l ea rn by do ing . They take on the v i t a l , c r e a t i v e , impor tant , cent ra l concern of the i r l i ve s (they ,: a r e assured) , wi th ve ry l i t t l e adv ice o r background. New mothers a r e expected to ac t by ins t inct ; and this expectation in i t s e l f sets them apar t f rom the res t of soc ie ty , where people assume that they w i l l be taught the bas ic rules of the jobs they have to do . The expectation that they w i l l be able to ac t by inst inct sets women apar t , a l so by suggesting that they operate on a more p r i m i t i v e l eve l than is n o r m a l f o r the res t of our w o r l d . Only ve ry recent ly has attention been paid to the needs of the woman in prepara t ion for motherhood as opposed to prepara t ion f o r c h i l d b i r t h . (The same may be sa id fo r fathers who rece ive even l e s s a t tent ion.) 125 Standard procedure has been prenata l c l a s s e s w i t h l i t t l e o r no emphas i s on the postnatal per iod and " l i f e w i t h baby" . T h i s may have been due i n par t to the myth of maternal ins t inc t wh ich a s s u m e s that love i s enough and that because a woman has had a baby she both loves i t and knows what to do . Of the par t ic ipants in the study (N=106) 46% stated that they developed a s t rong maternal fee l ing toward t h e i r baby i m m e d i a t e l y af ter the b i r t h ; 33% developed this feel ing wi th in three days , w h i l e the remain ing 21% did not have this fee l ing by the t ime they left the h o s p i t a l . Regard ing the length of t ime that the women thought that i t would take to "know" the baby, e .g . , the reason f o r w h i c h he / she c r i e d , the frequency was as fo l lows : The f inding that those women i n the f a m i l y centred ma te rn i ty p r o -g r a m m e had a more pos i t ive atti tude toward t h e i r baby and gained m o r e exper ience and ass i s tance f r o m the hospi ta l in t h e i r new mother ing ro l e suggests that components of mother ing behaviour can be l ea rned ( in addi t ion to the co r r e l a t i on between pos i t ive att i tude toward the baby, and ease of adjustment, feel ings of competence and s e l f confidence;) that w i t h l ea rn ing come inc reased confidence and fee l ings o f competence , a more pos i t ive attitude toward the baby and a dec rease in d e p r e s s i v e I know h i m / h e r a l r e a d y 3 days one week one month more than one month 43% 27% 19% 3% 8% 126 affect . The s igni f icant co r re l a t ions between depres s ive affect and number of p rob lems experienced af ter one week and five weeks at home support th i s , as does tine re la t ionship between depres s ive affect and l e s s pos i t ive attitude towards the baby. T h i s i s consis tent w i t h . B e r n ' s theory of s e l f percept ion which p red ic t s that attitudes fol low behaviour (Bern 1965; 1967; 1970; Jones & G e r a r d 1967; C a l d e r and Ross 1973), and that a person infers h is attitude by obse rv ing h i s own behaviour and the context in which it o c c u r s . P rena ta l c l a s s teachers bel ieve that the prenata l t ime i s not the most p rop i t i ous f o r teaching parenting s k i l l s . One suggest ion based on the present study is that postpartum c l a s s e s fo r parents and the i r i n -fants be incorpora ted into the education f o r c h i l d b i r t h c l a s s e s as soon as feas ib ly poss ib le after the b i r th of a baby . These c l a s s e s cou ld i n -c lude such i tems as parenting s k i l l s a s w e l l a s deal ing wi th the emot ions and fee l ings of the new parents . S u c h c l a s s e s could a l s o s e r v e as a veh ic l e f o r the detection of parents who have p a r t i c u l a r d i f f i cu l t i e s i n the i r re la t ionship wi th the i r infant w i th a view .to the prevent ion of mother ing d i s o r d e r s . Conc lus ion S e a r c h fo r the Holy G r a i l In d i scuss ing the concept of "hea l th" , K i s s i c k (1972) stated that i t i s both a commonplace w o r d and an i l l u s i v e concept f rus t ra t ing 127 desc r ip t i on and quant i f icat ion. He states, "In a sense health i s an abs t rac t ion that may be viewed as the 20th century equivalent of the H o l y G r a i l — the never- to-be-a t ta ined object of a re len t less s e a r c h " . Cowen (1973) stated that p r i m a r y prevent ion in mental health seeks (a) to fo r e s t a l l dysfunction by reducing the rate of occu r r ence of d i s -o r d e r in the population at l a rge and (b) to p romote psycho log ica l heal th and w e l l b e i n g . Cowen saw p r i m a r y prevent ion as a "bonafide concep-tual a l te rna t ive to mental health problems' 'and stated that to be effective p r i m a r y p reven t ion should be a c t i v e l y or ien ted to the effects of e n v i r o n -ments and the sett ings on development . P r i m a r y prevent ion t yp i ca l l y does not o c c u r unt i l a ch i l d reaches p r e - s c h o o l age ( three) . The y e a r s f r o m b i r th to school age have often been d e s c r i b e d as the " s i l en t yea r s" (Stephenson, 1976, note 3 ) . K e l l a m (1972) pointed out that " F i r s t g r a d e r s a r e the youngest total subpopulation in the communi ty , i . e . the youngest age other than b i r t h at wh ich names and add res s a r e known" . T h i s may be s o ; however , there i s a convergence in the l i t e r a tu re indica t ing that pregnancy, ch i l db i r t h and subsequent motherhood should be the focus of sustained i n t e r d i s c i p l i n a r y r e sea rch and in tervent ion a c t i o n s . M u r p h y and Chandle r (1972) make an eloquent plea in this v e i n . They state that in a g r i c u l t u r e "prevent ion" of d isease o r of growth f a i l u r e i s seen l a r g e l y in te rms of provid ing fo r health and s tu rdy g rowth . " S c i e n t i f i c data relevant to the total development a r e made a c c e s s i b l e f r o m federa l , 128 state and county agencies and a r e r ead i ly appl ied to growth of ca t t l e , hogs, wheat and c o r n " . They d i s cus s the s i tuat ion in the automobi le f i e l d , where the consumers ' advocate , i f not the consumer , demands r e p a i r of recognized defects in c a r s , the development of safety checks , f inding ways of improv ing the roads and developing bet ter con t ro l of t raff ic wi th the ul t imate a i m of reducing percentage of deaths and i n -j u r i e s that o c c u r each y e a r . Murphy and Chandle r compare this wi th the f a i lu re to produce healthy c h i l d r e n . They state that the u t i l i z a t i on of a l l s c i en t i f i c knowledge relevant to the opt imum development in the a rea of ch i l d r en i s spotty and inadequate. They ci te the 161 ,000 infant deaths each y e a r ( U . S . ) and the re la ted b i r th hazards which predispose the infant to dis turbance of functioning in a l l a r e a s . M u r p h y and Chandler c i te the w o r k of Pasaman ick and his a s s o c i -ates as demonstrat ing the c lose re la t ion of major f o r m s of d is turbance i n development on the one hand wi th pregnancy and b i r th on the o ther . They ask "Can we think in te rms of a comprehens ive p r o g r a m m e to produce s t ronger babies , better equipped fo r s u r v i v a l in a changing s t ress fu l cu l tu re , comparable to the p r o g r a m m e s for a g r i c u l t u r a l product iv i ty? " Hofer (1975), C h a i r m a n of the C i b a Foundation Paren t - In te rac t ion S y m p o s i u m w r i t e s . . . "we have come to recognize that the ea r ly -pa ren t infant re la t ionship has a profound impac t on the development of 129 emotional behaviour , cognit ive f acu l t i e s , even b io log i ca l o rgan iza t ion and res i s tance to i l l n e s s " . A c c o r d i n g to K e s s l e r and A l b e e (1975): The National A s s o c i a t i o n fo r Menta l Heal th has p repared one of the most spec i f i c b luepr ints fo r ac t ion in p r i m a r y p r e v e n -t ion . It g ives actual steps to be taken by c i t i z e n s ' groups in the i r communi ty to achieve the goal of the prevent ion of l a t e r emotional d i s tu rbance . The N A M H proposa l focuses s p e c i f i c a l l y on prenatal and per ina ta l condit ions as a reas where definite ac t ion should be taken. The t ime f r o m conception to 6 months af ter b i r th was chosen as the ac t ion p e r i o d . A m o n g the act ions recommended are-prenata l and per ina ta l c a r e affecting the expecting mother and the developing fetus , ways of coping wi th l i f e c r i s i s s i tuat ions affecting the mother p a r t i c u l a r l y , the development of better parenting s k i l l s , the modif ica t ion of the s o c i a l sys t em which may be expected to be a sou rce of s t r e s s i f unmodif ied (welfare , med ica l c a r e , day ca re e t c . ) and the insurance of adequate medica l c a r e fo r mother and infant fo l lowing b i r th . (p .573) The w r i t e r feels that we should stop sea rch ing for the i l l u s i v e Ho ly G r a i l and s t a r t putting into effect some of the present knowledge attained f r o m s e r v i c e and r e s e a r c h . T h e r e i s an i nc rea s ing awareness of the impor tance , p h y s i c a l l y , deve lopmenta l ly , men ta l ly , e m o t i o n a l V c o g n i -t ive ly fo r both parents and ch i l d r en of the whole t ime per iod of pregnancy, ch i l db i r t h and e a r l y infancy. Instead of the re len t less s e a r c h we need re len t less m u l t i - d i s c i p l i n a r y ac t ion and focus on this p e r i o d . It can be done. F in land f o r example has a s t rong and f ree prevent ive s e r v i c e for antenatal c a r e , hospi ta l d e l i v e r y , postnatal c a r e and p reschoo l c h i l d -health ca re (Wynne and Wynne, 1974), a long wi th homemakers and home helps which a r e cons idered essent ia l prevent ive s e r v i c e s . F i n n i s h l aw 130 es tabl ished one C h i l d Heal th Cent re in e v e r y l o c a l author i ty i n 1944. T h e r e i s a schedule fo r developmental a s se s smen t r e q u i r i n g e x a m i n a -t ion at monthly in te rva l s fo r those babies under 12 months . It i s the p o l i c y i n F i n l a n d that a c h i l d have at l eas t one developmental e x a m i n a -tion pe r y e a r up to school age . The Wynne repor t states that "The coverage of these ch i ld ren i s coverage of t he i r homes and of the i r paren ts . The C h i l d Health Cen t re s teach parents nu t r i t i on , the m a n -agement of m i n o r a i lments and of behaviour p r o b l e m s , the impor tance of play and of s t imula t ion in the h o m e " . T h e r e i s delegation downwards f o r the operat ion of the maternal and ch i ldhea l th s e r v i c e s f r o m the p r o v i n c i a l governments to the l o c a l gove rnmen t s . T h i s delegat ion of au thor i ty is accompanied by obl igat ions that ensure that the l o c a l gov -ernments have s t rong prevent ive s e r v i c e s . In add i t ion , there i s accoun t -a b i l i t y of two kinds on the par t of the l o c a l au thor i ty , to the M i n i s t e r of Heal th ; accountabi l i ty fo r the f inanc ia l expendi tures and , m o r e s i g n i f i -can t ly , accountabi l i ty f o r pe r fo rmance . A s a resul t F i n l a n d has become . one of the w o r l d leaders in materna l and c h i l d heal th . It can be done e l sewhere . A s S ta l lwor thy (1972) pointed ou t , "Obs te t r i c s i s no longer an e x e r c i s e in mechanics but an opportunity f o r p r a c t i s i n g prevent ive medic ine at i ts bes t" . 131 Notes 1. S t o v e l , S . Nut r i t ion in Pregnancy: L i t e r a tu re Rev iew. P r e p a r e d fo r the P a c i f i c Health Educat ion A s s o c i a t i o n wi th ass i s tance of the Vancouver C i ty Health Department and B r i t i s h Columbia P r o v i n c i a l Department of Hea l th . 2 . K h a i r a t , L . and Costanzo, G . A project to evaluate the ef fec t ive-ness of an educational p rog ramme for expectant parents . Vancouver , B . C . Met ropo l i t an Health S e r v i c e of G r e a t e r Vancouver , M a y 1974. 3 . Stephenson, S . Bonding and At tachment dur ing the P u e r p e r i u m . P a p e r presented at Nur s ing C a r e in the P u e r p e r i u m . Continuing Educat ion in the Health S c i e n c e s . The U n i v e r s i t y of B r i t i s h C o l u m b i a , M a r c h 1976. 132 References A l p e r , M . H . , B r o w n , W . U . , O s t h e i m e r , G . W . , and S c a n l o n , J . W . , Effects of Mate rna l A n a l g e s i a on the Newborn . C l i n i c s in obs te t r ics and gynaecology, J . J . B o n i c a , (ed.) 1975, 2 ( 3 ) , 661-671 . B a k e r , M . , Dorzab , J . , W i n o k u r , G . & Cadore t . Deores s ive Di sease : The Effect of the Pos tpar tum S ta t e . B i o l o g i c a l P s y c h i a t r y , 1971, 3 , 357-365. Barne t t , C . R - . , L e i d e r m a n , P . 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No h i s t o r y of p s y c h i a t r i c d i s o r d e r s 6 . P r i m i p a r o u s 7. D e l i v e r e d of a s ing le infant in one of three major Vancouver hospi ta l s 8 . No major med ica l compl i ca t ions dur ing pregnancy, d e l i v e r y o r the postpartum of e i ther the mother o r infant. 148 Appendix 3 Desc r ip t ion of demographic c h a r a c t e r i s t i c s f o r sample of women in the present study N=106 Y e a r s 1 9 - 2 4 25 - 30 31 - 35 37 A G E O F W O M E N N o . 23 69 13 1 B I R T H P L A C E O F W O M E N N= 106 Count ry N o . Canada B r i t a i n U . S . A . A u s t r a l i a European Y e a r s Under 12 12 13 87 9 Y E A R S O F E D U C A T I O N N = 106 33 8 N = 94 21 60 12 • 1 N = 94 76 9 5 2 2 N = 94 3 26 8 came to Canada as infants, r a i sed in Vancouver , B . C . 149 Y e a r s N = 106 N = 94 14 9 6 15 8 8 16 22 21 17 19 19 18 2 2 i no response 1 1 M A J O R O C C U P A T I O N S O F W O M E N N = 106 N = 94 Nurses 20 18 Teache r s 19 17 S e c r e t a r i e s 16 14 Housewives 16 15 Other 35 30 E M P L O Y E D D U R I N G P R E G N A N C Y N = 106 N = 94 1 - 3 months 12 11 4 - 5 months 13 10 6 - 7 months 37 3 4 8 months 20 17 9 months 7 7 not employed 16 14 no response 1 1 150 P L A N N I N G T O R E T U R N T O W O R K A F T E R T H E B I R T H O F T H E B A B Y N=106 N=94 W i t h i n two months 11 11 before s i x months 19 16 after s i x months 7 7 unsure 11 8 not re turning to w o r k 56 50 no response 2 2 151 Appendix C Greenberg Mate rn i ty Ques t ionnai re ~ Se lec ted Quest ions 1. A f t e r having been in the hospi ta l f o r about one week, I now feel that my se l f -conf idence on the question of ch i ld ca r e i s V e r y l a rge (5) Rather la rge (4) Nei the r l a rge nor s m a l l (3) Rather s m a l l (2) V e r y l i t t l e (1) 2 . Do you think that you w i l l need help in the home the f i r s t t ime? N o , not at a l l (5) Y e s , a l i t t l e (4) Y e s , a moderate amount (3) Y e s , a l a rge amount (2) 3 . W h i c h of the fol lowing is true f o r you? I have been v e r y happy i n the hospi ta l and I a m thus not in such a h u r r y to go home (5) I have been happy at the hospi ta l but I s t i l l would l i k e to go home a s soon a s poss ib le (4) I have not been e spec i a l ly unhappy in the hospi tal but I s t i l l want to go home ve ry much (3) I have been unhappy i n the hospi ta l and want to go home v e r y much (2) 4 . A t this t ime how do you feel? V e r y t i r ed (1) A l i t t l e t i red (2) A s usual (3) Pepped up (4) F u l l of energy (5) 5. Check what i s true f o r y o u . I think that this new baby is a great r e spons ib i l i t y and I a m ve ry anxious about h i s ca re ( 1) I think that this new baby is a great r e spons ib i l i t y but I a m not anxious about h is ca re (2) I don't think that this baby is such a great r e spons ib i l i t y but I a m s t i l l anxious about h is ca r e (3) I don't think that this baby is such a great r e spons ib i l i t y and I a m not anxious about his ca r e(4) 152 6. How do you feel about y o u r coming ro le of being a mother? I am happy about i t and feel confident in m y s e l f (5) I a m happy but a l i t t l e uneasy (4) • I a m a l i t t l e anxious (3) I a m a l i t t l e anxious and uncer ta in (2) I a m ve ry anxious (1) V e r y glad (5) Glad (4) A s usual (3) A l i t t l e sad (2) Depressed (1) 8 . Many mothers don't develop a s t rong feel ing towards the baby r ight away . T h i s i s comple te ly n o r m a l . When did you f i r s t get the feel ing that the baby was a l l y o u r s ? Immediately after the b i r th (5) A f t e r the f i r s t 3 days (4) A f t e r the f i r s t week (3) It's coming but I don' t quite have i t yet (2) 9 . A f t e r having been in the hospi ta l fo r about one week, I now feel that my competence on the question of ch i l d c a r e i s V e r y l a rge (5) Rather l a rge (4) Nei ther la rge nor s m a l l (3) Rather s m a l l (2) V e r y l i t t l e (1) 10. How long do you think that i t w i l l take you to know y o u r infant; the reason f o r which he c r i e s e tc . I know h i m a l r eady (6) Th ree days (5) One week (4) Two weeks (3) One month(2) M o r e than one month (1) 11. How much do you think that the baby w i l l r e s t r i c t y o u r usual ac t iv i t i e s? 7 . A t this t ime how do you feel? Not at a l l (5) A l i t t l e (4) Somewhat (3) Modera t e ly (2) G r e a t l y (1) 153 12. How did you feel after ' the d e l i v e r y ? V e r y t i r ed (1) A l i t t le , t i red (2) A s usual (3) Pepped up (4) F u l l of energy (5) 13. How much help d id you rece ive f r o m the nurs ing personnel? A l i t t l e (1) Rather much (2) M u c h (3) A great deal (4) 14. How did you feel immed ia t e ly af ter the de l i ve ry? V e r y glad (5) Glad (4) A s usual (3) A l i t t l e sad (2) Depressed (1) 15. D i d you feel that the help that you rece ived f r o m the hospi ta l personnel was M o r e than enough (5) About r ight (3) Not enough (1) 154 Appendix D Greenberg ' s F o l l o w - u p — Selec ted Quest ions 1 . A f t e r having been at home for about 1 week, I now feel that my s e l f confidence in the question of ch i l d ca re i s V e r y l a rge (5) Rather la rge (4) Nei ther la rge no r s m a l l (3) Rather s m a l l (2) V e r y l i t t l e (1) 2 . D i d you feel that y o u r adjustment f r o m the hospi ta l to the home was V e r y easy (5) E a s y (4) Nei ther d i f f icul t nor easy (3) Dif f icu l t (2) V e r y di f f icul t (1) 3 . How much exper ience did you feel that you rece ived wh i l e in the hospi ta l (Exper i ence in how to take ca re of a baby) V e r y l a rge (5) Rather l a rge (4) Nei ther l a rge nor s m a l l (3) Rather s m a l l (2) V e r y l i t t l e (1) 4 . I fel t that the materni ty hospi ta l helped me V e r y much (5) Rather much (4) Nei ther l i t t l e nor much - to be prepared fo r my ro le Rather l i t t l e (2) of being a mother V e r y l i t t l e (1) 5. How long do you think i t w i l l take fo r you to know y o u r infant the reason for which he c r i e s , e t c . I know h i m a l ready (5) Two weeks more (4) One month more (3) Th ree months m o r e (2) M o r e than three months (1) 155 6. When I f i r s t came home f r o m the materni ty hospi ta l I fel t V e r y ce r t a in (5) Rather ce r t a in (4) Ne i the r ce r t a in nor uncer ta in (3) - about the question of Rather uncer ta in (2) how one should take ca re V e r y uncer ta in (1) of a newborn baby 7« How much help d id you need when you f i r s t a r r i v e d home f r o m the hospi ta l? None (5) A l i t t l e (4) A moderate mount (3) A la rge amount (2) Appendix E Means and Standard Deviat ions fo r the Demographic Data of Women who De l ive red T h e i r Babies in the T h r e e M a j o r Hospi ta l s in Vancouver , B r i t i s h Co lumbia Hosp i ta l A N=2S Hospi ta l B N=34* Hospi ta l C N=45 Mean S D Mean S D Mean S D A g e Number of Y e a r s of Educat ion — W i f e Annua l Income of Wi fe Number of Y e a r s of Educat ion — Husband 27 .35 14.62 3 .60 26.88 1 .81 14.62 3 .45 2 .13 $5,808 $2,522 $6,147 $2,159 15.69 3 .16 15.44 3 .16 26.93 14.33 14.88 2 .90 2 .24 $6,378 $1,946 2 .99 A n n u a l Income of Husband $13,827 $5,600 $13,706 $4,488 $13,100 $4,609 *The prenatal data f r o m one woman in this group we re los t in the m a i l and not r ecove red . Appendix F Means and Standard Deviat ions of the Measu res Col lec ted • in the Ninth Month of Pregnancy for the Women Who D e l i v e r e d T h e i r Babies in the Three M a j o r Hospi ta l s in Vancouver , B r i t i s h Columbia Hospi ta l A N=26 Hospi ta l B N = 34* Hospi ta l C N=45 At t i tude to Pregnancy Beck Dep re s s ion Index Mean 5 .65 S D 165.27 20 .49 2 .90 Mean 163.88 6.41 S D 15.19 3.67 Mean 158.98 5.84 S D 38 .48 3 .78 D A C L 47 .50 7 .55 47.12 6.67 46.93 6.88 P leasant Events Schedule 70 .88 13.30 67.09 21 .95 67.56 18.87 *The prenatal data f r o m one woman in this group were los t in the m a i l and not r e c o v e r e d . 159 Appendix H 1. L E N G T H O F G E S T A T I O N N=106 N=94 O v e r 40 weeks 38 34 40 weeks 30 27 38 - 39 weeks 26 24 36 - 37 weeks 6 4 less than 36 weeks 2 2 no response 4 3 2 . L E N G T H O F L A B O U R N=106 N=94 Under 5 hours 18 15 5 - 8 hours 25 21 9 - 19 36 34 over 20 hours 23 20 no response 4 4 3 . M E T H O D O F D E L I V E R Y N=1Q6 N=94 Caesa r i an 21 21 Vaginal 85 73 4 . A N A S T H E T I C N=106 N=94 Sp ina l 7 6 Ep idu ra l 63 56 P e r i n e a l B l o c k 11 11 160 N=106 N=94 Ni t rous Oxide 17 14 Other 8 7 5. S E X O F I N F A N T N=106 N=94 Fema le 49 48 M a l e 57 46 6. B I R T H W E I G H T O F I N F A N T N=106 N=94 O v e r 3 ,600 g r a m m e s 31 28 O v e r 3,375 24 21 O v e r 3 ,150 14 13 O v e r 2 ,925 18 16 O v e r 2 ,700 14 12 O v e r 2 ,475 5 4 7 . M E T H O D O F F E E D I N G N=106 N=94 Breast feeding 91 80 Bott le feeding 11 10 Both 4 4 161 Append ix I Means and s tandard deviat ions f o r the demographic data F a m i l y centred ma te rn i ty p r o -g r a m m e N=20 Mean S D T r a d i t i o n a l P r o g r a m m e N=52 * Mean S D A g e Number of Y e a r s Educat ion — Wife Number of y e a r s Educat ion — Husband 27 .40 14.40 Annua l Income of Wife $5 ,950 15.60 3 .07 1 .76 3 .32 26 .79 14.40 $2 ,559 $6 ,105 15. 10 3 . 3 6 2 . 2 6 $2,197 3 .02 Annua l Income of Husband $13,550 $6 ,149 $12,606 $4 ,793 * The prenatal data f rom one woman in this group we re los t in the m a i l and not recovered 162 Append ix J Means and s tandard deviat ions of the measures co l lec ted i n the ninth month of pregnancy D A C L Pleasant Events Schedule F a m i l y Cent red M a t e r n i t y P r o -g r a m m e N=20 M e a n At t i tude to Pregnancy • 166.05 B e c k Depress ion Index 5 .55 4 7 . 0 5 71 .30 S D 19.19 2 .54 7 .06 13 .75 T r a d i t i o n a l P r o g r a m m e N = 52* Mean 165.25 5 .92 46 .29 69 .63 S D 15.24 3 .00 6 .30 20 .07 * The prenatal data f r o m one woman in this group w e r e los t in the m a i l and not recovered 163 Appendix K Means and s tandard deviat ion of responses to Greenberg ' s quest ionnaire F a m i l y Centred Mate rn i ty C a r e P r o g r a m m e N=20 Mean S D T r a d i t i o n a l P r o g r a m m e N=53 Mean S D S e l f Confidence 3 .40 .60 3 .26 .84 regarding c h i l d c a r e Percep t ion of help 3 .90 .79 3 .66 .85 needed at home Happiness in Hosp i ta l 4 . 0 5 .76 4.01 .60 P re sen t energy l eve l 2 .15 1 .04 2 .19 .86 Absence of anxiety regard ing 1 .40 .50 1 .45 .54 r e spons ib i l i t y of baby Confidence regard ing the 4 . 3 0 .80 4 .47 .80 ro le of motherhood Presen t feel ings of gladness 4 . 2 5 .85 4 .28 .95 versus depress ion Mate rna l feel ing to baby 3 .75 1 .29 4 . 2 5 1 .02 Competence regard ing ch i l dca re 3.45 .76 3 .28 .72 Immediacy of understanding 1.80 1 .06 2 .15 1 .18 baby's needs L a c k of r e s t r i c t i o n in usual ac t i v i t i e s 2 .35 1 .09 2 .83 1 .01 Energy l e v e l af ter d e l i v e r y 2 .30 1 .42 2 .79 1 .60 Amoun t of help f rom 2 .55 .76 2 .36 .83 nurs ing personnel Fee l ings of gladness versus 4 . 5 5 .83 4.81 .62 depress ion af ter d e l i v e r y Amount of help received 3 .30 1.17 3 .08 .78 f r o m hospi ta l personnel \6h Appendix L Means and standard deviations of the measures completed after f ive weeks at home At t i tude to Baby A r e a s of Concern B e c k Depress ion Index D A C L Pleasant Events Schedule F a m i l y Centred Mate rn i ty C a r e P r o g r a m m e N=20 Mean 176.30 8.20 5.05 46 .35 59.60 S D 4 .77 3 .99 T r a d i t i o n a l P r o g r a m m e N=53 Mean 6 .06 4 .72 S D 16.33 182.17 13.87 6.02 3 .47 6 .60 45 .79 10.77 18.74 62 .09 20 .88 165 A p p e n d i x M M e a n s a n d s t a n d a r d d e v i a t i o n s f o r t h e d e m o g r a p h i c d a t a A g e N u m b e r o f Y e a r s o f E d u c a t i o n — W i f e A n n u a l I n c o m e o f W i f e N u m b e r o f Y e a r s E d u c a t i o n — H u s b a n d A n n u a l I n c o m e o f H u s b a n d V a g i n a l D e l i v e r i e s N = 7 2 * M e a n 2 6 . 9 6 1 4 . 4 0 $ 6 , 0 6 3 1 5 . 2 4 $ 1 2 , 8 6 8 S D 3 . 2 6 C a e s a r i a n S e c t i o n N=21 M e a n 2 7 . 6 2 S D 3 . 6 3 2 . 1 2 1 4 . 8 1 2 . 1 1 $ 2 , 2 8 6 $ 6 , 4 0 5 $ 1 , 7 2 9 3 . 0 9 1 5 . 8 1 3 . 1 7 $ 5 , 1 7 7 $ 1 4 , 5 9 5 $ 3 , 8 2 6 T h e p r e n a t a l d a t a f r o m o n e w o m a n i n t h i s g r o u p w e r e l o s t i n the m a i l a n d n o t r e c o v e r e d 166 Appendix N Means and s tandard deviat ions of the measu res co l lec ted in the ninth month of pregnancy At t i tude to Pregnancy B e c k Depres s ion Index D A C L Vaginal D e l i v e r y N=72* Mean 165.47 5.82 46 .50 S D 16.30 2 .87 Caesa r i a n S e c t i o n N=21 M e a n 5 .90 6.48 49 .62 S D 158.10 4 0 . 1 5 4.21 7 .39 P leasant Events Schedule 70 .10 18.45 63 .76 15.68 * The prenatal data f r o m one woman in this group w e r e l o s t in the m a i l and not recovered 167 Appendix O Means and standard deviations of the measures completed after one wee!-; at home At t i tude to Baby A r e a s of C o n c e r n Sel f -conf idence re : ch i l dca re Ease of adjustment f rom hospi tal Expe r i ence rece ived in Hosp i t a l P repa ra t ion fo r ro le of Mother ing Length of t ime to understand infant Cer ta in ty regard ing c h i l d b i r t h Amount of help needed D A C L vaginal D e l i v e r y N=73 Mean 161.22 9.38 3.48 3 .19 2 .85 3 .16 3.71 3 .05 3.21 48 .55 7,38 .80 1 .00 .96 .73 7.41 Caesjj r i a n Sec t i on N=21 S D Mean 18.30 150.38 7 .38 3 .10 1.05 2 .86 2 .62 1.09 2.81 1.10 3 .43 2 .90 S D 39.12 6 .18 1 .30 1 .42 1 .47 1 .60 1 .57 1 .48 2.71 1.15 46 .62 12.85 168 Appendix P Means and standard deviations fo r the measures completed after f ive weeks at home Vaginal C a e s a r i a n D e l i v e r y S e c t i o n N=73 N=21 Mean S D Mean S D At t i tude to Baby 180.56 14.70 174.62 14.05 A r e a s of Conce rn 6.64 5 .76 6 .76 6 .39 B e c k Depress ion Index 4.81 3 .59 5 .43 3 .26 D A C L 45 .95 9 .77 4 9 . 0 5 6.87 Pleasant Events Schedule 61.41 20 .22 59.43 17.92 163 Key for Appendix Q 25 A i d when 23 Know 10 Room 17 Infant 20 Ad jus t 24 C e r t 22 Help 19 Conf i 21 E x p e r 18 Cone 7 Sex 4 Incoh 13 Concern 3 Educh 1 A g e 2 EducW 15 V12 8 W G T 16 V14 14 D A C L C 9 Feed 6 Lab 12 labdel 11 A t t p r e g 5 Dayspp Help needed at home Immediacy of understanding infant N o . of days rooming- in attitude towards baby ease of adjustment f r o m hospi ta l cer ta in ty regarding ca re of newborn help rece ived f rom hospi ta l s e l f confidence regarding c h i l d c a r e exper ience received in hosp i ta l no, of p rob lems in hospi ta l Sex of infant Income of husband no. of p rob lems at home education of husband A g e of wife education of wife energy leve l in hospi tal weight of infant feel ings of gladness D A C L in hospi tal bottle feeding length of labour attitude towards labour and d e l i v e r y attitude towards pregnancy number of days in hospi tal 170 Appendix Q F'actor A n a l y s i s of Data F a c t o r s and fac tor loading of selected va r i ab l e s N = 93 F a c t o r V a r i a b l e 25 A i d when 23 Know 10 Room 17 Infant 20 Adjus t 24 C e r t 22 Help 19 Confi 21 E x p e r 18 Cone 7 Se& 4 Incoh 13 Concern 3 Educh 1 A g e 2 EducW 15 VI2 8 W G T 1 - 0 . 4 3 8 6 -0 .4437 -0 ,4644 -0 .5935 -0 .6151 -0 .6513 -0 .6731 -0 .6968 -0 .7191 0.1618 0.1698 -0 .0767 0.1403 -0 .0048 -0 .0907 0.0426 0.1099 -0 .0869 0.2733 -0.0031 -0 .1918 0.2055 0.2215 0.0740 -0 .2547 0.2116 -0 .3158 -0 .2639 -0.2851 - 0 . 3 060 -0 .4177 -0 .4199 -0 .4907 -0 .5722 0.0266 -0 .0530 - 0 . 0 7 6 9 0 .0159 - 0 . 2 1 2 3 0.1284 0.1624 - 0 . 0 9 0 0 0.2708 0.0701 0 .1752 - 0 . 1 3 3 2 0.2198 - 0 . 1 5 2 8 - 0 . 0 4 0 8 0.1937 - 0 . 0 7 9 0 -0 .0291 0 .5293 0 .4323 4 0.1358 -0 .0523 -0 .0581 0.2353 0.0241 0.1622 - 0 . 1 8 1 5 0.1124 - 0 . 1 2 5 0 0.0641 0 .0473 -0 .0862 0.1649 - 0 . 1 2 6 5 - 0 . 1 5 6 0 - 0 . 0 2 1 4 0.1327 0.0541 17) 16 V I 4 14 D A C L C 9 Feed 6 Lab 12 labdel 11 A t t p r e g 5 Dayspp 0.0143 0.2395 0.2143 -0 .0603 -0 .0827 •-0.0952 - 0 . 0 0 3 6 0.1347 -0 .1047 0.0369 -0.3481 -0 .0978 0.1702 -0 .2447 0 .4125 - 0 . 3 2 9 6 -0 .3671 -0 .4717 0 .1675 0 .1319 -0 .2081 0 .1673 -0 .1252 0 .0310 0 .3483 0.8169 0 . 1985 - 0 . 3 7 4 5 

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