Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

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

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1976_A1 B73.pdf [ 7.48MB ]
Metadata
JSON: 831-1.0093925.json
JSON-LD: 831-1.0093925-ld.json
RDF/XML (Pretty): 831-1.0093925-rdf.xml
RDF/JSON: 831-1.0093925-rdf.json
Turtle: 831-1.0093925-turtle.txt
N-Triples: 831-1.0093925-rdf-ntriples.txt
Original Record: 831-1.0093925-source.json
Full Text
831-1.0093925-fulltext.txt
Citation
831-1.0093925.ris

Full Text

THE  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 ON  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  by  Christine B.A.  (Honours)  M.Sc.  A  THESIS  T O  Felecia  McGIU  (Applied)  University,  McGill University,  B E S U B M I T T E D  THE  Bradley  IN  In t h e  Montreal,  P . Q .  D E G R E E  O F  PHILOSOPHY  Department  of Psychology  We  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 the r e q u i r e d  THE  gus 9 7I 6T I S H U N I V E R SA I Tu Y Ot F, B1R  standard  C O L U M B I A  Christine Felecia Bradley,  1976  1968  P . Q .  P A R T I A L F U L F I L L M E N T  R E Q U I R E M E N T S F O R T H E D O C T O R O F  Montreal,  O F  1970  In  presenting  this  an a d v a n c e d d e g r e e the I  Library  further  for  agree  in p a r t i a l  fulfilment  of  at  University  of  Columbia,  the  make  it  freely  that permission  this  representatives. thesis  for  It  financial  for  gain  Department  of  British  2075 Wesbrook Place Vancouver, Canada V6T 1W5  for  extensive by  the  Columbia  shall  not  the  requirements  reference copying of  Head o f  is understood that  written permission.  The U n i v e r s i t y  British  available  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 h i s of  shall  thesis  I  agree  and this  be a l l o w e d  that  study. thesis  my D e p a r t m e n t  copying or  for  or  publication  w i t h o u t my  ii  Abstract The  purpose o f this investigation w a s twofold.  First,  to investigate  the 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 first child.  S e c o n d , to evaluate the effectiveness  ofa f a m i l y  centred  m a t e r n i t y p r o g r a m m e i np 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 the i n fant a n d i nt e r m s ofp r e p a r i n g them o t h e r s f o r t h e i r new r o l e . The with  subjects  were  their husbands.  94 m a r r i e d women who attended prenatal  They were white,  C a u c a s i a n ,  with a mean ageof  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 . women were raised i nNorth  classes  A m e r i c a o r theB r i t i s h  The  Commonwealth.  A l l w o m e n delivered a single full t e r m infant a n d experienced no m a j o r •medical complications ofeither themselves o r their infant during pregnancy, delivery o r the postpartum  period.  E a c h w o m a n completed a series ofquestionnaires relating to attitude towards pregnancy, labour and delivery, c h i l d b i r t h , the new baby a n d thehospital experience.  These measures were completed at  f o u r points i ntime; i ntheninth month ofpregnancy, w h i l e i n hospital and  after one and five weeks a thome.  Depression Adjective  Checklists,  In a d d i t i o n ,  she c o m p l e t e d t h e  theB e c k D e p r e s s i o n Index a n d the  P l e a s a n t Events S c h e d u l e i nthe ninth month o fpregnancy a n d i n the 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 .  The Depression  Adjective  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 that t h e w o m a n w a s i n h o s p i t a l .  i ii  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  iv  delivery.  T h e r e w a s no d i f f e r e n c e between these two g r o u p s of w o m e n  in e i t h e r t h e i r attitude towards t h e i r infant o r t h e i r f e e l i n g s of s e l f confidence.  A repeated m e a s u r e s a n a l y s i s of v a r i a n c e r e v e a l e d that  those w o m e n who had c a e s a r i a n s w e r e m o r e d e p r e s s e d a f t e r the b i r t h of t h e i r baby than those w o m e n who d e l i v e r e d t h e i r baby v a g i n a l l y . A l t h o u g h the w o m e n in t h e ' p r e s e n t study w e r e not c l i n i c a l l y d e p r e s s e d there w e r e s i g n i f i c a n t c o r r e l a t i o n s between l e v e l s of d e p r e s s i v e affect and o t h e r v a r i a b l e s .  F o r e x a m p l e , i n the ninth month of  p r e g n a n c y d e p r e s s i v e affect w a s r e l a t e d to a l e s s p o s i t i v e attitude towards p r e g n a n c y ; i n h o s p i t a l d e p r e s s i v e affect w a s r e l a t e d to a l e s s p o s i t i v e attitude t o w a r d s l a b o u r and d e l i v e r y and t o w a r d s the baby; a t s i x w e e k s p o s t p a r t u m d e p r e s s i v e affect w a s r e l a t e d to a l e s s p o s i t i v e attitude towards the b a b y . T h e d i s c u s s i o n c e n t r e d a r o u n d the i m p l i c a t i o n of the f i n d i n g s f o r h o s p i t a l p r o g r a m m e s and p r e n a t a l c l a s s c u r r i c u l a , c u r r e n t b e h a v i o u r a l t h e o r i e s of d e p r e s s i o n a n d the myth of m a t e r n a l i n s t i n c t . f  V  T A B L E OF CONTENTS Chapter  Page  Abstract  ii  L i s t of T a b l e s  vi i  L i s t of F i g u r e s  ix  Glossary Acknowledgements I  x «  xi 1  Introduction and P u r p o s e of S t u d y . R e v i e w of the l i t e r a t u r e  2,  T h e r o l e of e m o t i o n a l and a t t i t u d i n a l f a c t o r s i n o b s t e t r i c outcome  II  k  Postpartum disorders  22  Hospital environment  32  Conclusions from review.  54  Present Study  56  Evaluation research  57 62  Method Setting.  62  Subjects  64  Measures Procedures Statistical analyses„  •  67 ~]k 7c  vi  Chapter III  IV  Page  Results  .  78  C o m p a r i s o n between h o s p i t a l p r o g r a m m e s  yg  C o m p a r i s o n between v a g i n a l d e l i v e r y and c a e s a r i a n section  94  C o r r e l a t i o n coefficients between v a r i a b l e s  ]01  Factor analysis «  ] 03  Discussion F a c t o r s affecting p r e s e n t study  105  I m p l i c a t i o n s f r o m findings  j 8  References Appendix  0  131  vi i  LIST O F T A B L E S Table I  Page D i s t r i b u t i o n of w o m e n i n the t h r e e m a j o r h o s p i t a l s in Vancouver  65  S c h e d u l e f o r c o m p l e t i o n of d a t a , t i m e p e r i o d and m e a s u r e s involved „  68  III  A l p h a r e l i a b i l i t y c o e f f i c i e n t s f o r attitude q u e s t i o n n a i r e s .  69  IV  P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x f o r the d e m o g r a p h i c data  79  II  V  P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x f o r the c o l l e c t e d in the ninth month of p r e g n a n c y  measures 80  VT  M e a n s and s t a n d a r d d e v i a t i o n s of h o s p i t a l data — h o s p i t a l programme 82  VTI  P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x f o r the completed while in hospital  measures 8^  VIII  P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x of the r e s p o n s e s to 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 85  IX  M e a n s and s t a n d a r d d e v i a t i o n s of the m e a s u r e s c o m p l e t e d a f t e r one week at home — H o s p i t a l p r o g r a m m e . 86  X  P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x of the m e a s u r e s c o m p l e t e d after one w e e k a t h o m e  88  XI  P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x f o r the m e a s u r e s c o m p l e t e d a f t e r five w e e k s at h o m e • • • 89  XII  Repeated m e a s u r e s a n a l y s i s of v a r i a n c e — l e v e l of d e p r e s s i v e affect o v e r t i m e — h o s p i t a l p r o g r a m m e 91  XIII  M e a n s and s t a n d a r d d e v i a t i o n s of the h o s p i t a l data — type of d e l i v e r y 96  vi i i  Table XIV  XV  •  Page M e a n s and s t a n d a r d d e v i a t i o n s of responses to 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 - type of delivery. Repeated m e a s u r e s a n a l y s i s of v a r i a n c e — l e v e l of d e p r e s s i v e affect o v e r t i m e — type of d e l i v e r y .  97  99  ix  LIST OF FIGURES Figure  Page  1  S c h e m a f o r d i s o r d e r s of m o t h e r i n g  ^3  2  M e a n s of D A C L s c o r e s at s e v e n points i n t i m e — Hospital programme.  92  M e a n s of D A C L s c o r e s at s e v e n points i n t i m e — T y p e s of d e l i v e r y .  100  M c L e a n ' s s c h e m a i l l u s t r a t i n g the consequence o f ineffective coping t e c h n i q u e s .  119  M o d i f i c a t i o n of M c L e a n s ' s c h e m a i l l u s t r a t i n g effect of having a c a e s a r i a n s e c t i o n  119  3  4  5  GLOSSARY gravid  pregnant  gravidity  pregnancy  mulipa rous  having b o r n e m o r e than one c h i l d  parity  the fact of h a v i n g borne l i v i n g c h i l d r e n  parturient  to be i n l a b o u r  parturition  childbirth  primiparous  b e a r i n g a c h i l d f o r the f i r s t t i m e  puerperal  a c c o m p a n y i n g o r ensuing upon c h i l d b i r t h  puerperium  immediate postpartum period  xi  ACKNOWLEDGEMENTS I would l i k e to thank m y c o m m i t t e e f o r t h e i r support and t h e i r valued c r i t i c a l c o m m e n t s .  S p e c i a l thanks a r e due to D r . P . O .  D a v i d s o n , C h a i r m a n of m y committee., f o r h i s guidance and e n c o u r a g e ment i n a l l a s p e c t s of the study, and for h i s c o n s t r u c t i v e c r i t i c i s m s and editorial comments.  I owe m u c h to D r . R a l p h H a k s t i a n f o r h i s  s t a t i s t i c a l a d v i c e and to M s . V i r g i n i a G r e e n f o r h e r p e r s i s t e n t good h u m o u r and patience t o w a r d s a c o m p u t e r neophyte. T h i s study w o u l d not have been p o s s i b l e without the c o o p e r a t i o n of the t e a c h e r s of the V a n c o u v e r C h i l d b i r t h A s s o c i a t i o n and the L o w e r M a i n l a n d C h i l d b e a r i n g A s s o c i a t i o n who a l l o w e d m e a c c e s s to the c o u p l e s who p a r t i c i p a t e in t h e i r education f o r c h i l d b i r t h c l a s s e s .  N o r would  the study have been p o s s i b l e without the w o m e n who volunteered to p a r t i c i p a t e in the study and who c o m p l e t e d the many q u e s t i o n n a i r e s under sometimes trying c i r c u m s t a n c e s . The a s s i s t a n c e of M s . J a n e t Q u i n l a n and the staff at the 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 f o r t h e i r a s s i s t a n c e and helpful c o m m e n t s i s appreciated. St.  A s p e c i a l thank y o u to M s . B e r n a d e t t e M . R a t s o y o f  P a u l ' s H o s p i t a l f o r h e r continuing i n t e r e s t and e n c o u r a g e m e n t .  1  CHAPTER  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 M o d e r n P e r s p e c t i v e s i n 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 l a c k of s y s t e m a t i c attention to tine p s y c h o l o g y of n o r m a l p r e g n a n c y , a n d , a s a c o r o l l a r y , the r e l a t i v e absence of c o m p r e h e n s i v e t e a m w o r k w h i c h w i l l be seen to be e s s e n t i a l f o r the management of the s t r e s s e s of n o r m a l p r e g n a n c y and f o r the p r e v e n t i o n of m o t h e r i n g breakdown . . . p r e g n a n c y r e s e a r c h i s s t i l l f r a g m e n t a r y and s o m e t i m e s m i s d i r e c t e d in its f a i l u r e to c o r r e l a t e o b s t e t r i c , p s y c h o l o g i c a l and s o c i a l f a c t o r s , (p. 292) He m a i n t a i n e d that s t a n d a r d o b s t e t r i c textbooks pay l i t t l e a t t e n tion to the p s y c h o l o g i c a l needs of the a v e r a g e w o m a n , and that s t a n d a r d textbooks of p s y c h i a t r y c o n t r i b u t e nothing to the v e r y r e a l p r o b l e m of the p s y c h o l o g i c a l management o f n o r m a l expectant p a r e n t s . A s y s t e m a t i c s e a r c h of the m o r e r e c e n t m e d i c a l , n u r s i n g and p s y c h o l o g i c a l l i t e r a t u r e f o r e m p i r i c a l s t u d i e s into p r e g n a n c y and c h i l d b i r t h c o r r o b o r a t e s the v a l i d i t y of H o r s l e y ' s s t a t e m e n t , and d e m o n s t r a t e s the l a c k of e m p i r i c a l data and t h e o r e t i c a l p r o p o s i t i o n s w h i c h would guide those doing r e s e a r c h in this a r e a . T h e r e have been t h r e e m a i n a r e a s of e n q u i r y w h i c h a r e c o n c e r n e d a l m o s t e x c l u s i v e l y w i t h the study o f a b n o r m a l c o n d i t i o n s of p r e g n a n c y .  2  T h e m o s t c o n c e n t r a t e d a r e a has been to d e t e r m i n e w h e t h e r t h e r e i s a r e l a t i o n beh/veen e m o t i o n a l , a t t i t u d i n a l o r p s y c h o l o g i c a l f a c t o r s d u r i n g the c o u r s e of p r e g n a n c y and o b s t e t r i c o u t c o m e .  The second area was  concerned with puerperal d i s o r d e r s , such as postpartum depression o r post-partum psychoses.  T h e t h i r d a r e a i n v o l v e d the e f f i c a c y of  education f o r c h i l d b i r t h both in t e r m s of the r e d u c t i o n of s t r e s s and in p r e p a r a t i o n f o r n a t u r a l c h i l d b i r t h . One a r e a that has r e c e i v e d l i t t l e e m p i r i c a l attention i s that of the h o s p i t a l and the type of d e l i v e r y — w h e t h e r v a g i n a l o r c a e s a r i a n s e c t i o n — and t h e i r effects upon the m o t h e r and n e w b o r n infant.  It  w a s i n this context that this study w a s u n d e r t a k e n . T h e p r e s e n t study a r o s e f r o m two i n t e r e s t s .  F i r s t , the need f o r  an e v a l u a t i o n of the effects of 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 i t i a t e d i n a V a n c o u v e r h o s p i t a l i n N o v e m b e r 1971.  S e c o n d , the  w r i t e r ' s i n t e r e s t in the p s y c h o l o g i c a l a s p e c t s of p r e g n a n c y , c h i l d b i r t h and e a r l y p a r e n t / i n f a n t r e l a t i o n s h i p s . Initial p r o b l e m s w h i c h r e f l e c t e d the d i f f i c u l t y i n conducting a p p l i e d r e s e a r c h i n the c o m m u n i t y , i n c l u d e d a l a c k of funding and a l a c k of i n t e r d i s c i p l i n a r y i n v o l v e m e n t . Both of these f a c t o r s p l a c e d c o n s t r a i n t s on the type of data c o l l e c t e d and on the o p p o r t u n i t y f o r l o n g - t e r m follow-up.  T y p i c a l of a p p l i e d r e s e a r c h w a s the i n a b i l i t y to a s s i g n the  p a r t i c i p a n t s r a n d o m l y to the two h o s p i t a l p r o g r a m m e s s t u d i e d .  "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  twofold.  First,  to  investigate  the attitudes a n d affect 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  first  baby toward their experience of pregnancy and childbirth and toward e x p e r i e n c e s e n c o u n t e r e d in the h o s p i t a l a n d the e a r l y p o s t p a r t u m Second,  to e v a l u a t e  the e f f e c t i v e n e s s of a f a m i l y  gramme  in p r o m o t i n g a positive feeling toward  -preparing its participants f o r their new  role.  period.  centred maternity  A  review  of the  the 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 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 the p r e s e n t  the c o n v e r g e n c e of 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  literature  Mental  Health,  1973)  1975;  to,  is  1972;  National A s s o c i a t i o n f o r  s e q u e n t m o t h e r h o o d s h o u l d be the f o c u s of s u s t a i n e d  and commitment  One  cognitive  i n d i c a t i n g that p r e g n a n c y , c h i l d b i r t h a n d  research and intervention action.  regarding  study.  nutrition and mental health (Murphy and C h a n d l e r ,  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 ,  sub-  interdisciplinary  The second is a personal belief  the i m p o r t a n c e o f this p e r i o d f r o m  the  in,  viewpoint  of prevention a n d p r o m o t i o n of p s y c h o l o g i c a l health a n d w e l l b e i n g of family as a  whole.  of  obtain  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 .  psychology,  pro-  the infant a n d in t e r m s  w a s u n d e r t a k e n to a s c e r t a i n both the p r e s e n t s t a t e of k n o w l e d g e  The  the  the  R e v i e w of L i t e r a t u r e T h e R o l e of E m o t i o n a l and A t t i t u d i n a l F a c t o r s in O b s t e t r i c O u t c o m e Tanzer  (19G7)  stated that m o s t of the e m p i r i c a l w o r k c o n c e r n i n g  the i n t e r r e l a t i o n s between r e p r o d u c t i v e and p s y c h o l o g i c a l functions a p p e a r e d i n the o b s t e t r i c a l and g y n e c o l o g i c a l l i t e r a t u r e r a t h e r than in the p s y c h o l o g i c a l l i t e r a t u r e , and w a s c o n c e r n e d with p a t h o l o g i c a l clinical conditions.  S h e s t a t e d , that the m o r e s y s t e m a t i c ,  t h e o r e t i c a l and c o m p r e h e n s i v e a p p r o a c h e s to the r e l a t i o n s h i p of p s y c h o l o g i c a l and r e p r o d u c t i v e functions have been w r i t t e n f r o m a F r e u d i a n o r p s y c h o a n a l y t i c point of v i e w .  T h e r e a d e r i s r e f e r r e d to  the w r i t i n g s of Deutsch  (1952),  Wengraf  (1953),  (1944/5),  Benedek  and S h e r e s h e f s k y & Y a r r o w  Bibring  (1973).  (1959/1961),  These works are  v u l n e r a b l e to s u c h c r i t i c i s m s as unproven t h e o r e t i c a l a s s u m p t i o n s , l a c k 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 histories alone. Grimm  (1967)  w r o t e one of the f i r s t c o m p r e h e n s i v e and c r i t i c a l  r e v i e w s of tine r o l e of c u l t u r a l , s o c i a l and p s y c h o l o g i c a l f a c t o r s i n pregnancy and o b s t e t r i c o u t c o m e .  S h e stated that a r e v i e w of this  literature revealed more a r t i c l e s which described general c l i n i c a l i m p r e s s i o n s o r c a s e h i s t o r i e s r a t h e r than e m p i r i c a l r e s e a r c h .  Grimm  e m p h a s i z e d the g r e a t need f o r r i g o u r i n r e s e a r c h design and m e t h o d ology; the need to make the s t a t e m e n t of a s s u m p t i o n s m o r e e x p 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,  status, number of pregnancies, social class and race.  marital  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 heterogenous 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 c h a r -  acteristics of women experiencing a single complication with those of normal pregnancies.  The second involved comparison of several c o m -  plications to determine possible personality characteristics specific to a clinical entity.  The third approach was derived from conceiving a l l  complications as derivatives of a single common process.  According  6  to M c D o n a l d , i t i s this l a t t e r m e t h o d o l o g i c a l a p p r o a c h that has g e n e r a l l y p r o d u c e d the best s t u d i e s .  He stated that the b e t t e r c o n t r o l l e d s t u d i e s  i n d i c a t e that " p s y c h o l o g i c a l d i f f e r e n c e s w e r e c o n s i s t e n t l y found between c o m p l i c a t i o n s a m p l e s and n o r m a l s a m p l e s . . . the c o m m o n d e n o m i n a t o r d i f f e r e n t i a t i n g the groups being an i n c r e a s e i n a n x i e t y l e v e l s , r e g a r d l e s s of the test i n s t r u m e n t u s e d " .  M c D o n a l d c r i t i c i z e d the l i t e r a t u r e  he r e v i e w e d f o r its n u m e r o u s m e t h o d o l o g i c a l s h o r t c o m i n g s and s a i d that s u c h " l i m i t a t i o n s i n v a l i d a t e o r at l e a s t s e r i o u s l y weaken the c o n c l u s i o n s d e r i v e d f r o m these s t u d i e s , and s t r e s s the need f o r w e l l designed e x p e r i m e n t s ,  r i g o u r o u s a p p l i c a t i o n of s t a t i s t i c a l t e c h n i q u e s ,  and a s y s t e m a t i c e x p l o r a t i o n 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 e p i d e m i o l o g i c a l v a r i a b l e s . " A r e v i e w of the l i t e r a t u r e subsequent to 1968 r e v e a l s that h i s c r i t i c i s m s and s u g g e s t i o n s of the need f o r w e l l designed s t u d i e s a r e s t i l l v a l i d . T h e s t u d i e s i n v o l v i n g a n x i e t y and o b s t e t r i c o u t c o m e w i l l be d i s c u s s e d to i l l u s t r a t e the type of r e s e a r c h c a r r i e d out i n this a r e a . One of the e a r l i e s t s y s t e m a t i c s t u d i e s of a n x i e t y in p r e g n a n c y and c h i l d b i r t h w a s c a r r i e d out by K l e i n , P o t t e r and D y k (1950), who a t tempted to p r e d i c t p s y c h o l o g i c a l and p h y s i o l o g i c a l d i s t r e s s f r o m two m e a s u r e s a s s i g n e d to the w o m e n p a r t i c i p a t i n g in t h e i r s t u d y .  Klein  and c o l l e a g u e s i n t e r v i e w e d 27 p r i m i p a r o u s w o m e n at each c l i n i c v i s i t and d i v i d e d them into two g r o u p s .  T h e f i r s t group e x p e r i e n c e d an e a s y  pregnancy and the s e c o n d group a d i f f i c u l t p r e g n a n c y .  Two general  7  m e a s u r e s w e r e used based on (a) f a v o u r a b l e n e s s of attitudes t o w a r d s conception and pregnancy and (b) g e n e r a l s t a b i l i t y in t e r m s of n e u r o t i c s y m p t o m s , coping m e c h a n i s m s and c a p a c i t y f o r adapting.  No d i f f e r -  ences w e r e found in these m e a s u r e s between the two g r o u p s of w o m e n . In 1956, S c o t t and T h o m s o n attempted to e s t a b l i s h w h e t h e r m a t e r n a l p s y c h o l o g i c a l c h a r a c t e r i s t i c s investigated d u r i n g the s i x t h month of pregnancy a r e r e l a t e d to the c l i n i c a l nature of l a b o u r . 278 p r i m i p a r o u s m a r r i e d w o m e n .  T h e y studied  V a r i o u s m e a s u r e s w e r e used  i n c l u d i n g a p e r s o n a l h i s t o r y , i n t e l l i g e n c e t e s t s , the M a u d s l e y M e d i c a l Q u e s t i o n n a i r e and i n t e r v i e w s .  No o v e r a l l r e l a t i o n s h i p w a s found b e -  tween p s y c h o l o g i c a l m e a s u r e s of adjustment and total length of l a b o u r , c l i n i c a l c o u r s e of l a b o u r , o b s t e t r i c c o m p l i c a t i o n s o r s e l f c o n t r o l d u r i n g labour.  H o w e v e r , it w a s found that those w o m e n judged to be e m o t i o n a l l y  w e l l - a d j u s t e d (rated by the p s y c h o l o g i s t on a three point s c a l e ) and who obtained l o w s c o r e s on the M a u d s l e y M e d i c a l Q u e s t i o n n a i r e had a r e l a t i v e l y low i n c i d e n c e of d i f f i c u l t l a b o u r , w h i l e those w o m e n w h o w e r e judged unstable and p o o r l y adjusted had a m o r e difficult l a b o u r . D a v i d s , de Vault and T a l m a d g e , (1961a; 1961b) s t u d i e d the p s y c h o l o g i c a l adjustment of 48 pregnant w o m e n (mean age 25 y e a r s ) d u r i n g pregnancy and after d e l i v e r y . A b a t t e r y of p s y c h o l o g i c a l t e s t s , i n c l u d i n g p r o j e c t i v e techniques and objective t e s t s , was a d m i n i s t e r e d d u r i n g pregnancy (in the t h i r d t r i m e s t e r ) and again a f t e r the w o m e n had  8  delivered their babies.  On the b a s i s - o f m e d i c a l o b s e r v a t i o n a n d  r e c o r d i n g in the d e l i v e r y r o o m , the m o t h e r s w e r e c l a s s i f i e d a c c o r d i n g to the d e g r e e of p h y s i c a l d i f f i c u l t y i n v o l v e d i n l a b o u r and d e l i v e r y and w h e t h e r the c h i l d had any p h y s i c a l a b n o r m a l i t y ,  It w a s found that  the w o m e n i n the a b n o r m a l group s c o r e d s i g n i f i c a n t l y h i g h e r on the T a y l o r M a n i f e s t A n x i e t y S c a l e ( T a y l o r , 1953) d u r i n g p r e g n a n c y than d i d w o m e n who l a t e r had n o r m a l d e l i v e r i e s .  It w a s noted that a f t e r  c h i l d b i r t h the d i f f e r e n c e s in the a n x i e t y s c o r e s between the n o r m a l and a b n o r m a l group w e r e no l o n g e r s i g n i f i c a n t .  It should be pointed  out that not a l l of the 48 w o m e n w e r e tested both before and after d e l i v e r y — only 13 i n the n o r m a l group and o n l y seven i n the a b n o r m a l group.  In a d d i t i o n , no a t t e m p t w a s made to c o n t r o l f o r the p a r i t y of  the w o m e n . T o e x a m i n e the r e l a t i o n s h i p between m a t e r n a l anxiety d u r i n g p r e g n a n c y and c h i l d b i r t h a b n o r m a l i t y , D a v i d s and de V a u l t (1962) s t u d i e d 50 c l i n i c patients in the t h i r d t r i m e s t e r w i t h a b a t t e r y of tests s i m i l a r to that used in t h e i r 1961 s t u d y .  A f t e r d e l i v e r y the patients  w e r e c l a s s i f i e d into n o r m a l and a b n o r m a l groups based on m e d i c a l r e c o r d s . Tne c o m p l i c a t i o n s and a b n o r m a l i t i e s reported v a r i e d f r o m c o n g e n i t a l conditions to p r e m a t u r i t y and s t i l l - b i r t h .  The psychological  data w e r e then e x a m i n e d to see i f the two groups differed on m e a s u r e s of a n x i e t y d e r i v e d f r o m d i r e c t and i n d i r e c t m e a s u r e s and p r o j e c t i v e  9  techniques.  T h e r e s u l t s showed that w i t h the e x c e p t i o n of the s e l f -  r a t i n g s c a l e a l l a n x i e t y r a t i n g s w e r e found to be s i g n i f i c a n t l y h i g h e r f o r the a b n o r m a l g r o u p .  T h e a u t h o r s pointed out that they have no  i n f o r m a t i o n r e g a r d i n g tine c a u s e s o r u n d e r l y i n g r e a s o n s f o r the h i g h a n x i e t y s c o r e s i n the a b n o r m a l g r o u p and s u g g e s t e d that e x a m i n a t i o n of s o c i o l o g i c a l , m e d i c a l and h i s t o r i c a l data m a y be p e r t i n e n t . G r i m m (1961) c a r r i e d out a n i n v e s t i g a t i o n to d e t e r m i n e (a) w h e t h e r "there a r e d i f f e r e n c e s i n d e g r e e of p s y c h o l o g i c a l t e n s i o n o v e r the 40 w e e k s of p r e g n a n c y , and (b) w h e t h e r the d e g r e e of tension i s r e l a t e d to a s p e c t s of the c o u r s e of p r e g n a n c y , i . e . w e i g h t g a i n , length of l a b o u r , c o m p l i c a t i o n s d u r i n g l a b o u r and d e l i v e r y and p h y s i c a l s t a t u s of the c h i l d .  U s i n g a s h o r t b a t t e r y of p r o j e c t i v e t e s t s , G r i m m  evaluated 200 w o m e n , 40 at each of f i v e d i f f e r e n t s t a g e s of p r e g n a n c y . E a c h group w a s equated f o r p a r i t y , p r e v i o u s o b s 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 b a c k g r o u n d , m a r i t a l s t a t u s , r e l i g i o n , age and e d u c a t i o n . A n index of tension w a s c o m p u t e d f r o m the p r o j e c t i v e techniques u s e d (the t e r m tension w a s u s e d " u n t i l m o r e i n f o r m a t i o n c a n be g a t h e r e d a s to s p e c i f i c a l l y what the index m e a s u r e s — w h e t h e r i t be a n x i e t y , p e n t up h o s t i l i t y , d e p r e s s i v e f e e l i n g s , e t c . " ) . It w a s found that those i n the l a s t h a l f of the l a s t t r i m e s t e r had s i g n i f i c a n t l y h i g h e r index o f t e n s i o n than d i d the o t h e r g r o u p s . One of the f i r s t p r e d i c t i v e s t u d i e s w a s c a r r i e d out by Z e m l i c k and  10  W a t s o n (1953).  T h e y studied 15 w o m e n (of m i x e d s o c i o e c o n o m i c status  and v a r i e d ethnic origin) throughout p r e g n a n c y to a s c e r t a i n w h e t h e r a c c e p t a n c e - r e j e c t i o n of p r e g n a n c y and m o t h e r h o o d , d e g r e e of a n x i e t y and tendency to s o m a t i c i z e w e r e p r e d i c t i v e of the m o t h e r ' s  adjustment  d u r i n g p r e g n a n c y and d e l i v e r y and h e r r e l a t i o n s h i p w i t h the n e w b o r n . A s p r e d i c t i v e m e a s u r e s they used s e l e c t e d T h e m a t i c A p p e r c e p t i o n T e s t c a r d s ( T A T ) ( M u r r a y , 1943),a l o c a l l y d e v i s e d p r e g n a n c y attitude s c a l e and a p s y c h o s o m a t i c s y m p t o m i n v e n t o r y .  C r i t e r i a for adjust-  ment d u r i n g p r e g n a n c y w e r e based on two m e a s u r e s ; f i r s t , the o b s t e t r i c i a n ' s r a t i n g of e m o t i o n a l s y m p t o m s  and adjustment and  s e c o n d , the f r e q u e n c y , d u r a t i o n and i n t e n s i t y of p s y c h o s o m a t i c s y m p toms.  A d j u s t m e n t at p a r t u r i t i o n  w a s m e a s u r e d by the length of t i m e  in l a b o u r and adjustment d u r i n g l a b o u r and d e l i v e r y a s rated by t h e ^ o b s t e t r i c i a n , and the p o s t p a r t u m adjustment of m o t h e r and c h i l d . Z e m l i c k and W a t s o n found that a n x i e t y , p s y c h o l o g i c a l and s o m a t i c s y m p t o m s , and attitudes of r e j e c t i o n of p r e g n a n c y and m o t h e r h o o d w e r e seen to be p o s i t i v e l y r e l a t e d to independent c l i n i c a l c r i t e r i a of p r e n a t a l and p a r t u r i e n t a d j u s t m e n t .  A n x i e t y a s m e a s u r e d by the T A T  w a s found to be r e l a t e d to adjustment d u r i n g p r e g n a n c y 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 , N u r n b e r g e r , G a r d i n e r , V a n d i v e e r , B a r r e t t , den B r e e i j e n (1963) tested the h y p o t h e s i s that s o m a t i c c o m p l a i n t s d u r i n g  11  p r e g n a n c y and d i f f i c u l t i e s in c h i l d b i r t h a r e r e l a t e d to a n x i e t y a n d c o n f l i c t s i n v o l v i n g attitudes and f e e l i n g s t o w a r d s o t h e r p e o p l e .  A series  of tests and s t r u c t u r e d i n t e r v i e w s w e r e g i v e n to 52 p r i m i p a r o u s w o m e n , who w e r e p r e d o m i n a n t l y b l a c k , of l o w o r l o w e r / m i d d l e c l a s s b a c k g r o u n d , and o f v a r y i n g m a r i t a l s t a t u s .  Delivery room records were  r a t e d by a s e n i o r o b s t e t r i c i a n f o r d u r a t i o n o f l a b o u r a n d the a m o u n t of analgesic required.  O n l y one s i g n i f i c a n t r e l a t i o n s h i p w a s found —  a n x i e t y d u r i n g p r e g n a n c y , as m e a s u r e d by the A f f e c t A d j e c t i v e C h e c k L i s t ( Z u c k e r m a n , 1960), w a s d i r e c t l y r e l a t e d to the a m o u n t o f a n a l g e s i c r e q u i r e d by the patient d u r i n g the l a b o u r .  . .  M c D o n a l d , G u n t h e r and C h r i s t o k o s (1963) s t u d i e d 86 w h i t e m a r r i e d patients f r o m a v e r y l o w s o c i o e c o n o m i c c l a s s i n a n a t t e m p t to d e t e r m i n e w h e t h e r o b s t e t r i c a l f a c t o r s s u c h a s c o m p l i c a t i o n s and length of l a b o u r a r e r e l a t e d to m a t e r n a l a n x i e t y .  The I P A T Anxiety Scale  ( C a t t e l l , 1957) and the M i n n e s o t a 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 / s e n s i t i z a t i o n s c a l e w e r e a d m i n i s t e r e d at the b e g i n n i n g o f the t h i r d t r i mester.  P r e g n a n c y , d e l i v e r y r o o m and p o s t p a r t u m r e c o r d s w e r e  used f o r c l a s s i f y i n g patients into e i t h e r the n o r m a l o r s u b n o r m a l groups.  T h e l i s t of p o s s i b l e a b n o r m a l i t i e s w a s obtained f r o m two w e l l  known o b s t e t r i c textbooks, and v a r i e d w i d e l y ( e . g . , s u b n o r m a l a p g a r rating, postpartum psychosis, puerperal s e p s i s ) .  A c c o r d i n g to the  12 a u t h o r s , the two groups w e r e c o m p a r a b l e f o r a g e , i n t e l l i g e n c e , p a r i t y and total n u m b e r of p r e g n a n c i e s .  A s i g n i f i c a n t d i f f e r e n c e between the  n o r m a l and a b n o r m a l group w a s found on the a n x i e t y s c o r e of the I P A T . T h e a b n o r m a l group a l s o s c o r e d s i g n i f i c a n t l y h i g h e r on the R e p r e s s i o n S e n s i t i z a t i o n S c a l e i n d i c a t i n g that they responded to threatening s i t u a t i o n s u s i n g i n t e l l e c t u a l and o b s e s s i o n a l defenses w h i l e d e n i a l and r e p r e s s i o n w a s used by the n o r m a l g r o u p .  T h e a u t h o r s stated that  t h e i r data suggest that " a n x i e t y m a y be p h y s i o l o g i c a l l y manifested i n a w i d e v a r i e t y of a b n o r m a l o b s t e t r i c c o n d i t i o n s " . A s i m i l a r study by E d w a r d s and h i s a s s o c i a t e ( E d w a r d s , 1970; E d w a r d s and J o n e s , 1970) r e s u l t e d i n c o n t r a r y f i n d i n g s . e x t e n s i v e test b a t t e r y i n c l u d i n g s e l f - r e p o r t m e a s u r e s ,  U s i n g an  projective  techniques and r a t i n g s by o b s e r v e r s E d w a r d and J o n e s i n v e s t i g a t e d p e r s o n a l i t y changes a s s o c i a t e d w i t h p r e g n a n c i e s and v a r i o u s p a t h o l o g i cal obstetric conditions.  T h e y h y p o t h e s i s e d that those w o m e n who have  o b s t e t r i c c o m p l i c a t i o n s w o u l d show m o r e e m o t i o n a l d i s t u r b a n c e as r e f l e c t e d by h i g h e r l e v e l s of a n x i e t y d u r i n g p r e g n a n c y .  The subjects  in t h e i r study w e r e 53 u n m a r r i e d pregnant w o m e n , m o s t of w h o m w e r e tested n e a r o r at the beginning of the t h i r d t r i m e s t e r of p r e g n a n c y . F o l l o w i n g the i n i t i a l a d m i n i s t r a t i o n of the test b a t t e r y , a l l the w o m e n c o m p l e t e d the S t a t e A n x i e t y Inventory on a w e e k l y b a s i s , u n t i l they entered the h o s p i t a l f o r d e l i v e r y of t h e i r b a b y .  W e e k l y r a t i n g s of  13  each w o m a n w e r e made b y a n u r s e , s o c i a l w o r k e r and h o u s e m o t h e r . A f t e r d e l i v e r y a p e d i a t r i c i a n p l a c e d w o m e n i n e i t h e r the n o r m a l o r a b n o r m a l group based on t h e i r p r e g n a n c y , d e l i v e r y and p o s t p a r t u m records.  F o u r to ten d a y s a f t e r d e l i v e r y , the t e s t b a t t e r y w a s r e a d -  ministered.  A c c o r d i n g to E d w a r d s and J o n e s the r e s u l t s f a i l e d to  confirm their hypothesis.  T h e r e w e r e no d i f f e r e n c e s between the  n o r m a l and a b n o r m a l g r o u p s on f o u r out of the f i v e m e a s u r e s r e l a t e d to attitudes towards the p r e g n a n c y .  T h e r e w e r e no d i f f e r e n c e s b e -  tween the n o r m a l and a b n o r m a l g r o u p on the p r e n a t a l m e a s u r e s i n d i c a t i v e of a n x i e t y o r r e p r e s s i v e n e s s (as m e a s u r e d by the R e p r e s s i o n / Sensitization  s c a l e of the M M P I ) .  A m o r e r e c e n t study i n v o l v i n g the r e l a t i o n s h i p o f a n x i e t y to o b s t e t r i c o u t c o m e w a s conducted b y G o r s u c h a n d K e y (1974),  These  a u t h o r s s t a t e that m o s t s t u d i e s m e a s u r e d a n x i e t y e i t h e 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 p o i n t s i n t i m e , d u r i n g p r e g n a n c y , o r at b e s t , at two points i n t i m e , and u s u a l l y l a t e i n the p r e g n a n c y , o r even p o s t delivery.  It i s p o s s i b l e , t h e r e f o r e , that the r e p o r t s of a n x i e t y , often  obtained r e t r o s p e c t i v e l y , a r e i n f l u e n c e d by the m o t h e r s ' knowledge of her condition. T h e a u t h o r s a l s o noted that p r e v i o u s s t u d i e s m e a s u r e d t r a i t - t y p e a n x i e t y w h i c h , because of i t s g l o b a l n a t u r e , d o e s not d i s c r i m i n a t e the exact levels of felt anxiety over short time p e r i o d s .  14  T h e purpose of G o r s u c h and K e y ' s study w a s to i n v e s t i g a t e p r o s p e c t i v e l y the r e l a t i o n s h i p of a n x i e t y and l i f e s t r e s s to a b n o r m a l i t i e s of p r e g n a n c y , p a r t u r i t i o n and the postnatal p e r i o d .  T h e y e x a m i n e d the  r e l a t i o n s h i p of t i m e - s p e c i f i c a n x i e t y to the d e v e l o p m e n t of o b s t e t r i c a b n o r m a l i t i e s and the r e l a t i o n s h i p of the amount of l i f e changes to the s a m e type of a b n o r m a l i t i e s .  T h e subjects w e r e 118 w o m e n attending  an o b s t e t r i c c l i n i c that s e r v e d l o w i n c o m e p a t i e n t s .  T h e y w e r e of  m i x e d m a r i t a l s t a t u s , g r a v i d i t y and r a c e , and ranged i n age between 17 and 41 .  T h e a u t h o r s pointed out that these w o m e n a r e in a " h i g h  r i s k " c a t e g o r y a s f a c t o r s s u c h as y o u t h , g r a v i d i t y , r a c e , s i n g l e s t a t u s tend to be a s s o c i a t e d w i t h a " h i g h e r i n c i d e n c e of m e d i c a l p r o b l e m s in p r e g n a n c y " .  A t the f i r s t c l i n i c v i s i t (which v a r i e d f r o m the  s e c o n d to eighth month of pregnancy) the w o m e n c o m p l e t e d 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 L u s h e n e , 1970) f o r both state and t r a i t a n x i e t y .  A f t e r i n s p e c t i o n of the m e d i c a l r e p o r t s of  the m o t h e r and infant the s u b j e c t s w e r e d i v i d e d into p r o b l e m f r e e p r e g nancy and d e l i v e r y and those w h o s e p r e g n a n c y and d e l i v e r y had one o r m o r e a b n o r m a l i t i e s w i t h i n the f i r s t twelve h o u r s .  State anxiety m e a s -  u r e s w e r e c o l l a t e d on the b a s i s of l u n a r month of p r e g n a n c y and c o r r e l a tions w e r e run between m e a s u r e s of t r a i t a n x i e t y before  pregnancy  ( a s s e s s e d r e t r o s p e c t i v e l y 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 abnormality.  It w a s found that t r a i t a n x i e t y l e v e l s before  pregnancy  15  d i d not d i f f e r s i g n i f i c a n t l y f o r the two groups o f w o m e n . H o w e v e r , those w o m e n i n the a b n o r m a l group had s i g n i f i c a n t l y h i g h e r s t a t e s o f a n x i e t y d u r i n g the t h i r d and f o u r t h l u n a r months o f p r e g n a n c y than d i d those w o m e n i n the n o r m a l g r o u p s .  The authors also reported a  s i g n i f i c a n t c o r r e l a t i o n between a n x i e t y and the n u m b e r of a b n o r m a l i t i e s . T h e two g r o u p s d i d not d i f f e r throughout the r e s t of t h e i r p r e g n a n c y . G o r s u c h and K e y stated that i t a p p e a r s that h i g h e r s t a t e s o f a n x i e t y e a r l y i n p r e g n a n c y a r e p r e d i c t o r s of a b n o r m a l i t i e s d u r i n g the p r e g n a n c y . T h e a u t h o r s pointed out that t h e i r f i n d i n g s a r e c o n s i s t e n t w i t h E d w a r d s (1970) who found no r e l a t i o n s h i p between s t a t e s o f a n x i e t y i n the l a s t s e v e n w e e k s o f p r e g n a n c y and subsequent c o m p l i c a t i o n s . T h e y s u g gested that future r e s e a r c h i n v o l v i n g s u c h a r e l a t i o n s h i p be c e n t r e d on the s t a t e s of a n x i e t y d u r i n g the f i r s t t r i m e s t e r of p r e g n a n c y . L u b i n , G a r d e n e r , Roth (1975),who u s e d a p r e d o m i n a n t l y w h i t e m i d d l e c l a s s s a m p l e of w o m e n , r e p o r t e d that s t a t e a n x i e t y a s m e a s u r e d by the A f f e c t A d j e c t i v e C h e c k l i s t ( A A C L ) ( Z u c k e r m a n a n d L u b i n , 1965) v a r i e d s i g n i f i c a n t l y a s a function of t r i m e s t e r .  T h e i r sample consisted  of 88 w h i t e w o m e n and f o u r n e g r o w o m e n , w h o s e m e a n age w a s 27 y e a r s and mean l e v e l of education 1 4 . 1 9 y e a r s .  F o r a l l s u b j e c t s the m e a n  a n x i e t y s c o r e s of the A A C L taken a t the s e c o n d t r i m e s t e r w e r e s i g n i f i c a n t l y l o w e r than the s c o r e s obtained i n the f i r s t and t h i r d t r i m e s t e r . In a l l subjects a n x i e t y d e c r e a s e d i n the s e c o n d t r i m e s t e r and r e v e r t e d  16  b a c k to i t s i n i t i a l l e v e l in the t h i r d t r i m e s t e r . F r o m this b r i e f s e l e c t e d r e v i e w o f the s t u d i e s i n v o l v i n g a n x i e t y and o b s t e t r i c o u t c o m e , i t i s a p p a r e n t 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. status.  There was seldom control f o r parity o r socioeconomic  S m a l l s a m p l e s of w o m e n w e r e u s e d who w e r e often a s s i g n e d  to n o r m a l o r a b n o r m a l g r o u p s w i t h no c l e a r - c u t c r i t e r i a of a b n o r m a l i t y . In a d d i t i o n a w i d e v a r i e t y of a b n o r m a l c o n d i t i o n s w e r e used r a n g i n g f r o m c o n g e n i t a l c o n d i t i o n s to p r e m a t u r i t y and s t i l l b i r t h .  Reliance  w a s often p l a c e d on p r o j e c t i v e m e a s u r e s ; t h e r e w a s often a l a c k of •information r e g a r d i n g the r e l i a b i l i t y of m e a s u r i n g i n s t r u m e n t s  used,  and a l a c k of o p e r a t i o n a l d e f i n i t i o n s r e g a r d i n g t e r m s used; e . g . , e a s y and d i f f i c u l t p r e g n a n c i e s , a b n o r m a l d e l i v e r i e s , n o r m a l and a b n o r m a l groups. One of the m o r e s e r i o u s p r o b l e m s w i t h these s t u d i e s that has r e c e i v e d l i t t l e c o m m e n t i n the l i t e r a t u r e i s the s o c i o e c o n o m i c s t a t u s of the population of w o m e n s t u d i e d .  T h e r e l a t i o n s h i p of a n x i e t y to  o b s t e t r i c outcome i s confounded by the s o c i o e c o n o m i c s t a t u s of the women.  T h e m a j o r i t y of s t u d i e s u s e d w o m e n f r o m l o w s o c i o e c o n o m i c  c l a s s , and a c c o r d i n g to S t o v e l (note 1) who r e v i e w e d the l i t e r a t u r e of n u t r i t i o n i n p r e g n a n c y , l o w s o c i o e c o n o m i c c l a s s has been r e l a t e d to a p o o r outcome i n p r e g n a n c y and p a r t i c u l a r l y to low b i r t h w e i g h t infants.  17  H i g g i n s (1975) stated that the r e l a t i o n s h i p between m a t e r n a l f a c t o r s and infant m o r t a l i t y and m o r b i d i t y has r e c e i v e d e x t e n s i v e study and i t has been found that " . . .infants b o r n i n p o v e r t y have h i g h e r m o r t a l i t y rates because of the low b i r t h weight and that a g e , r a c e , and s o c i o e c o n o m i c s t a t u s , w e r e i m p o r t a n t o n l y i n s o f a r as they w e r e r e l a t e d to b i r t h w e i g h t " .  S i n g e r , W e s t p h a l , N i s w a n d e r (1968),  found that low b i r t h weight i s r e l a t e d to i n c r e a s e d i n c i d e n c e o f s t i l l b i r t h , neonatal death, p o o r infant development, c e r e b r a l p a l s y , m e n t a l r e t a r d a t i o n and l o w e r e d i n t e l l i g e n c e . A n o t h e r , i m p o r t a n t f a c t o r that has been o v e r l o o k e d in the s t u d i e s r e v i e w e d i s tine o b s t e t r i c h i s t o r y of the w o m e n .  A c c o r d i n g to S t o v e l ,  many a u t h o r s have i n d i c a t e d that subsequent p r e g n a n c i e s tend to repeat t h e m s e l v e s in t e r m s of o u t c o m e , e . g . , p r e m a t u r i t y , d i s a b i l i t y , fetal l o s s and so o n . A f u r t h e r f a c t o r not taken into account w a s the p r e g r a v i d w e i g h t of the m o t h e r and the amount of weight gain d u r i n g p r e g n a n c y .  Higgins  stated that there have been n u m e r o u s studies w h i c h showed a high p o s i t i v e r e l a t i o n s h i p between b i r t h weight and m a t e r n a l p r e g r a v i d w e i g h t and w e i g h t gain during pregnancy.  S i n g e r and a s s o c i a t e s in the c o l l a b o r a t i v e study  found a s i g n i f i c a n t reduction in m o r b i d i t y and an i m p r o v e m e n t in growth and development in infants f r o m mothers w i t h above a v e r a g e weight gain during pregnancy. T h e c o n c l u s i o n s to be d r a w n f r o m the foregoing r e v i e w a r e that no  18  r e l a t i o n s h i p has been e s t a b l i s h e d between a n x i e t y and o b s t e t r i c o u t c o m e . W h i l e this question needs to be i n v e s t i g a t e d f u r t h e r i t r e q u i r e s a n i n t e r d i s c i p l i n a r y a p p r o a c h and i s thus beyond the s c o p e of the p r e s e n t s t u d y . S e v e r a l r e s e a r c h e r s have i n v e s t i g a t e d the attitude of w o m e n toward their pregnancy experience.  In one of the e a r l i e s t i n v e s t i g a t i o n s  into attitudes toward p r e g n a n c y , H a l l and M o h r (1933) stated that t h e i r c a s u a l e n q u i r y into the attitudes of w o m e n e x p e c t i n g t h e i r f i r s t baby r e v e a l e d m e n t a l hygiene p r o b l e m s i n i m i c a l to the p r o s p e c t of s u c c e s s f u l childbearing.  T h e y suggested that " . . .the r a t i o n a l a p p r o a c h of the  expectant m o t h e r s h o u l d i n c l u d e a m e n t a l h y g i e n e a p p r o a c h " .  Similarly,  T h o m p s o n (1942) d i s c u s s e d the c a s e h i s t o r i e s o f w o m e n i n t e r v i e w e d at p r e n a t a l c l i n i c s r e g a r d i n g t h e i r attitudes t o w a r d p r e g n a n c y .  H e pointed  out the n e c e s s i t y of paying "attention to the adjustment of the total i n d i v i d u a l and not f o c u s i n g a l l the attention on the l o w e r h a l f of the t o r s o ' ' . ~ an attitude w h i c h p r e v a i l s o v e r 30 y e a r s l a t e r . G r i m m (1967) c i t e d the d e v e l o p m e n t o f the P r e g n a n c y R e s e a r c h Q u e s t i o n n a i r e by S c h a e f e r and M a n h e i m e r (1960) w h i c h a t t e m p t e d to e v a l uate the e m o t i o n a l status of pregnant pregnancy.  w o m e n a s it r e l a t e d to the c o u r s e of  T h e a u t h o r s of this q u e s t i o n n a i r e c o l l e c t e d data f r o m o n l y 37  19 w o m e n and t h e i r one s i g n i f i c a n t f i n d i n g w a s that w o m e n who w e r e f e a r f u l about the baby o r t h e m s e l v e s w h i l e p r e g n a n t tended to be . . f e a r f u l , s e l f - b l a m i n g and i n s e c u r e i n the c a r e of t h e i r i n f a n t s , and to need m u c h  reassurance."  C l i f f o r d (1962) used the P r e g n a n c y R e s e a r c h Q u e s t i o n n a i r e to i n v e s t i g a t e the attitude of pregnant w o m e n a s a function of t h e i r m a r i tal status and p a r i t y .  T h e t h r e e g r o u p s of 50 w o m e n who w e r e g i v e n  the q u e s t i o n n a i r e w e r e -1. unwed m o t h e r s ; 2 . f i r s t baby a n d 3 . quent b a b y .  women expecting their  women who w e r e expecting t h e i r second o r s u b s e -  F i v e of the s e v e n s u b s c a l e s d e a l i n g w i t h attitudes t o w a r d  p r e g n a n c y r e v e a l e d s i g n i f i c a n t d i f f e r e n c e s a m o n g the m e a n s obtained by these t h r e e g r o u p s .  Unwed w o m e n e x p r e s s e d l e s s d e s i r e f o r p r e g -  nancy and l e s s m a t e r n a l f e e l i n g than e i t h e r of the two o t h e r g r o u p s ; u n w e d w o m e n e x p r e s s e d m o r e d e p r e s s i o n and w i t h d r a w a l and p e r c e i v e d the m a t e r n a l r o l e a s being ' l e s s a s c e n d a n t ' than d i d w o m e n e x p e c t i n g their f i r s t baby.  T h e w o m e n who w e r e e x p e c t i n g t h e i r f i r s t b a b y  e x p r e s s e d g r e a t e r f e a r s f o r the b a b y , 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 d e g r e e of m a r i t a l h a p p i n e s s than w o m e n who had m o r e than one c h i l d . G r i m m and Venet (1966) s t u d i e d the r e l a t i o n s h i p of e m o t i o n a l adjustment and attitudes a s m e a s u r e d e a r l y i n p r e g n a n c y to a d j u s t m e n t  20  i n l a t e r pregnancy and the p u e r p e r i u m a s w e l l a s to the m o t h e r s ' p h y s i c a l condition.  W h i l e a d e g r e e o f r e l a t i o n s h i p w a s found between e a r l y  e m o t i o n a l and a t t i t u d i n a l c h a r a c t e r i s t i c s and emotional adjustment l a t e r i n the m a t e r n i t y c y c l e , none w a s seen between these attitudes and the p h y s i c a l c o n d i t i o n of e i t h e r m o t h e r and c h i l d .  A c c o r d i n g to the  a u t h o r s , the s a m p l e of w o m e n a p p e a r e d to be typical, of the total o b s t e t r i c population and i n c l u d e d w h i t e and n e g r o , m i x e d p a r i t y , r e l i g i o n , s o c i o e c o n o m i c status and e d u c a t i o n , and a w i d e v a r i e t y of c u l t u r a l b a c k g r o u n d s . G r i m m and Venet felt that there m a y be a confounding of the effect of p a r i t y and age of m o t h e r w h i c h i n d i c a t e d the need for study of p r i m i p a r a e w i t h i n a n a r r o w age r a n g e .  T h e y a l s o suggested that s i n c e there w e r e no  g r o s s l y p a t h o l o g i c a l c o n d i t i o n s in the s a m p l e , emotional f a c t o r s w i t h i n the " n o r m a l " range m a y be too m i n o r to e x e r t an influence i n the d e v e l o p ment of pathology. Doty (1967) i n v e s t i g a t e d the effects of s o c i a l c l a s s and pa r i t y i n h e r a t t e m p t to r e l a t e e x p r e s s e d attitudes i n pregnancy to a v a r i e t y of maternal characteristics.  S h e developed a pregnancy attitude s c a l e  and a m a t e r n a l c h e c k l i s t of infant p r o b l e m s concerned w i t h g e n e r a l h e a l t h , feeding b e h a v i o u r , s l e e p i n g p a t t e r n s and amount of c r y i n g .  Her  s a m p l e of 200 w o m e n w e r e a s s i g n e d to m i d d l e and l o w e r c l a s s on the b a s i s of the H o l l i n g s h e a d Index of S o c i a l P o s i t i o n .  T h e subjects c o m -  pleted the attitude s c a l e and the M M P I d u r i n g the third t r i m e s t e r of  21  pregnancy.  W h e n the infant w a s s i x m o n t h s o l d the m o t h e r c o m p l e t e d  the m a t e r n a l c h e c k l i s t of p r o b l e m s d e v i s e d b y Doty,and the P a r e n t a l A t t i t u d e R e s e a r c h I n s t r u m e n t ( S c h a e f e r and B e l l , 1958).  Doty's results  i n d i c a t e d that s o c i a l c l a s s s i g n i f i c a n t l y affected the a t t i t u d e s r e f l e c t i n g e m o t i o n a l d i s t u r b a n c e , p h y s i c a l s y m p t o m s a n d r e j e c t i o n of p r e g n a n c y . T h e m i d d l e c l a s s group e n d o r s e d s i g n i f i c a n t l y f e w e r i t e m s i n d i c a t i n g e m o t i o n a l d i s t u r b a n c e and e x p r e s s e d s i g n i f i c a n t l y l e s s r e j e c t i o n of p r e g n a n c y than the l o w e r c l a s s g r o u p .  M i d d l e c l a s s w o m e n had s i g n i -  f i c a n t l y m o r e p h y s i c a l s y m p t o m s of p r e g n a n c y than d i d the l o w e r c l a s s group.  B o t h m i d d l e and l o w e r c l a s s m u l t i p a r a e e x p r e s s e d s i g n i f i c a n t l y  g r e a t e r r e j e c t i o n of p r e g n a n c y and s i g n i f i c a n t l y l e s s f e a r of p r e g n a n c y and c h i l d b i r t h than d i d p r i m i p a r a e .  Lower class multiparae expressed  s i g n i f i c a n t l y g r e a t e r r e j e c t i o n o f p r e g n a n c y a n d m a t e r n a l r o l e than d i d the o t h e r g r o u p s .  Doty c o n c l u d e d that 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 v a r y  a s 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 r e v i o u s p r e g n a n c i e s . H e i n s t e i n (1967) h y p o t h e s i z e d that the m o r e negative the 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 the m o r e s e v e r e the p h y s i c a l c o m p l i c a t i o n s s u r rounding p r e g n a n c y .  A v a r i a n t of the P r e g n a n c y R e s e a r c h Q u e s t i o n n a i r e  w a s a d m i n i s t e r e d to 156 pregnant w o m e n , one t h i r d of w h o m w e r e b l a c k . T h e s u b j e c t s w e r e c l i n i c patients f r o m l o w i n c o m e f a m i l i e s w i t h a m e d i a n age between 24 and 2 5 . education.  O n e t h i r d o f the group had c o l l e g e  One t h i r d of the w o m e n w e r e s e e n i n t h e i r f i r s t f o u r months  22  of pregnancy; one t h i r d in t h e i r fifth to s i x t h month and one t h i r d in the l a s t three months of p r e g n a n c y .  The questionnaire was given during  the f i r s t contact w i t h the c l i n i c .  T h e total m e d i c a l data ( i n v o l v i n g  p r e g n a n c y , l a b o u r and d e l i v e r y , p e d i a t r i c and n e u r o l o g i c a l e x a m i n a tion of the infant) w e r e grouped into three c a t e g o r i e s by the o b s t e t r i c i a n and s e n i o r o b s t e t r i c n u r s e , depending on the type of c o m p l i c a t i o n . O n l y s i x t e e n of the 272 i t e m s of the q u e s t i o n n a i r e w e r e s i g n i f i c a n t l y r e l a t e d to the degree of p h y s i c a l c o m p l i c a t i o n s , thus t h e i r h y p o t h e s i s w a s not c o n f i r m e d . W h i l e the o v e r a l l r e s u l t s a r e e q u i v o c a l r e g a r d i n g the effects of m a t e r n a l p r e n a t a l attitude to o b s t e t r i c o u t c o m e , there i s e v i d e n c e that attitudes do v a r y a c c o r d i n g to p a r i t y and s o c i a l c l a s s .  It w o u l d  s e e m r e a s o n a b l e t h e r e f o r e to c o n t r o l f o r s u c h v a r i a b l e s i n f u r t h e r research. Postpartum Disorders A m a j o r l i n e of e n q u i r y has c o n c e r n e d i t s e l f w i t h p u e r p e r a l d i s o r d e r s s u c h as p o s t p a r t u m p s y c h o s e s o r p o s t p a r t u m d e p r e s s i o n .  The  focus of these i n v e s t i g a t i o n s has been the p s y c h o p a t h o l o g i c a l c o n d i t i o n of w o m e n r e s u l t i n g f r o m the e x p e r i e n c e of p r e g n a n c y and c h i l d b i r t h . P o s t p a r t u m p s y c h o s i s w a s g e n e r a l l y defined as p s y c h o s i s w i t h o n s e t w i t h i n s i x months a f t e r d e l i v e r y , a c c o r d i n g to K a i j and N i l s s o n (1972), who stated that p s y c h o t i c c o m p l i c a t i o n s i n pregnancy o c c u r i n  23  one o r two c a s e s p e r 1,000 d e l i v e r i e s and who c i t e d s t u d i e s i n d i c a t i n g that 4 - 5 % of a l l a d m i s s i o n s of f e m a l e s to m e n t a l h o s p i t a l s 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 , C a d o r e t , (1971) defined a p o s t p a r t u m d e p r e s s i v e episode "as a p e r s i s t e n t d e p r e s s i v e s y n d r o m e l a s t i n g a m i n i m u m of s i x w e e k s , w h o s e onset w a s w i t h i n s i x months of the t i m e of g i v i n g b i r t h " . W h i l e there i s s o m e c o n f l i c t i n the l i t e r a t u r e , the c o n s e n s u s a p p e a r s to be that d i s o r d e r s o c c u r r i n g in a s s o c i a t i o n with c h i l d b e a r i n g a r e i n d i s t i n g u i s h a b l e f r o m those o c c u r r i n g at other times i n t e r m s of s y m p t o m a t o g y and p r o g n o s i s ( R y l e , 1961; C r u i k s h a n k , 1940; S e a g a r , 1960; B r a t f o s and H a u g , 1966; B a k e r , D o r z a b , W i n o k u r , C a d o r e t , 1971; B r o w n and S h e r e s h e f s k y , 1972; W i l s t o n , 1972). A f t e r r e v i e w i n g many e a r l y s t u d i e s S e a g e r (1960) c o n c l u d e d that t h e r e w a s no e v i d e n c e f o r s p e c i f i c p u e r p e r a l m e n t a l d i s o r d e r s , but that the p u e r p e r i u m acted a s a s t r e s s , p r e c i p i t a t i n g b r e a k d o w n i n p r e disposed women.  T o d d (1964) c a r r i e d out one of the f i r s t p r o s p e c t i v e  e p i d e m i o l o g i c a l s t u d i e s and stated that h i s f i g u r e s suggested that p u e r p e r a l d e p r e s s i o n i s the end r e s u l t of a long e s t a b l i s h e d m a l a d j u s t ment, not a s p e c i f i c d i s o r d e r — and that the p r e g n a n c y , c o n f i n e m e n t and p u e r p e r i u m a r e the s t r e s s l e a d i n g to the b r e a k d o w n . A l e a d i n g 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 r e g a r d i n g p u e r p e r a l p s y c h o s i s as d i s t i n c t f r o m  2k  p s y c h o s i s outside the p u e r p e r i u m .  In a s i m i l a r v e i n , S i l v e r m a n (1968)  s t a t e d that the view s e e m s uncontested c l i n i c a l l y that m e n t a l i l l n e s s a s s o c i a t e d w i t h c h i l d b e a r i n g i s no d i f f e r e n t f r o m mental i l l n e s s u n r e l a t e d to c h i l d b i r t h .  H o w e v e r , f o r the p r e g n a n c y p h a s e , " T h e r e i s a  g e n e r a l a i r of d i s s a t i s f a c t i o n r e g a r d i n g m e n t a l d i s t u r b a n c e s w h i c h o c c u r after d e l i v e r y " . K a i j and N i l s s o n pointed out that, a l t h o u g h i n t e r e s t i n g , the p s y c h o s e s m u s t be regarded, a s a s m a l l group of d i s e a s e s f r o m a s o c i o m e d i c a l point of view and of s u b s t a n t i a l l y l e s s s i g n i f i c a n c e than the m i n o r psychiatric illness following pregnancy.  T h e y noted that i n v e s t i -  gations have i n d i c a t e d that n e u r o s e s , n o n - p s y c h o t i c d e p r e s s i o n s , a s t h e n i c r e a c t i o n s , e t c . , a r e e x t r e m e l y c o m m o n d u r i n g the p o s t p a r t u m year.  T h e w o r k of N i l s s o n (1970) and J a c o b s o n , K a i j and N i l s s o n  (1965) i n d i c a t e d that a s many a s one w o m a n i n f o u r e x p e r i e n c e s m o r e o r less incapacitating neurotic a n d / o r depressive symptoms during this p e r i o d .  T h e s e a u t h o r s f e l t that this i m p l i e d that the w e l l b e i n g of  the w o m a n i s d i s t u r b e d and h e r n o r m a l w a y of functioning i s r e s t r i c t e d . A c c o r d i n g to K a i j and N i l s s o n " S y s t e m a t i c i n v e s t i g a t i o n s on i n c i d e n c e , e t i o l o g y , p r o g n o s i s and s y m p t o m s of n e u r o t i c r e a c t i o n s i n p r e g n a n c y and p u e r p e r i u m a r e v i r t u a l l y n o n e x i s t e n t " .  Y a l o m , Lunde, M o o s ,  H a m b u r g (1968) stated that the o c c u r r e n c e o f p o s t p a r t u m b l u e s i s " . . . s o ubiquitous and o s t e n s i b l y benign that i t has not often been  25  d e e m e d w o r t h y of s e r i o u s s t u d y . . . e x c e p t f o r a s e r i e s o f u n c o n t r o l l e d r e t r o s p e c t i v e q u e s t i o n n a i r e s t u d i e s . . . the r e l a t i o n s h i p between t h i s s y n d r o m e and p e r s o n a l i t y t r a i t s , p r e v i o u s m e n t a l h e a l t h , 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 , c o m p l i c a t i o n s of p r e g n a n c y , m e n s t r u a l o r o t h e r endocrine disturbances, previous postpartum depression, severity of l a b o u r have not been p r e v i o u s l y s t u d i e d " .  A r e v i e w of the m o r e  r e c e n t l i t e r a t u r e i n v o l v i n g p o s t p a r t u m d e p r e s s i o n and " b l u e s " s u p p o r t s the v a l i d i t y of the above s t a t e m e n t . . Y a l o m and a s s o c i a t e s s t a t e d that b e c a u s e of the l a c k o f c o n s e n s u a l d e f i n i t i o n o r o b j e c t i v e s t u d i e s of t h i s s y n d r o m e , the i n c i d e n c e r a t e s r e p o r t e d v a r y g r e a t l y w i t h e s t i m a t e s r a n g i n g f r o m 5% to 80%. T h e postulated r e a s o n s f o r the p o s t p a r t u m " b l u e s " have been v a r i o u s l y a t t r i b u t e d to h o r m o n a l c h a n g e s , p s y c h o l o g i c a 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 l a c t a t i o n ( P i t t 1968).  The symptoms  that o c c u r i n the p o s t p a r t u m " b l u e s " i n v o l v e c r y i n g , (the m o s t c h a r a c t e r i s t i c s i g n ) , v u l n e r a b i l i t y to m i n o r r e b u f f s , t e n s i o n , a n x i e t y , 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 , L u n d e , M o o s ,  H a m b u r g , 1968; P i t t , 1968). Y a l o m and a s s o c i a t e s s t u d i e d the d e g r e e o f d e p r e s s i o n b e f o r e d e l i v e r y and f o r ten days p o s t p a r t u m i n a g r o u p of 39 w o m e n , w h o s e a v e r a g e age w a s 23 y e a r s .  A l l but two w o m e n w e r e m a r r i e d and c a m e  f r o m a w i d e v a r i e t y of s o c i o e c o n o m i c b a c k g r o u n d s .  O f the total g r o u p ,  26  37 w e r e w h i t e , two negro; nine of the w o m e n w e r e expecting t h e i r f i r s t baby.  D e p r e s s i o n w a s m e a s u r e d by i n t e r v i e w s , b e h a v i o r a l  o b s e r v a t i o n s and p s y c h o l o g i c a l t e s t s .  T h e findings f r o m these  m e a s u r e s w e r e c o r r e l a t e d w i t h data gathered f r o m the p e r s o n a l h i s t o r y and h o s p i t a l r e c o r d s c o n c e r n i n g l a b o u r and d e l i v e r y f o r each s u b j e c t . C l i n i c a l data obtained f r o m d a i l y i n t e r v i e w s i n d i c a t e d that c r y i n g w a s not s y n o n y m o u s w i t h a f e e l i n g of d e p r e s s i o n .  S o m e of the stated  rea-  sons f o r c r y i n g w e r e a s f o l l o w s : — i n c r e a s e d v u l n e r a b i l i t y o r h y p e r s e n s i t i v i t y to p o s s i b l e r e j e c t i o n ; p o o r l y t o l e r a t e d l o n e l i n e s s in h o s p i t a l ; a n g e r d i r e c t e d at husbands f o r l a c k of c o n s i d e r a t i o n o r u n w i l l i n g n e s s to h e l p . A m u l t i p l e c o r r e l a t i o n of . 7 6 w a s obtained between a n a v e r a g e d a i l y d e p r e s s i o n s c o r e and s e v e n v a r i a b l e s of w h i c h the m a i n c o n t r i b u t i o n s w e r e made by l o w e r p a r i t y , i n c r e a s e d length of t i m e f r o m l a s t p r e g n a n c y , p r e v i o u s p o s t p a r t u m d e p r e s s i o n and y o u n g e r age at m e n a r c h e .  Y a l o m and a s s o c i a t e s pointed out that i t has been  d e m o n s t r a t e d that the m o r e s e v e r e p o s t p a r t u m e m o t i o n a l d i s t u r b a n c e i s c o r r e l a t e d w i t h l o w p a r i t y , and this s u g g e s t s that the f i r s t p r e g n a n c y r e p r e s e n t s a unique s t r e s s ,  that " . . . p r i m i p a r a e , u n l i k e the m u l t i p a r a e ,  cannot p r e p a r e t h e m s e l v e s f o r the p h y s i c a l s e n s a t i o n s of p r e g n a n c y , f o r the p e r s o n a l s e n s a t i o n of c r e a t i o n , f o r the d e l i v e r y p r o c e s s , f o r the m a j o r p h y s i c a l and e m o t i o n a l changes n e c e s s i t a t e d by the a s s u m p tion of m o t h e r h o o d " .  T h e r e i s , however, conflicting evidence  27  r e g a r d i n g the a s s o c i a t i o n of l o w p a r i t y w i t h d e p r e s s i o n .  F o r example,  T o d d (1964) conducted a p r o s p e c t i v e e p i d e m i o l o g i c a l study of p u e r p e r a l d e p r e s s i o n . A n e v a l u a t i o n of p a r i t y r e v e a l e d a p r e p o n d e r a n c e o f t h i r d p r e g n a n c i e s w i t h i n the d e p r e s s e d g r o u p s .  A c c o r d i n g to T o d d  primiparous women "seem relatively immune from psychological d i s turbances in the p u e r p e r i u m " .  D a v i d s o n (1972) u s e d a s a m p l e of  n e g r o w o m e n and found that p o s t p a r t u m b l u e s w e r e s i g n i f i c a n t l y a s s o c i a t e d w i t h a g r e a t e r i n c i d e n c e of m u l t i p a r i t y . C o n c u r r i n g w i t h 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 c o m m o n knowledge that w o m e n often b e c o m e d e p r e s s e d a f t e r c h i l d b i r t h , there has been l i t t l e e v a l u a t i o n of what this d e p r e s s i o n amounts t o .  A c c o r d i n g to P i t t , t r a n s i t o r y t e a r f u l n e s s i n the e a r l y  p u e r p e r i u m i s c o m m o n and i s g e n e r a l l y r e g a r d e d a s a n o r m a l p h e n o menon.  He q u e r i e s what l i e s between the e x t r e m e s of s e v e r e p u e r p e r a l  d e p r e s s i o n occurring in no m o r e than one i n 500 b i r t h s and the " t r i v i a l w e e p i n e s s of the b l u e s " . sion".  He s u g g e s t s the c o n c e p t of " a t y p i c a l d e p r e s -  P i t t s u r v e y e d 305 m a t e r n i t y patients who w e r e given a q u e s t i o n -  n a i r e d e s i g n e d to m e a s u r e a n x i e t y and d e p r e s s i o n a r o u n d the 28th w e e k of p r e g n a n c y and a g a i n s i x to eight w e e k s a f t e r d e l i v e r y . T e n p e r cent of the w o m e n developed p u e r p e r a l d e p r e s s i o n , and of these o n l y one of the w o m e n had a c l a s s i c a l d e p r e s s i o n , w h i l e the p a t t e r n of s y m p t o m s f o r the r e s t of the group w a s that of " a t y p i c a l " d e p r e s s i o n — " a  28  m i l d e r v a r i a n t of p h y s i o l o g i c a l d e p r e s s i o n m o s t often s e e n i n y o u n g e r women o r immature personalities".  It i s c a l l e d a t y p i c a l d e p r e s s i o n  b e c a u s e of the p r o m i n e n c e o f n e u r o t i c s y m p t o m s , i . e . , a n x i e t y ,  irrita-  b i l i t y and p h o b i a s , o r b e c a u s e s o m e f e a t u r e s do not c o i n c i d e w i t h c l a s s i c a l c a s e s of d e p r e s s i o n .  P i t t stated that i t w a s a f t e r "the r e t u r n  h o m e that d e p r e s s i o n w a s a l w a y s m o s t e v i d e n t , c h i e f l y a s  tearfulness,  despondence, f e e l i n g s of inadequacy and i n a b i l i t y to cope — p a r t i c u l a r l y w i t h the b a b y " .  The depression was nearly always accompanied  by a n x i e t y o v e r the baby, a n x i e t y w h i c h w a s not j u s t i f i e d by i t s h e a l t h . In 1973 P i t t d e c i d e d to e x a m i n e the i n c i d e n c e , phenomenology and a s s o c i a t e d f e a t u r e s of the " b l u e s " .  H e i n t e r v i e w e d 100 w o m e n between  the seventh and tenth day p o s t p a r t u m and found that h a l f of these w o m e n r  c o u l d be diagnosed a s h a v i n g the " b l u e s " .  O f these 35% o c c u r r e d w i t h -  i n f o u r days of p a r t u r i t i o n , 26% on the t h i r d d a y .  Those women  s u f f e r i n g the " b l u e s " d i f f e r e d f r o m the r e s t of the w o m e n o n l y in that they e x p e r i e n c e d m o r e d i f f i c u l t y in b r e a s t - f e e d i n g .  No s i g n i f i c a n t d i f -  f e r e n c e s i n attitudes t o w a r d s p r e g n a n c y , e x p e r i e n c e of l a b o u r , b a b y ' s health o r s o c i a l s t r e s s w e r e apparent.  S i x of the w o m e n who h a d the  " b l u e s " developed p u e r p e r a l d e p r e s s i o n , a s t a t e of despondency l a s t i n g a month o r m o r e .  P i t t stated that the " b l u e s " i s "a t r i v i a l , f l e e t i n g  phenomenon"and should not be confused w i t h the ' a t y p i c a l ' o r n e u r o t i c f o r m of p u e r p e r a l d e p r e s s i o n .  29  Postpartum Adjustment T h e G o r d o n s ( G o r d o n and G o r d o n , 1 9 5 9 ; G o r d o n and G o r d o n , 1 9 6 0 ; G o r d o n , K a p o s t i n u s , Gordon,1965) have shown that p e r s o n a l a n d s o c i a l s t r e s s i t e m s s i g n i f i c a n t l y 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 m o t h e r s and those who have p o s t p a r t u m e m o t i o n a l u p s e t .  The authors  gave a s o c i a l h i s t o r y q u e s t i o n n a i r e to 98 n o r m a l w o m e n w h o had j u s t delivered their babies.  F o u r months a f t e r d e l i v e r y the p h y s i c i a n of e a c h  w o m a n c o m p l e t e d a r a t i n g s c a l e a s to the d e g r e e of e m o t i o n a l d i s t u r bance e x p e r i e n c e d by these w o m e n subsequent to d e l i v e r y . T h e 98 w o m e n w e r e c o m p a r e d w i t h m a t e r n i t y p a t i e n t s who had sought p s y c h i atric help. groups:  T h e f o l l o w i n g i t e m s s i g n i f i c a n t l y d i f f e r e n t i a t e d tine two  e m o t i o n a l p r o b l e m s i n the w o m a n ' s b a c k g r o u n d ; p h y s i c a l c o m -  l i c a t i o n s of p r e g n a n c y ; age of w i f e ; r e l i g i o u s i n t e r m a r r i a g e ; no h e l p a v a i l a b l e a f t e r the b i r t h . N i l s s o n and h i s a s s o c i a t e s ( 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 r o s p e c t i v e s t u d i e s i n v o l v i n g the p o s t natal adjustment of S w e d i s h w o m e n . fold;  T h e a i m of these s t u d i e s w a s t h r e e -  F i r s t , to study the o c c u r r e n c e , n a t u r e and p r o g n o s i s of p a r a p a r turn  e m o t i o n a l i l l n e s s u s i n g a p r o s p e c t i v e m e t h o d ; s e c o n d , to i n v e s t i g a t e w h i c h a e t i o l o g i c a l f a c t o r s influence s u c h i l l n e s s ; and t h i r d , to e s t a b l i s h c h a r a c t e r i s t i c patterns of adaptation i n r e l a t i o n to the s t r e s s s i t u a t i o n which birth entails. T h e i r study i n v o l v e d the i n v e s t i g a t i o n of 165 u n s e l e c t e d w o m e n  30  attending p r e n a t a l c l i n i c s f o r the f i r s t t i m e d u r i n g the c u r r e n t p r e g nancy.  T h e w o m e n w e r e i n t e r v i e w e d on three o c c a s i o n s ; a f t e r t h e i r  f i r s t v i s i t to the c l i n i c , two to t h r e e days p o s t p a r t u m and s i x months postpartum.  T h e content of s u c h i n t e r v i e w s included p s y c h i a t r i c h i s -  t o r y , g e n e r a l s o c i a l and e n v i r o n m e n t a l questions and attitudes towards t h e i r c u r r e n t p r e g n a n c y . A c l i n i c a l e v a l u a t i o n w a s c a r r i e d out and the p s y c h i a t r i c s t a t u s of the w o m e n w a s n o t e d .  A t the f i r s t and t h i r d i n t e r -  v i e w , the w o m e n w e r e given p s y c h o l o g i c a l tests including an a s s e s s m e n t of i n t e l l e c t u a l and c o g n i t i v e functioning and a p e r s o n a l i t y a s s e s s m e n t . F o u r q u e s t i o n n a i r e s w e r e designed to m e a s u r e n e u r o t i c i s m , p r e n a t a l i d e n t i f i c a t i o n and d e g r e e of i d e n t i f i c a t i o n w i t h s t e r e o t y p e d f e m i n i n e and masculine characters.  M e a s u r e s used by the authors a s c r i t e r i a of  the w o m e n ' s adjustment to c h i l d b i r t h i n c l u d e d the o c c u r r e n c e of p s y c h i a t r i c s y m p t o m s ( b e f o r e , d u r i n g and a f t e r pregnancy); c l i n i c a l s i g n s of i l l n e s s ; d e v i a t i o n s in t e s t s , attitudes and s e x u a l adjustment. In P a r t One of t h e i r study they s u r v e y e d p s y c h i a t r i c m o r b i d i t y . On the b a s i s of r e p o r t e d s y m p t o m s , the extent .of adaptional d i f f i c u l t i e s d u r i n g p r e g n a n c y and p o s t p a r t u m w a s c a l c u l a t e d . T h e p r i n c i p a l m e a s u r e in this s u r v e y w a s the a u t h o r ' s e s t i m a t i o n of the d e g r e e of d i s turbance based upon the s e r i o u s n e s s and n u m b e r of i n d i v i d u a l p s y c h i a t r i c s y m p t o m s r e p o r t e d i n each p e r i o d . T h e y found that the s i g n s of mental d i s t u r b a n c e w e r e of the s a m e magnitude d u r i n g p r e g n a n c y  31  a s d u r i n g the p o s t p a r t u m p e r i o d and the o c c u r r e n c e of s u c h s i g n s , e . g , lowered mood, affective l a b i l i t y , psychomotor retardation,was high i n both p e r i o d s .  N i l s s o n and a s s o c i a t e s stated that the h i g h o c c u r -  r e n c e of m e n t a l s y m p t o m s and d i s t u r b a n c e s d u r i n g the p r e g n a n c y p e r i o d w a s r e m a r k a b l e i n view of the g e n e r a l b e l i e f that p s y c h i a t r i c s y m p t o m s o c c u r i n f r e q u e n t l y d u r i n g this p e r i o d and since, s e v e r a l a u t h o r s m a i n tained that m e n t a l i l l n e s s i s m o r e c o m m o n a f t e r d e l i v e r y . In P a r t T w o of t h e i r s t u d y N i l s s o n and a s s o c i a t e s c o m p a r e d the f r e q u e n c i e s of s u b j e c t i v e p s y c h i a t r i c s y m p t o m s b e f o r e , -during and a f t e r p r e g n a n c y w i t h v a r i o u s b a c k g r o u n d f a c t o r s , tests and c l i n i c a l observations.  R e l a t i o n s h i p s w e r e found between s y m p t o m s o c c u r r i n g  d u r i n g p r e g n a n c y and the p o s t p a r t u m p e r i o d and s u c h f a c t o r s a s the w o m e n ' s attitude t o w a r d s p r e g n a n c y , r e l a t i o n s h i p w i t h the c h i l d ' s f a t h e r and e n v i r o n m e n t a l c o n d i t i o n s a t the t i m e of p r e g n a n c y .  Accord-  i n g to the a u t h o r s the h i g h f r e q u e n c y of s y m p t o m s d u r i n g p r e g n a n c y often s e e m e d r e l a t e d to u n f a v o u r a b l e e n v i r o n m e n t a l c i r c u m s t a n c e s , w h i l e p o s t p a r t u m s y m p t o m s , to a g r e a t extent, i n d i c a t e d the e x i s t e n c e of " m o r e d e e p l y s e a t e d c o n f l i c t s " connected w i t h r e p r o d u c t i v e f u n c t i o n ing.  T h e s e c o n c l u s i o n s w e r e based on the a s s o c i a t i o n w h i c h w a s found  between p o s t p a r t u m m e n t a l s y m p t o m s and s u c h f a c t o r s a s u n s a t i s f a c t o r y e a r l y r e l a t i o n s w i t h the p a r e n t s , a m o r a l i z i n g attitude t o w a r d s s e x at the p a r e n t a l h o m e , a negative attitude t o w a r d s m o t h e r h o o d .  32 T h e r e is l i t t l e e m p i r i c a l r e s e a r c h into the p s y c h o l o g i c a l a s p e c t s of postpartum adjustment.  It i s d i f f i c u l t t h e r e f o r e to d r a w any c o n c l u s i o n s  about a p o s s i b l e r e l a t i o n s h i p between p o s t p a r t u m adjustment and attitude t o w a r d the infant. Hospital Environment A n o t h e r a r e a of r e s e a r c h that has r e c e i v e d l i t t l e attention to date and that m a y influence the p o s t p a r t u m m a t e r n a l b e h a v i o u r o f w o m e n and t h e i r e a r l y r e l a t i o n s h i p w i t h t h e i r infantsis the study of the h o s p i t a l e x p e r i e n c e and i t s effects, i f a n y , upon the m o t h e r and h e r infant. r e v i e w of the l i t e r a t u r e showed o n l y a few o b j e c t i v e s t u d i e s ,  A  concerned  p r i m a r i l y w i t h the h o s p i t a l e x p e r i e n c e of the m o t h e r , although there a r e many a r t i c l e s d e s c r i b i n g the i n s t i g a t i o n , p h i l o s o p h y and advantages of r o o m i n g - i n and f a m i l y c e n t r e d m a t e r n i t y c a r e ( E n g e l a , 1963; F a l e t t a , 1963; W o o d e n , 1962a, 1962b; J a c k s o n , 1946; E n g e l b , 1 9 6 3 ; T i m b e r l a k e , 1975; T h o r n s , 1962; R a t s o y , 1974; H a i r e and H a i r e , 1968; C o x , 1974). Shea, Klatski.n, S J a c k s o n (1952) c o m p a r e d the h o m e adjustment o v e r a p e r i o d of one month post h o s p i t a l d i s c h a r g e of m o t h e r s who e x p e r i e n c e d r o o m i n g - i n w i t h those w o m e n who p a r t i c i p a t e d i n the t y p i c a l m a t e r n i t y ward.  A l t h o u g h r o o m i n g - i n w a s not defined in the s t u d y , t y p i c a l l y i t  i n v o l v e s the s i t u a t i o n w h e r e the newborn infant i s p l a c e d in a b a s s i n e t i n the m o t h e r ' s r o o m , u s u a l l y d u r i n g the d a y . i s r e t u r n e d to the c e n t r a l n u r s e r y .  A t night the infant  T h e study i n v o l v e d e l e v e n matched  p a i r s of p r i m i p a r a e , equated a s c l o s e l y a s p o s s i b l e f o r a g e ,  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 m o t h e r s '  f i r s t day home f r o m the h o s p i t a l and then a r r a n g e d a c c o r d i n g to the mother's need.  T h e s e 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 r o j e c t .  A general outline  c e r t a i n t o p i c s w a s u s e d f o r each v i s i t , and the v i s i t i n g w r o t e down h e r o b s e r v a t i o n s a f t e r w a r d s .  covering  researcher  T o m a k e these o b s e r v a t i o n s  m o r e o b j e c t i v e , a r a t i n g s c a l e w a s d e v i s e d to code the d a t a .  Shea  and a s s o c i a t e s stated that because of the s m a l l n u m b e r of subjects i n v o l v e d , no s t a t i s t i c a l a n a l y s i s w a s done, ( n o r w e r e , the data p r e s e n t e d i n s u c h a w a y a s to a l l o w one to m a k e s t a t i s t i c a l a n a l y s e s ) . C e r t a i n trends w e r e noted by the a u t h o r s , e . g . , the r o o m i n g - i n m o t h e r s w e r e rated m o r e competent in h a n d l i n g t h e i r baby, they f e l t m o r e s e l f confident i n u n d e r s t a n d i n g t h e i r b a b y ' s needs and b e h a v i o r s and r e q u i r e d f e w e r n u r s i n g 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 ; n o n - r o o m i n g - i n , s e v e n v i s i t s . )  S h e a and a s s o c i a t e s c o n -  c l u d e d that " m o t h e r s having r o o m i n g - i n e x p e r i e n c e have g r e a t e r f a c i l i t y i n handling the baby and m o r e s e l f - c o n f i d e n c e i n u n d e r s t a n d i n g the b a b y ' s b e h a v i o u r " . A s e c o n d study c o m p a r i n g r o o m i n g - i n w i t h w a r d s w a s c a r r i e d out i n S w e d e n .  traditional maternity  G r e e n b e r g , R o s e n b e r g and L i n d  (1973) r a n d o m l y a s s i g n e d 100 p r i m i p a r o u s w o m e n , matched f o r a g e , socioeconomic  status and education of f a t h e r s to e i t h e r a r o o m i n g - i n  34  facility o r a traditional w a r d .  T h e w o m e n i n 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 s c h e d u l e .  T h e infants w e r e b r o u g h t to the  m o t h e r 12 to 16 h o u r s a f t e r b i r t h and r e m a i n e d i n the b a s s i n e t i n the " r o o m f r o m 9 . 0 0 a . m . to 6 . 0 0 p . m .  In the t r a d i t i o n a l w a r d , the  m o t h e r s s a w the infant f o r 20 m i n u t e s at each f e e d i n g .  F a t h e r s in  both g r o u p s v i s i t e d f o r one h o u r a day d u r i n g w h i c h t i m e the infant w a s not p e r m i t t e d i n the r o o m . T h e a u t h o r s developed a 50 - i t e m m u l t i p l e c h o i c e q u e s t i o n n a i r e w h i c h w a s g i v e n to a l l w o m e n .  The important  s i g n i f i c a n t findings f r o m this s t u d y w e r e that r o o m i n g - i n m o t h e r s judged t h e m s e l v e s 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; c o u l d u n d e r s t a n d one o r m o r e a t t r i b u t e s o f the b a b y ' s c r y ; and developed m a t e r n a l f e e l i n g s f a s t e r than those w o m e n i n the t r a d i tional m a t e r n i t y w a r d . One s i g n i f i c a n t feature of the u s u a l 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 not i n c o r p o r a t e d into the above s t u d i e s w a s the p a r t i c i p a t i o n by f a t h e r s .  A n e a r l y study c o m p a r i n g c o n v e n t i o n a l m a t e r n i t y s y s t e m s  with 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 , a n d L u d t k e (1966).  T h e a u t h o r s s t a t e d that i t w a s d i f f i c u l t to define  e i t h e r the c o n v e n t i o n a l m a t e r n i t y c a r e p r o g r a m m e o r the f a m i l y c e n t r e d p r o g r a m m e i n a b s o l u t e t e r m s because of the m a n y v a r i a t i o n s to be found.  T h e two p r a c t i c e s c a n be d i s t i n g u i s h e d i n a g e n e r a l  s e n s e , h o w e v e r , and the a u t h o r s c i t e d f i v e r e l a t i v e l y d i s t i n c t d i f f e r e n c e s  35  between the two p r o g r a m m e s a s a p p l i e d to the h o s p i t a l in w h i c h they c a r r i e d out t h e i r r e s e a r c h .  These differences are listed below:  Conventional p r o g r a m m e 1.  F a t h e r not p r e s e n t d u r i n g d e l i v e r y  2.  Infant housed in c e n t r a l n u r s e r y  3.  S c h e d u l e d feedings  4.  Father present only during regular visiting hours  5.  F a t h e r cannot handle the baby F a m i l y centred programme  1.  Father present during delivery  2.  Infant housed w i t h m o t h e r  3.  D e m a n d feeding  4.  F a t h e r has u n r e s t r i c t e d v i s i t i n g p r i v i l e g e s  5.  F a t h e r a l l o w e d to handle the baby In 1964, the h o s p i t a l i n w h i c h M o y e r and a s s o c i a t e s c a r r i e d out  the r e s e a r c h changed f r o m a c o n v e n t i o n a l m a t e r n i t y d e l i v e r y s y s t e m to a f a m i l y c e n t r e d s y s t e m .  T h e m o s t pronounced d i f f e r e n c e between  the two p r o g r a m m e s w a s the added e m p h a s i s p l a c e d on c l o s e c o n t a c t a m o n g the f a m i l y m e m b e r s d u r i n g the h o s p i t a l i z a t i o n . T h e b a s i c d e s i g n of the study w a s to make a post hoc c o m p a r i s o n of two g r o u p s of f a m i l i e s .  In one group the m o t h e r s had been c a r e d f o r u n d e r the  t r a d i t i o n a l p r o g r a m m e , w h i l e the second group c o n s i s t e d of those who  36  e n t e r e d the h o s p i t a l a f t e r the c h a n g e o v e r to the f a m i l y c e n t r e d p l a n . F o r t y c a s e s w e r e s e l e c t e d a t r a n d o m f r o m those mothers who d e l i v e r e d t h e i r baby p r i o r to the c h a n g e o v e r and 40 c a s e s f r o m those w h o d e l i v e r e d t h e i r baby a f t e r the c h a n g e o v e r o c c u r r e d .  Questionnaires  w e r e then m a i l e d to both groups at the a p p r o p r i a t e t i m e i n t e r v a l s after hospital discharge.  T h e q u e s t i o n n a i r e s i n v o l v e d i n d i c a t o r s of  p o s t h o s p i t a l a d j u s t m e n t and i n c l u d e d m o t h e r s ' and f a t h e r s ' t e n s i o n l e v e l i n h a n d l i n g the infant; m o t h e r s ' and f a t h e r s ' i r r i t a b i l i t y l e v e l ; d e g r e e of m o t h e r s ' p o s t p a r t u m d e p r e s s i o n ; h e a l t h p r o b l e m s of the infants w h i c h m i g h t have e m o t i o n a l e t i o l o g y . E i g h t y p e r c e n t o f the q u e s t i o n n a i r e s w e r e r e t u r n e d f r o m e a c h group of p a r e n t s .  The most  s i g n i f i c a n t finding w a s that.'.88% of m o t h e r s i n the t r a d i t i o n a l p r o g r a m m e r e p o r t e d v a r y i n g l e v e l s of i r r i t a b i l i t y , w h i l e o n l y 53% of those i n the f a m i l y c e n t r e d p r o g r a m m e r e p o r t e d the s a m e .  M o y e r and a s s o c i a t e s  c o n c l u d e d by s t a t i n g that t h e i r f i n d i n g s " . . . g i v e s o m e c r e d e n c e to the a s s u m p t i o n s u n d e r l y i n g the f a m i l y c e n t r e d m a t e r n i t y c a r e p l a n .  How-  e v e r , c o n s i d e r a b l e r e s e a r c h s t i l l needs to be done i n o r d e r to a s c e r tain the r e l a t i v e v a l u e of the v a r i o u s facets of the p r o g r a m m e " . M o y e r ' s study i s r e t r o s p e c t i v e and w h i l e the g r o u p s i n e a c h p r o g r a m m e a p p e a r to be s i m i l a r , t h e r e i s no i n f o r m a t i o n d e a l i n g w i t h g r o u p c o m p o s i t i o n . T h e r e w a s a 20% dropout r a t e f r o m both g r o u p s . M o y e r a r g u e d that h i s f i n d i n g s g i v e s t r o n g s u p p o r t to the p r o p o n e n t s  37  of f a m i l y c e n t r e d m a t e r n i t y c a r e i n a s m u c h a s the p r o g r a m m e c o n t r i b uted to. the e m o t i o n a l adjustment and s t a b i l i t y of the f a m i l y .  In  f a c t , t h e r e w e r e no d i f f e r e n c e s between the groups r e p o r t e d f o r m o t h e r s ' p o s t p a r t u m d e p r e s s i o n a s m e a s u r e d on a f o u r point s c a l e . In view of the fact that the study took p l a c e r e l a t i v e l y soon a f t e r the i n s t i g a t i o n of the new p r o g r a m m e t h e r e i s the d i s t i n c t p o s s i b i l i t y of a H a w t h o r n e effect. A s e c o n d and m o r e a m b i t i o u s study of the d i f f e r e n t i a l effects of a f a m i l y c e n t r e d m a t e r n i t y c a r e p r o g r a m m e w a s c a r r i e d out by J o r d a n between 1969 and 1971 ( J o r d a n , 1973a, 1973b, 1973c).  T h i s study  w a s c a r r i e d out in two h o s p i t a l s , one of w h i c h offered 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 and the o t h e r a m o r e t r a d i t i o n a l p r o g r a m m e . T w o hundred and nine f a m i l i e s p a r t i c i p a t e d in the s t u d y .  One hundred  and e l e v e n f a m i l i e s w e r e i n v o l v e d w i t h the hospital having the 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 and 98 at the m o r e t r a d i t i o n a l l y o r i e n t e d hospital. groups.  T h e w o m e n w e r e d i v i d e d into p r i m i p a r o u s and m u l t i p a r o u s A l l the p a r t i c i p a n t s w e r e seen f i v e t i m e s by one of two p r o j e c t  investigators as follows:  d u r i n g the ninth month of p r e g n a n c y , 24-48  h o u r s a f t e r d e l i v e r y of the baby; s e v e n to ten days a f t e r d i s c h a r g e f r o m the h o s p i t a l and at f i v e and eight w e e k s after d i s c h a r g e .  Each  t i m e the subjects w e r e seen an a p p r o p r i a t e set of q u e s t i o n n a i r e s w e r e left to be c o m p l e t e d by the husband and w i f e .  Data w e r e a n a l y z e d i n  38  2 x 2 c o n t i n g e n c y tables u s i n g c h i s q u a r e a s the test of s i g n i f i c a n c e . S i g n i f i c a n t findings i n c l u d e d the f o l l o w i n g :  a patient, has a g r e a t e r  degree of t r u s t and confidence i n the n u r s e when a s p e c i f i c n u r s e patient a s s i g n m e n t i s made; the p a r e n t s ' confidence i s g r e a t e r and they have l e s s f e a r of t h e i r i n a b i l i t y to c a r e f o r the baby when the h o s p i t a l e n v i r o n m e n t has offered a v a r i e t y of l e a r n i n g o p p o r t u n i t i e s i n the c a r e of the baby; the f a m i l y r e l a t i o n s h i p i s s t r o n g e r when the h o s p i t a l e n v i r o n m e n t p e r m i t s , t h e p a r e n t s to be together d u r i n g the l a b o u r i n g p r o c e s s and to handle t h e i r baby a s m u c h as they d e s i r e ; a r e a s of c o n c e r n to the m o t h e r a r e e x p r e s s e d m o r e f r e q u e n t l y when a v a r i e t y of l e a r n i n g o p p o r t u n i t i e s a r e offered to the m o t h e r i n the h o s p i t a l ; m o r e f a t h e r s feel confident i n c a r i n g f o r the b a b y , being of g r e a t e r help w i t h the baby and do not object to h e l p i n g w i t h the infant when the couple have p a r t i c i p a t e d i n the f a m i l y c e n t r e d p r o g r a m m e ; m o t h e r s r e q u i r e l e s s help w i t h i n s t r u c t i o n and r e q u i r e l e s s  reassurance.  J o r d a n made the i m p l i c i t a s s u m p t i o n that " r o o m i n g - i n " i s f a m i l y centred maternity c a r e .  It has been pointed out by H a i r e and H a i r e  (1968) that " m o d i f i e d r o o m i n g - i n " i s an i m p o r t a n t part of f a m i l y c e n tred m a t e r n i t y c a r e .  T h e s e a u t h o r s stated that r o o m i n g - i n r e q u i r e s  the m o t h e r to " c a t e g o r i z e 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 c a r e she often knows l i t t l e a b o u t " .  F l e x i b l e r o o m i n g - i n , on  the o t h e r h a n d , a l l o w s the m o t h e r r a t h e r than the h o s p i t a l to d e t e r m i n e  39  how m u c h t i m e she spends w i t h the b a b y . J o r d a n a l s o a s s u m e d that the g r o u p s i n e a c h h o s p i t a l w e r e c o m p a r a b l e r e g a r d i n g d e m o g r a p h i c data w h e n , i n f a c t , s i g n i f i c a n t d i f f e r e n c e s e x i s t e d between the two g r o u p s of p r i m i p a r o u s w o m e n i n f a v o u r of the f a m i l y c e n t r e d m a t e r n i t y h o s p i t a l .  It i s unfortunate that  the study w a s c o m p l e t e d w i t h a s a m p l e that d i d not m e e t the i n i t i a l selection c r i t e r i a .  F i f t y p e r cent of those in the t r a d i t i o n a l h o s p i t a l  d i d not meet the c r i t e r i a of no p r e n a t a l c l a s s e s , thus, confounding the r e s u l t s obtained r e g a r d i n g the e f f i c a c y of f a m i l y c e n t r e d c a r e w i t h the effects of attending p r e n a t a l c l a s s e s . A n o t h e r d i f f i c u l t y w i t h the study w a s that J o r d a n ' s method of obtaining tine s a m p l e d i f f e r e d f o r the two g r o u p s .  One g r o u p (the f a m i l y  c e n t r e d m a t e r n i t y ) w a s a p p r o a c h e d p e r s o n a l l y w h i l e the o t h e r g r o u p (traditional-) w a s r e f e r r e d by the d o c t o r . A c c o r d i n g to J o r d a n d i f f e r e n t i n d i v i d u a l s conducted the v a r i o u s interviews which apparently resulted in slight differences in the manner i n w h i c h the i n t e r v i e w data were r e p o r t e d , and this m a y have c o n t r i b u t e d to d i s t o r t i o n o r b i a s i n the r e s u l t s .  T h e r e w a s no i n d i c a t i o n i n J o r d a n ' s  r e p o r t a s to w h e t h e r the q u e s t i o n n a i r e s w e r e r e l i a b l e i n t e r m s o f either internal consistency o r stability over time. of the data w a s conducted u s i n g the c h i s q u a r e .  Statistical analysis  T h i s resulted in  hundreds of c o m p a r i s o n s being made w h i c h l e d to the v e r y s t r o n g  p o s s i b i l i t y of m a n y T y p e 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 r e s e n t l y being conducted b y K l a u s and K e n n e l 1 a n d t h e i r a s s o c i a t e s w h i c h r e l a t e s to the h o s p i t a l e n v i r o n m e n t of the m a ternity patient. K l a u s and K e n n e l l (1970) m a i n t a i n e d that b e h a v i o u r a l s t u d i e s in a l a r g e range of a n i m a l s p e c i e s a s w e l l a s p r e l i m i n a r y s t u d i e s of human m a t e r n a l b e h a v i o u r suggested that w h a t happens in the p e r i o d i m m e d i a t e l y f o l l o w i n g d e l i v e r y of the baby " m a y be c r i t i c a l to l a t e r m a t e r n a l behaviour".  Seashore,  L e i f e r , B a r n e t t and L e i d e r m a n (1973) a g r e e d ,  c i t i n g s t u d i e s of m a t e r n a l b e h a v i o u r i n the nonhuman m a m m a l s w h i c h suggest "that r e s t r i c t i o n of i n t e r a c t i o n of the m o t h e r and baby in the e a r l y p o s t p a r t u m p e r i o d influences subsequent m a t e r n a l  performance  and m a y , in f a c t , produce c l e a r l y incompetent m o t h e r i n g . "  The  a u t h o r s pointed out that p r e v i o u s s t u d i e s i n v o l v i n g m a t e r n a l / i n f a n t s e p a r a t i o n of the human have c o n c e n t r a t e d on the effects of long t e r m s e p a r a t i o n on the development of the infant, p a y i n g l i t t l e attention to the q u e s t i o n of how the m o t h e r i s affected by s u c h a s e p a r a t i o n . K l a u s and K e n n e l l c i t e d a p e r s o n a l c o m m u n i c a t i o n f r o m B a r n e t t , a n a n t h r o p o l o g i s t who s e a r c h e d  the H u m a n R e l a t i o n s F i l e ( w h i c h l i s t s  220 cultures) f o r variations in human maternal behaviour following d e l i v e r y of the b a b y .  B a r n e t t found that a l l s o c i e t i e s e x h i b i t a  " r e g u l a r i z e d " w a y of d e a l i n g w i t h b i r t h .  In m o s t c u l t u r e s m o t h e r and  41  infant a r e s e c l u d e d  together d u r i n g the three to s e v e n days a f t e r  b i r t h , u n t i l the u m b i l i c a l c o r d h e a l s .  Apparently "routine complete  s e p a r a t i o n of m o t h e r and infant i n the f i r s t days a f t e r d e l i v e r y e x i s t s only i n the high r i s k and p r e m a t u r e n u r s e r i e s of the W e s t e r n W o r l d " . K l a u s and K e n n e l l stated that In this c e n t u r y both b i r t h and death, the two m o s t i m p o r t a n t events i n the l i f e of an i n d i v i d u a 1,have been moved into the h o s p i t a l and away f r o m the f a m i l y and c e n t u r i e s of t r a d i t i o n s and c u l t u r a l p a t t e r n s of b e h a v i o u r . P r a c t i c e s s u r r o u n d i n g both events appear to have been a l m o s t w h o l l y d e t e r m i n e d by the p s y c h o l o g i c a l n e e d s , the c o n v e n i e n c e , the l i m i t e d p e r s p e c t i v e , and the b i a s of the dominant m e m b e r s of the h o s p i t a l c u l t u r e ( n u r s e , p h y s i c i a n , and a d m i n i s t r a t o r ) , (p. 1026) K l a u s and K e n n e l l m a i n t a i n e d that m o s t n o r m a l d e l i v e r i e s i n the U n i t e d S t a t e s a r e a s s o c i a t e d w i t h s e v e r a l days of what B a r n e t t c a l l s " d e p r i v a t i o n " f o r the m o t h e r — " O n l y m o t h e r s who d e l i v e r at home o r r o o m - i n w i t h t h e i r infants e x p e r i e n c e no d e p r i v a t i o n " . W h i l e this i s an o v e r s t a t e m e n t the point i s w e l l t a k e n .  (Rooming-in, in studies m e n -  tioned p r e v i o u s l y , s e e m s to be on a d a i l y b a s i s r a t h e r than f u l l t i m e . ) T h e a u t h o r s pointed out that the n a t u r a l i s t i c a r r a n g e m e n t s of r o o m i n g in p r o c e d u r e s m a y be of i m m e n s e value f o r the m o t h e r and c h i l d . T h e o b s e r v a t i o n s made by M c B r y d e (1951) w e r e u s e d by K l a u s and K e n n e l l to s u p p o r t the concept that c l o s e contact between m o t h e r and infant d u r i n g the i n i t i a l days a f t e r d e l i v e r y m a y w e l l f a c i l i t a t e m o t h e r i n g  behaviour.  M c B r y d e r e p o r t e d that when r o o m i n g - i n w a s made c o m -  p u l s o r y at. Duke H o s p i t a l "the i n c i d e n c e of b r e a s t feeding r o s e f r o m 35% to 5 8 . 5 % w h i l e telephone c a l l s f r o m a n x i o u s m o t h e r s d u r i n g the f i r s t w e e k s a f t e r d i s c h a r g e d e c r e a s e d by 9 0 % . " K l a u s and K e n n e l l b e l i e v e d that the m o t h e r i n g b e h a v i o u r of each w o m a n , " h e r a b i l i t y to tolerate adverse s t r e s s e s ,  and h e r need f o r s p e c i a l attention d i f f e r  g r e a t l y and depend upon a m u l t i t u d e of f a c t o r s " .  F i g u r e 1 is a  m o d i f i c a t i o n of the s c h e m a that they have developed i l l u s t r a t i n g the m a j o r influence of m o t h e r i n g b e h a v i o u r and the r e s u l t i n g p o s s i b l e d i s t u r b a n c e s w h i c h a r i s e when this b e h a v i o u r i s d i s o r d e r e d .  The  d i s o r d e r s range f r o m m i l d c o n c e r n s to the m o s t s e v e r e — the battered child syndrome.  K l a u s and K e n n e l l suggested that the range of d i f f i -  c u l t i e s m a y be the end r e s u l t of s e p a r a t i o n in the n e w b o r n p e r i o d . L o w b i r t h w e i g h t and p r e m a t u r i t y often involved a p r o l o n g e d s e p a r a t i o n between m o t h e r and infant.  K e n n e l l , T r a u s e and K l a u s (1975) c i t e d  s t u d i e s showing that p r e m a t u r e infants constituted a " d i s p r o p o r t i o n a t e l y high n u m b e r of both battered c h i l d r e n (23-31%) and those w i t h the " f a i l u r e to t h r i v e " s y n d r o m e " . H e i f e r (1975) i n h i s d i s c u s s i o n of c h i l d abuse stated that " T h e p r e c i p i t a t i n g event m a y be r e a l o r i m a g i n e d , a b i r t h defect, a s o c i a l o r e c o n o m i c d i s r u p t i o n of the f a m i l y , a d i f f i c u l t p r e g n a n c y o r d e l i v e r y , o r e a r l y s e p a r a t i o n of m o t h e r 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 , s e p a r a t i o n of m o t h e r and infant  B e h a v i o r of d o c t o r s , n u r s e s , and hospital personnel  Infant  Normal  F i g u r e 1.  Disturbed mother-child relations  Behavioral problems in adopted c h i l d r e n  Practices of hospital  M o t h e r ' s attachment and earetaking  Vulnerable • child syndrome  Developmental Failure and emotional to p r o b l e m s i n highj t h r i v e r i s k infants  Battered child syndrome  D i s o r d e r s of m o t h e r i n g : adapted f r o m K l a u s M . and Kennell 0:. M o t h e r s s e p a r a t e d f r o m t h e i r newborn i n f a n t s . P e d i a t C l i n N A m e r 17:1015, 1970.  44  c h i l d r e n have a p r e m a t u r i t y rate t w i c e that of the g e n e r a l population and a c a e s a r i a n s e c t i o n rate m u c h h i g h e r than that of the g e n e r a l population.  (In a p e r s o n a l c o m m u n i c a t i o n to K e n n e l l , T r a u s e , and  K l a u s (1975),Hel fer  stated that the i n c i d e n c e of c h i l d abuse i s ten  t i m e s g r e a t e r w i t h a c a e s a r i a n s e c t i o n than w i t h v a g i n a l d e l i v e r i e s . ) F i n d i n g s f r o m the r e s e a r c h undertaken by K l a u s and h i s a s s o c i a t e s have d e m o n s t r a t e d that there i s indeed an influence of e a r l y s e p a r a t i o n on the subsequent r e l a t i o n s h i p between m o t h e r and infant. In a n e a r l y study K e n n e l l , G o r d o n , and K l a u s (1970) c o m p a r e d the b e h a v i o u r of m o t h e r s who had been s e p a r a t e d f r o m t h e i r p r e m a t u r e i n fants f o r the f i r s t 21 days of l i f e , w i t h those m o t h e r s who had been a l l o w e d p h y s i c a l contact w i t h i n the f i r s t f i v e d a y s .  Using time lapse photography,  o b s e r v a t i o n s w e r e r e c o r d e d and a n a l y z e d f o r the f i r s t ten m i n u t e s of the feeding i m m e d i a t e l y before d i s c h a r g e f r o m the h o s p i t a l .  Twenty-five  a c t i v i t i e s w e r e r e c o r d e d f o r each m o t h e r i n c l u d i n g c a r e t a k i n g s k i l l s and m a t e r n a l a f f e c t i o n . A s i g n i f i c a n t d i f f e r e n c e i n the percentage of 'en f a c e ' contact and c u d d l i n g t i m e w a s seen mothers.  between the e a r l y and late contact  A t a one month f o l l o w - u p it w a s found that l a t e contact m o t h e r s  held t h e i r babies d i f f e r e n t l y , changed p o s i t i o n l e s s , burped them l e s s and w e r e not a s s k i l l f u l i n feeding them a s those m o t h e r s who had had e a r l y contact w i t h t h e i r p r e m a t u r e i n f a n t s .  K e n n e l l and a s s o c i a t e s (1975) d i s c u s s e d  the follow-up of p r e m a t u r e infants and stated t h a t ' p r e l i m i n a r y data on the  kS  S t a n f o r d B i n e t I . Q . of the two g r o u p s of c h i l d r e n at 42 months i n d i c a t e d that those in the e a r l y contact group s c o r e d s i g n i f i c a n t l y h i g h e r than those i n the late contact group (mean I . Q . 99 vs 8 5 ) .  Furthermore, a signi-  f i c a n t c o r r e l a t i o n ( c o r r e l a t i o n c o e f f i c i e n t = .71) w a s found between the I . Q . a t 42 months and the amount of t i m e w o m e n spent l o o k i n g at t h e i r babies d u r i n g the f i l m e d feeding at one month of a g e " .  (It i s u n c l e a r  w h e t h e r this f o l l o w - u p i s of the c h i l d r e n s t u d i e d by K e n n e l l , G o r d o n and K l a u s (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 t e f f a , and K e n n e l l c a r r i e d out a study to d e t e r m i n e w h e t h e r h o s p i t a l p r a c t i c e s in the U n i t e d S t a t e s affected l a t e r m a t e r n a l b e h a v i o u r of w o m e n who had f u l l t e r m as opposed to p r e m a t u r e i n f a n t s .  T h e s a m p l e w a s 28 p r i m i -  p a r o u s w o m e n (26 n e g r o , 2 w h i t e ) w i t h an a v e r a g e age of 18 y e a r s w h o had r e a c h e d grade 10 o r 11 .  Of this group nine w e r e m a r r i e d .  Each  m o t h e r w a s p l a c e d in one of two study groups depending on the day of delivery.  A c c o r d i n g to the a u t h o r s the m e a n a g e , s o c i o e c o n o m i c c l a s s  m a r i t a l s t a t u s , r a c e , p r e m e d i c a t i o n , s e x of infant and d a y s h o s p i t a l i z e d w e r e " n e a r l y i d e n t i c a l " . F o u r t e e n m o t h e r s had the u s u a l a m o u n t of contact w i t h t h e i r i n f a n t s , i . e . , a g l i m p s e of the baby s h o r t l y a f t e r b i r t h , b r i e f contact and i d e n t i f i c a t i o n a t s i x to 12 h o u r s , then the u s u a l feeding s c h e d u l e d e v e r y f o u r h o u r s .  In a d d i t i o n to t h i s r o u t i n e , f o r  46  t h e three days after d e l i v e r y , the 14 m o t h e r s i n the extended contact group w e r e given t h e i r nude b a b i e s , f o r one h o u r w i t h i n the f i r s t t h r e e h o u r s a f t e r b i r t h and f o r five e x t r a h o u r s of contact each a f t e r n o o n . The m o t h e r s r e t u r n e d one month a f t e r d e l i v e r y f o r three s e p a r a t e o b s e r v a t i o n s c o n s i s t i n g of a s t a n d a r d i z e d i n t e r v i e w , a n o b s e r v a t i o n of m a t e r n a l p e r f o r m a n c e d u r i n g the p h y s i c a l e x a m i n a t i o n o f the infant and a f i e l d study of the m o t h e r feeding h e r infant.  The results indicat-  ed a s i g n i f i c a n t d i f f e r e n c e i n b e h a v i o u r of the groups of w o m e n t o w a r d s t h e i r infant, i n the a r e a of fondling and face contact.  The scores  obtained on i n t e r v i e w q u e s t i o n s and o b s e r v a t i o n s made d u r i n g the p h y s i c a l e x a m i n a t i o n of the infant a l s o i n d i c a t e d s i g n i f i c a n t d i f f e r e n c e s between the g r o u p s .  T h e extended contact m o t h e r s w e r e m o r e r e l u c -  tant to l e a v e t h e i r infants w i t h s o m e o n e e l s e , showed g r e a t e r s o o t h i n g b e h a v i o u r i f the infant c r i e d , and engaged in s i g n i f i c a n t l y m o r e e y e - t o eye contact w i t h and fondling of the infant.  In view of these d i f f e r e n c e s  i n m a t e r n a l b e h a v i o u r at one m o n t h , 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 K l a u s (1974) conducted a f o l l o w - u p s t u d y to see w h e t h e r these d i f f e r e n c e s p e r s i s t e d after one y e a r .  At  this t i m e the m o t h e r s w e r e o b s e r v e d b y i n v e s t i g a t o r s who w e r e not f a m i l i a r w i t h the m o t h e r s ,  n o r had  the  o b s e r v e r s had c o n t a c t w i t h  the m o t h e r s d u r i n g the p r e v i o u s eleven m o n t h s .  T h e a u t h o r s d i d not  s a y w h e t h e r the i n v e s t i g a t o r s w e r e a w a r e to w h i c h g r o u p the m o t h e r / infant p a i r b e l o n g e d .  The observers monitored mother/infant inter-  hi  a c t i o n through a t w o - w a y m i r r o r i n s e v e n s e p a r a t e s i t u a t i o n s . S i g n i f i c a n t d i f f e r e n c e s w e r e found between the two g r o u p s in t h e i r a n s w e r s to i n t e r v i e w questions and i n t h e i r b e h a v i o u r d u r i n g a p h y s i c a l e x a m i n a t i o n of the infant.  In the o b s e r v a t i o n p e r i o d d u r i n g  the p h y s i c a l e x a m i n a t i o n the w o m e n i n the extended contact group spent a s i g n i f i c a n t l y g r e a t e r total t i m e a-ssisting the p h y s i c i a n than d i d the c o n t r o l w o m e n . T h e extended contact group a l s o spent a s i g n i f i c a n t l y g r e a t e r t i m e soothing i n r e s p o n s e to c r y i n g and w e r e m o r e l i k e l y to k i s s t h e i r babies than.the c o n t r o l g r o u p .  In a d d i t i o n there w a s a s i g n i f i c a n t  d i f f e r e n c e on the B a y l e y mean d e v e l o p m e n t a l index between the two groups of infants — 98 f o r the infants of the extended c o n t a c t m o t h e r s and 93 f o r the c o n t r o l group m o t h e r s .  K e n n e l l and c o l l e a g u e s c o n -  cluded that these a p p a r e n t l y s t r i k i n g f i n d i n g s need to be r e p l i c a t e d i n a l a r g e study but that those who c a r e f o r infants and m o t h e r s s h o u l d be a w a r e of the p o s s i b l e long t e r m effects of the e a r l y p o s t p a r t u m p e r i o d . T w o y e a r s l a t e r f i v e m o t h e r s w e r e s e l e c t e d at r a n d o m f r o m each group and the l i n g u i s t i c b e h a v i o u r s of the two groups of m o t h e r s w e r e c o m p a r e d w h i l e s p e a k i n g to t h e i r c h i l d r e n .  It w a s found by R i n g l e r ,  K e n n e l l , J a r v e l l , N a v o j o s k y and K l a u s (1975) that "the extended contact m o t h e r s used t w i c e as many q u e s t i o n s , m o r e w o r d s p e r p r o p o s i t i o n , f e w e r contact w o r d s , m o r e a d j e c t i v e s and f e w e r c o m m a n d s than d i d the  48  controls.  T h e a u t h o r s pointed out that this m a y have been due to chance  s e l e c t i o n and the study s h o u l d be r e p e a t e d .  T h e y made the a d d i t i o n a l  point that the findings f r o m the above r e s e a r c h suggest "that 16 e x t r a h o u r s of contact i n the f i r s t three days of l i f e a p p e a r to have affected m a t e r n a l b e h a v i o u r f o r one y e a r and p o s s i b l y l o n g e r , thus offering s u p p o r t f o r the hypothesis that there i s a m a t e r n a l s e n s i t i v e p e r i o d soon a f t e r d e l i v e r y . " T h e r e a r e s e v e r a l p r o c e d u r a l d i f f i c u l t i e s w i t h the above r e s e a r c h that m a y have influenced the r e s u l t s .  It i s not p o s s i b l e to r u l e out  expectancy effects on the p a r t of the p a r t i c i p a t i n g m o t h e r s .  F i r s t , it  w a s not known w h e t h e r they w e r e a w a r e that they w e r e p a r t of a r e s e a r c h study; s e c o n d , a s K l a u s pointed out, the m o t h e r s m a y have seen h a n d l i n g t h e i r baby a s a s p e c i a l p r i v i l e g e , l e a d i n g to a subsequent change i n t h e i r b e h a v i o u r .  It i s unusual in any h o s p i t a l to be s u p p l i e d  w i t h a heat panel and y o u r naked baby to fondle — a v e r y o b t r u s i v e feature of the s t u d y .  A l s o , as K l a u s m e n t i o n e d , there w a s the question  of the t i m e and amount of contact w h i c h w a s not c o n t r o l l e d f o r .  In  a d d i t i o n , there w a s no attempt to c o n t r o l f o r the amount of s t i m u l a t i o n p e r se r e c e i v e d by the babies in the contact group — the d i f f e r e n c e s obtained m a y have been due i n s o m e p a r t to the effects of s t i m u l a t i o n r a t h e r than the l a c k of s e p a r a t i o n . L e i f e r , L e i d e r m a n , B a r n e t t and W i l l i a m s (1972) have conducted  49  s i m i l a r r e s e a r c h u s i n g a different population and m o r e s t r i n g e n t controls.  T h e i r s a m p l e w a s 80% w h i t e w o m e n .  T h e m e d i a n education  f o r the m o t h e r w a s c o m p l e t i o n of high s c h o o l , and f o r the f a t h e r w a s some college education.  T h e m e d i a n age f o r both parents w a s 2 5 - 2 9  and m e d i a n s o c i a l c l a s s w a s 111 a s m e a s u r e d by the H o l l i n g s h e a d Index.  T h e s a m p l e c o n s i s t e d of three groups of m o t h e r s ; 22 s e p a r a t e d  m o t h e r s of p r e m a t u r e b a b i e s , who had v i s u a l contact o n l y f o r three to 12 w e e k s a f t e r b i r t h ; 22 contact m o t h e r s of p r e m a t u r e b a b i e s who entered the i n t e n s i v e c a r e n u r s e r y two to three days a f t e r the b i r t h of the infant and handled the infants i n the i n c u b a t o r and p a r t i c i p a t e d i n n o r m a l c a r e a c t i v i t i e s a s f a r a s p o s s i b l e ; and 24 mothers of f u l l t e r m babies.  A s s i g n m e n t to the s e p a r a t e and contact group w a s made on a r a n -  d o m b a s i s and the w o m e n w e r e u n a w a r e of the e x i s t e n c e of the two g r o u p s . T h e s e p a r a t e d infants w e r e given a d d i t i o n a l h a n d l i n g by the n u r s e s to a v o i d the p o s s i b i l i t y of d i f f e r e n c e s a r i s i n g due to d i f f e r e n t i a l amounts of e a r l y s t i m u l a t i o n r a t h e r than m a t e r n a l c o n t a c t .  The f u l l - t e r m  mothers  w e r e matched a s f a r a s p o s s i b l e f o r p a r i t y , s o c i a l c l a s s and s e x of infant to tine w o m e n i n the p r e m a t u r e g r o u p .  A t t a c h m e n t b e h a v i o u r s of t h r e e  g r o u p s of w o m e n w e r e c o m p a r e d i n t i m e - s a m p l e d o b s e r v a t i o n s  p r i o r to  and one and f o u r w e e k s a f t e r the infants' d i s c h a r g e f r o m h o s p i t a l . M a t e r nal attachment b e h a v i o u r w a s defined a s "the degree to w h i c h a m o t h e r i s attentive to and m a i n t a i n s p h y s i c a l contact w i t h h e r i n f a n t . "  Major  50  f i n d i n g s f r o m this study w e r e that c o n t a c t m o t h e r s held t h e i r infant i n the v e n t r a l h o l d i n g p o s i t i o n f o r a s i g n i f i c a n t l y g r e a t e r p e r c e n t a g e of the t i m e than d i d the s e p a r a t e d m o t h e r s at the f i r s t w e e k p o s t d i s c h a r g e period.  It w a s a l s o found that f u l l t e r m m o t h e r s s m i l e d at t h e i r i n -  fants m o r e often and m a i n t a i n e d m o r e v e n t r a l contact w i t h them than d i d m o t h e r s of p r e m a t u r e b a b i e s w h i l e in h o s p i t a l , and a t the one w e e k and one month post d i s c h a r g e t i m e p e r i o d s . U s i n g a p a i r e d c o m p a r i s o n q u e s t i o n n a i r e f o r the two g r o u p s i n the above s t u d y , S e a s h o r e , L e i f e r , B a r n e t t , and L e i d e r m a n (1973) e x a m i n e d the attitudes of s e l f - c o n f i d e n c e i n c a r i n g f o r the i n f a n t s .  It  w a s found that s e p a r a t i o n r e s u l t e d i n l o w e r self-confidence f o r p r i m i p a r o u s m o t h e r s but not f o r m u l t i p a r o u s m o t h e r s .  A comparison was  made of m o t h e r s i n i t i a l l y l o w i n s e l f - c o n f i d e n c e and i t w a s s e e n that those m o t h e r s i n the s e p a r a t i o n g r o u p w e r e m o r e l i k e l y to r e m a i n l o w i n s e l f - c o n f i d e n c e u n t i l the infant w a s d i s c h a r g e d . B y one m o n t h , h o w e v e r , s e l f - c o n f i d e n c e of the p r i m i p a r a e had i n c r e a s e d to a l e v e l c o m p a r a b l e to that of the o t h e r m o t h e r s .  It w a s a l s o found, that although  p r i m i p a r o u s w o m e n i n the s e p a r a t i o n group f e l t s i g n i f i c a n t l y l e s s c o n fident than d i d o t h e r m o t h e r s , they w e r e o n l y s l i g h t l y l e s s s k i l l f u l at caretaking tasks.  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 i n d i c a t e d that s k i l l  never predicted self-confidence, whereas self-confidence for i n s t r u m e n t a l tasks s u c h a s d i a p e r i n g , feeding and bathing the b a b y , j u s t p r i o r  51  to d i s c h a r g e d i d p r e d i c t s k i l l one w e e k a f t e r d i s c h a r g e , thus d e m o n s t r a t i n g that a m o t h e r ' s d e g r e e of s e l f - c o n f i d e n c e does have s o m e b e a r i n g on h e r s k i l l i n c a r i n g f o r h e r infant.  A c c o r d i n g to the a u t h o r s  this suggested that m o d i f i c a t i o n i n attitudes p r i o r to d i s c h a r g e w a s a s s o c i a t e d w i t h subsequent b e h a v i o u r at one w e e k post d i s c h a r g e and a l s o suggested the " p r e p o t e n c y " of a s o c i a l s k i l l i n d i r e c t i n g o r o r g a n i z i n g one of the s p e c i f i c t a s k s " .  T h e a u t h o r s f e l t that the i m m e -  diate p o s t p a r t u m p e r i o d m a y be a t i m e when the m o t h e r i s p s y c h o l o g i c a l l y and p h y s i o l o g i c a l l y r e a d y to a s s u m e the m o t h e r i n g r o l e .  They sug-  gested that a w o m a n who i s u n c e r t a i n of h e r a b i l i t y to f u l f i l l this r o l e " m a y need the r e i n f o r c e m e n t and l e a r n i n g e x p e r i e n c e " that she i s denied w h e n s e p a r a t e d f r o m h e r infant. F r o m the above data L e i d e r m a n , L e i f e r , ' S e a s h o r e , B a r n e t t and G r o b s t e i n (1973) and L e i d e r m a n (1974) c o n c l u d e d that d e n i a l of contact between a m o t h e r and h e r infant w i l l influence both m a t e r n a l attitude and b e h a v i o u r w h i c h i s c o n s i s t e n t w i t h the a n i m a l l i t e r a t u r e w h i c h shows that d e l a y i n c o n t a c t d u r i n g the neonatal p e r i o d c a n l e a d to a d e t e r i o r a tion of m a t e r n a l c a r e t a k i n g b e h a v i o u r . finding that full  T h e y f u r t h e r stated that the  t e r m m o t h e r s s m i l e m o r e and m a i n t a i n m o r e  v e n t r a l contact w i t h t h e i r infants than do m o t h e r s of p r e m a t u r e babies may i n d i c a t e an "attenuated r e l a t i o n s h i p " between m o t h e r and p r e m a t u r e infant.  T h i s i s c o n s i s t e n t w i t h the data i n d i c a t i n g that p r e -  m a t u r e babies a r e m o r e frequently battered by t h e i r p a r e n t s than a r e  52  full t e r m babies.  L e i d e r m a n and a s s o c i a t e s a l s o stated that the  m a j o r influence of s e p a r a t i o n s e e m s to be on the m a t e r n a l s e l f c o n f i d e n c e , suggesting that the i m m e d i a t e p o s t p a r t u m p e r i o d i s a p a r t i c u l a r l y s e n s i t i v e one f o r the d e v e l o p m e n t of a p p r o p r i a t e m a t e r n a l behaviour. E l e v e n to fifteen months a f t e r the end of the s e p a r a t i o n p e r i o d , L e i d e r m a n and S e a s h o r e (1974) f o l l o w e d - u p the m o t h e r s i n the above studies.  B y the e l e v e n months p o s t d i s c h a r g e p e r i o d , the o n l y m a t e r -  nal b e h a v i o u r s w h i c h w e r e differentiated by tine e x p e r i m e n t a l c o n d i t i o n of contact o r s e p a r a t i o n w e r e s m i l i n g and t o u c h i n g .  F u l l term mothers  s m i l e d at t h e i r infants m o r e than d i d m o t h e r s of the p r e m a t u r e b a b i e s , and m o t h e r s in the contact group touched t h e i r babies m o r e than d i d the separated group.  T h e c o n c l u s i o n f r o m this f o l l o w - u p study w a s that  c i r c u m s t a n c e s o t h e r than the i n i t i a l s e p a r a t i o n d e t e r m i n e d , to a l a r g e extent, the b e h a v i o u r of m o t h e r s at t i m e of f o l l o w - u p .  L e i d e r m a n and  S e a s h o r e pointed out that this e m p h a s i z e d the need f o r " m e t h o d o l o g i c a l c l a r i t y and the use of m o r e s o p h i s t i c a t e d s t a t i s t i c a l techniques c o v e r i n g a w i d e range of f a c t o r s " before any d e f i n i t i v e c o n c l u s i o n s c a n be d r a w n r e g a r d i n g the effect of any s i n g l e e x p e r i m e n t a l m a n i p u l a t i o n on l a t e r maternal behaviour.  T h e a u t h o r s m a i n t a i n e d that the v a r i a t i o n s i n  m o t h e r s ' b e h a v i o u r can be understood m o r e s a t i s f a c t o r i l y u s i n g a l e a r n i n g theory m o d e l a s opposed to a n e t h o l o g i c a l m o d e l . T h i s l a t t e r  53  m o d e l w o u l d " d e s c r i b e bonding b e h a v i o u r a s s p e c i e s s p e c i f i c and r e l a t i v e l y uninfluenced by e i t h e r p r i o r e x p e r i e n c e of the m o t h e r , expectations o r c u l t u r a l v a l u e s " .  her  T h e y pointed out that the o p p o r t u n i t y  e x i s t s f o r r a p i d l e a r n i n g i n the n u r s e r y d u r i n g the neonatal p e r i o d a n d suggested u t i l i z i n g the n u r s e r y s i t u a t i o n to e n c o u r a g e s p e c i f i c k i n d s o f b e h a v i o u r i n p a r e n t s that m a y enhance c o g n i t i v e d e v e l o p m e n t of the infant on the one hand and f a m i l i a l r e l a t i o n s h i p s on the o t h e r .  In  a d d i t i o n to the i m m e d i a t e e x p e r i e n t i a l i n f l u e n c e s i n the neonatal n u r s e r y , the a u t h o r s b e l i e v e d that influences s u c h a s s o c i a l c l a s s , s e x of i n f a n t , and b i r t h o r d e r a s w e l l as p a r e n t a l attitudes and e x p e c t a n c i e s a r e a m o n g the many f a c t o r s w h i c h 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 . T h e y c o n c l u d e d that a n enlightened view of the i m p o r t a n c e of these e a r l y i n t e r a c t i o n s s h o u l d l e a d to a n a t t e m p t to e n r i c h the " s o c i a l l y s t e r i l e a t m o s p h e r e in today's h o s p i t a l s " thus a l l o w i n g the d e v e l o p m e n t of p a r e n t / i n f a n t r e l a t i o n s h i p s i n the e a r l y p o s t p a r t u m d a y s . T h e above r e s e a r c h i n v o l v i n g m o t h e r / i n f a n t bonding has ; i m p l i - ; ; ••c a t i o n s f o r the use of a n a l g e s i c and anaesthetic, d u r i n g l a b o u r and w h e t h e r the m o t h e r i s c o n s c i o u s at the t i m e o f the b i r t h of h e r b a b y . A l p e r , B r o w n , O s t e i m e r and S c a n l o n (1975) stated that although m a n y effects of m a t e r n a l l y a d m i n i s t e r e d d r u g s on the neonate have been d e s c r i b e d "the question of t h e i r s i g n i f i c a n c e i s b a s i c a l l y u n a n s w e r e d " . T h e y stated that a c o m p r e h e n s i v e l o n g t e r m s t u d y of the effect o f  54  m a t e r n a l m e d i c a t i o n on m a t e r n a l / i n f a n t bonding i s n e e d e d .  According  to M o s s (1967) this r e l a t i o n s h i p depends on the neonate's r e s p o n s i v e n e s s to m a t e r n a l " c u e s " , i t a l s o depends on the b a b y ' s a b i l i t y to trigger appropriate care-taking behaviour from its mother.  As  B r a z e l t o n (1970) s t a t e d , " W a t c h i n g a drugged m o t h e r and a d e p r e s s e d infant who m u s t m a k e a ' g o w i t h e a c h o t h e r s h o u l d s t i m u l a t e us to r e T  e v a l u a t e the r o u t i n e u s e of p r e m e d i c a t i o n and a n a e s t h e s i a i n p r e g n a n c y and d e l i v e r y in the l i g h t of its effect on e a r l y m o t h e r / i n f a n t i n t e r a c t i o n " . Conclusions from Review In l i g h t of the n u m e r o u s m e t h o d o l o g i c a l d i f f i c u l t i e s e n c o u n t e r e d i t i s not p o s s i b l e to d r a w m a n y m a j o r c o n c l u s i o n s about p r e g n a n c y , c h i l d b i r t h and the e a r l y p o s t p a r t u m p e r i o d .  One c o n c l u s i o n that m a y be  d e r i v e d , h o w e v e r , i s that t h i s r e s e a r c h r e f l e c t s to a g r e a t extent the two i n h e r e n t m e t h o d o l o g i c a l d i f f i c u l t i e s of d o i n g a p p l i e d r e s e a r c h . S u b j e c t s have to be a c c e p t e d a s a v a i l a b l e , and u s u a l l y i n e x i s t i n g groups.  G r o u p s a r e p r e f o r m e d , and bound to t h e i r s u b c u l t u r e and the  t i m e and p l a c e of the s t u d y .  A s a result, neither randomization nor  g e n e r a l i z a t i o n -:is:: p o s s i b l e . A s C a m p b e l l and R o s s (1970) point o u t : S o c i a l r e s e a r c h f r e q u e n t l y e n c o u n t e r s the task of e v a l u a t i n g change p r o d u c e d i n n o n r a n d o m l y s e l e c t e d groups by events w h i c h a r e beyond the r e s e a r c h e r ' s control B e c a u s e i n these s i t u a t i o n s the i n v e s t i g a t o r has no c o n t r o l o v e r the a s s i g n m e n t of i n d i v i d u a l s o r g r o u p s to " e x p e r i m e n t a l " and " c o n t r o l " s i t u a t i o n s , the l o g i c of the c l a s s i c a l e x p e r i m e n t m u s t be r e - e x a m i n e d in a s e a r c h f o r o p t i m a l i n t e r p r e t a t i v e p r o c e d u r e s . (p. 110)  55  G i v e n the d i f f i c u l t y of r a n d o m i z a t i o n i n a p p l i e d r e s e a r c h ,  there  a r e i n h e r e n t p r o b l e m s i n the s t u d i e s r e v i e w e d that r e s e a r c h e r s c o n t r o l m o r e s u c c e s s f u l l y , n a m e l y the use of n o n s t a n d a r d i z e d  could measures,  o r l o c a l l y d e v i s e d m e a s u r i n g i n s t r u m e n t s ; t h e r e i s a l a c k of o p e r a t i o n a l definitions of t e r m s used; a l a c k of i n f o r m a t i o n r e g a r d i n g the r e l i a b i l i t y and v a l i d i t y of m e a s u r e s u s e d .  It m u s t be mentioned that few m e a s u r e s  e x i s t i n the a r e a of attitudes towards p r e g n a n c y and c h i l d b i r t h . A n o t h e r d i f f i c u l t y w i t h the r e s e a r c h r e v i e w e d i s the frequent r e l i a n c e oh s i n g l e m e a s u r e s , e . g . , r a t i n g s by one i n d i v i d u a l o r s i n g l e q u e s t i o n n a i r e d a t a , a s c o r e on a d e p r e s s i o n o r a n x i e t y s c a l e .  Webb,  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 n e c e s s i t y f o r m u l t i p l e o p e r a t i o n i s m and the use of c o m b i n e d m e a s u r e s that a v o i d the same weaknesses.  O t h e r p r o b l e m s i n c l u d e the use of n o n - r e p r e s e n t a t i v e  s a m p l e s , e . g . , unwed m o t h e r s , i n r e s e a r c h i n v o l v i n g p r e g n a n c y and c h i l d b i r t h and then g e n e r a l i z i n g to a l l w o m e n .  It i s felt that s o m e of  these d i f f i c u l t i e s a r i s e because p r e g n a n c y and c h i l d b i r t h have been c o n c e p t u a l i z e d as happening to " w o m e n " r a t h e r than b l a c k o r w h i t e , r i c h o r poor, old o r young, primiparous o r multiparous women.  M u c h has  been w r i t t e n on c r o s s c u l t u r a l d i f f e r e n c e s i n attitudes and a p p r o a c h e s to d e l i v e r y , and the p o s t p a r t u m p e r i o d .  It i s suggested that we need to  a c k n o w l e d g e c u l t u r a l d i f f e r e n c e s a l s o and take into account ethnic o r i g i n , r a c e , s o c i o e c o n o m i c c l a s s and  concomitants"  as w e l l a s p a r i t y  56  and age of the w o m e n i n v o l v e d . A n o t h e r s e r i o u s d r a w b a c k r e f l e c t e d in the pregnancy l i t e r a t u r e i s the l a c k of an i n t e r d i s c i p l i n a r y a p p r o a c h to r e s e a r c h in this a r e a .  In  f a c t , one m i g h t go so f a r a s to s a y there i s a l a c k of c o m m i t m e n t to l o n g term programmed research. A f i n a l c o m m e n t w h i c h i s not unique but w h i c h needs r e i t e r a t i n g i s the e m p h a s i s i n the l i t e r a t u r e on the " a b n o r m a l " a s p e c t s of p r e g n a n c y and c h i l d b i r t h .  How can one m a k e meaningful s t a t e m e n t s r e g a r d i n g  a b n o r m a l i t y , w h e t h e r p s y c h o l o g i c a l o r m e d i c a l without r e g a r d to the n o r m a l population?  A s M e d w a r (1967) points out,"It i s not i n f o r m a t i v e  to study v a r i a t i o n s of b e h a v i o u r u n l e s s we know beforehand the n o r m f r o m w h i c h the v a r i a n t s d e p a r t " . T h e p r e s e n t study i s a p p l i e d r e s e a r c h and thus f a l l s h e i r to the difficulties discussed above.  T h e m a j o r d i f f i c u l t y w a s the i n a b i l i t y to  a s s i g n w o m e n r a n d o m l y to the two m a j o r independent v a r i a b l e s — h o s p i t a l m a t e r n i t y p r o g r a m m e and type of d e l i v e r y . T h e r e a r e , h o w e v e r , s o m e a s p e c t s of the p r e s e n t study w h i c h i m p r o v e upon p r e v i o u s work.  F o r e x a m p l e , the total group of w o m e n constitute a homogeneous  s a m p l e of p r i m i p a r o u s w o m e n .  It w a s f e l t n e c e s s a r y to c o n t r o l f o r  s o c i o e c o n o m i c status i n view of the r e l a t i o n s h i p between low s o c i o e c o n o m i c status and o b s t e t r i c outcome ( W e s t p h a l and N i s w a n d e r , 1968).  cf.,  H i g g i n s , 1975; S i n g e r ,  It w a s a l s o felt n e c e s s a r y to c o n t r o l  f o r p a r i t y as r e s e a r c h i n d i c a t e s that p r i m i p a r a e and m u l t i p a r a e do i n  57  f a c t d i f f e r i n t h e i r 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 and c h i l d b i r t h ( E r i c k s o n , 1965; D o t y , 1967; T a n z e r , 1967; C l i f f o r d , A l l w o m e n who p a r t i c i p a t e d i n the study attended childbirth classes.  1962). education-for-*  A r e v i e w of the l i t e r a t u r e showed that the e f f i c a c y  •of c h i l d b i r t h c l a s s e s i s e q u i v o c a l , but t h e r e i s evidence  to  suggest,  that w o m e n who p a r t i c i p a t e in p r e p a r a t i o n f o r c h i l d b i r t h d i f f e 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 t a n d a r d i z e d m e a s u r e s w e r e used w h e r e v e r p o s s i b l e .  W h e r e this  w a s not p o s s i b l e , e . g . , a t t i t u d e to p r e g n a n c y , q u e s t i o n n a i r e s w e r e used that had been u t i l i z e d i n a s t u d y of a population of  women  l i v i n g i n a m a j o r W e s t e r n C a n a d i a n c i t y ( J o r d a n 1973). P o s t p a r t u m adjustment w a s o p e r a t i o n a l l y defined a s a c o m p o s i t e of affect, b e h a v i o u r and p o s i t i v e attitude t o w a r d s baby(as opposed to a s i n g l e m e a s u r e of d e p r e s s i o n ) . Evaluation Research B e c a u s e One p r e s e n t study i s e s s e n t i a l l y evaluation r e s e a r c h , i t i s a p p r o p r i a t e to e x a m i n e the fundamental d i f f e r e n c e s between t h i s type of r e s e a r c h and e x p e r i m e n t a l  research.  W e i s s (1972) pointed out that w h i l e e v a l u a t i o n a p p l i e s the methods of s o c i a l s c i e n c e , t h e r e a r e s o m e f e a t u r e s that d i s t i n g u i s h e v a l u a t i o n r e s e a r c h f r o m o t h e r types of s o c i a l r e s e a r c h .  F o r example, evalua-  tion r e s e a r c h - i s used f o r d e c i s i o n m a k i n g , the questions c o n s i d e r e d  58  b y a n e v a l u a t o r a r e not h i s / h e r p e r se, r a t h e r they a r i s e f r o m q u e s t i o n s that those c o n c e r n e d w i t h d e c i s i o n m a k i n g m a y have and q u e s t i o n s m a y 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 j u d g m e n t a l q u a l i t y to e v a l u a t i o n r e s e a r c h that, i s b a s i c to e v a l u a t i o n and w h i c h d i f f e r e n t i a t e s it f r o m other kinds of r e s e a r c h .  E v a l u a t i o n takes p l a c e i n a n a c t i o n  s e t t i n g w h e r e the m o s t i m p o r t a n t a s p e c t i s what i s going on i n the programme.  In e v a l u a t i o n the r e s e a r c h r e q u i r e m e n t s often run up  a g a i n s t e s t a b l i s h e d p r o g r a m m e p r o c e d u r e ; t h e r e a r e often r o l e c o n f l i c t s between s e r v i c e and e v a l u a t i o n w h i c h t y p i c a l l y  do  not happen i n  o t h e r 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 p u r p o s e of e v a l u a t i o n 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 a g a i n s t i t s o b j e c t i v e s .  The usual  e v a l u a t i o n h y p o t h e s i s i s that the p r o g r a m m e i s a c c o m p l i s h i n g w h a t i t s e t s out to d o .  W e i s s s t a t e s that e x p e r i m e n t a l d e s i g n i s the o p t i m a l  r e s e a r c h d e s i g n to a s c e r t a i n 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 a c h i e v e s its goals.  It i s g e n e r a l l y a g r e e d that r a n d o m i z a t i o n p r o v i d e s a m e a n s  f o r c o n t r o l l i n g f o r the i n f l u e n c e o f e x t r a n e o u s v a r i a b l e s that cannot be c o n t r o l l e d d i r e c t l y and i s the soundest b a s i s f o r m a k i n g i n f e r e n c e s , c o n c e r n i n g the effects of intervention = ( S h e r w o o d , M o r r i s , S h e r w o o d , 1975). S h e r w o o d and a s s o c i a t e s stated that a n i n d i v i d u a l doing e v a l u a t i o n r e s e a r c h i s not a l w a y s a b l e to i m p l e m e n t a r a n d o m d e s i g n .  Social  i n t e r v e n t i o n does not take p l a c e i n a c l o s e d l a b o r a t o r y w i t h i n a n  59 a c a d e m i c s e t t i n g , w h e r e e x p e r i m e n t e r s c a n manipulate both i n t e r v e n tion and s u b j e c t s .  In the o p i n i o n of S h e r w o o d and a s s o c i a t e s ,  take p o l i c i e s of a g e n c i e s p r o v i d i n g the s e r v i c e , government  the i n regulation,and  f i n a n c i a l , p o l i t i c a l and c o m m u n i t y p r e s s u r e s a r e l i k e l y to affect d e c i s i o n s c o n c e r n i n g the s a m p l e s e l e c t i o n .  A s i n most a p p l i e d r e s e a r c h ,  e v a l u a t o r s often w o r k w i t h p r e f o r m e d groups s u c h a s s c h o o l c l a s s r o o m s , hospital wards etc.  T h e a u t h o r s m a i n t a i n e d that the o n l y t i m e one c a n  e t h i c a l l y r a n d o m l y a s s i g n i s when the n u m b e r of potential m e m b e r s f o r a new p r o g r a m m e i s l a r g e r than the n u m b e r of openings.  They stated  that r a n d o m i z a t i o n i s u s u a l l y not p o s s i b l e i f t h e r e a r e j u s t enough a p p l i c a n t s at the beginning of a p r o g r a m m e and w i t h p r e v i o u s l y i n i t i a ted p r o g r a m m e s w i t h e s t a b l i s h e d intake p o l i c i e s . If r a n d o m i z a t i o n i s not f e a s i b l e , what a r e the options?  They could  be (a) no a p p l i e d o r e v a l u a t i o n r e s e a r c h ; (b) c r i t i c a l use of q u a s i e x p e r i m e n t a l d e s i g n , a s suggested by C a m p b e l l and S t a n l e y (1966); (c) a m a t c h i n g technique, a s suggested by S h e r w o o d and a s s o c i a t e s (1975).  T h i s t h i r d a l t e r n a t i v e w i l l be d i s c u s s e d b r i e f l y a s i t a p p e a r s  to be a useful technique to u s e w h e n r a n d o m i z a t i o n i s not p o s s i b l e . f u l l d e s c r i p t i o n of t h e i r method a p p e a r s i n t h e i r a r t i c l e . context of subject d i f f e r e n c e s , a r g u e d that r a n d o m i z a t i o n  may  to m a t c h i n g , s i n c e one of the  In One  S h e r w o o d and h i s c o l l e a g u e s be goals  v i e w e d a s an  alternative  of r a n d o m i z a t i o n  is  A  60  to p r o d u c e c o m p a r a b l e o r m a t c h e d g r o u p s .  T h e y stated that w h i l e  m a t c h i n g a s an a l t e r n a t i v e f o r r a n d o m i z a t i o n i s viewed as i n f e r i o r i t a p p e a r s that o p p o s i t i o n i s to the p a r t i c u l a r m a t c h i n g p r o c e d u r e s than m a t c h i n g p e r s e .  rather  T h e y a r g u e d that w h i l e the r e g r e s s i o n to the  mean c r i t i q u e f o r b i d s the use of m a t c h i n g on the b a s i s of p r e m e a s u r e s of outcome v a r i a b l e s it does not n e c e s s a r i l y f o r b i d m a t c h i n g on the b a s i s of other v a r i a b l e s . The basic assumption underlying their multivariate matching p r o c e d u r e w a s that,to the extent i t i s p o s s i b l e to c o n s t r u c t s u b g r o u p s o f i n d i v i d u a l s a l i k e on key v a r i a b l e s , " i t i s r e a s o n a b l e to b e l i e v e that the m a t c h i n g of e x p e r i m e n t a l w i t h c o n t r o l s w i t h i n these s u b g r o u p s should l e a d to the c o n s t r u c t i o n of e q u i v a l e n t e x p e r i m e n t a l and c o n t r o l groups".  T h e a u t h o r s d r e w on the b a s i c 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 a s s u m p t i o n i s that an i n d i v i d u a l , h i s i d e a s , a t t i t u d e s , b e h a v i o u r s , etc., i s in l a r g e p a r t a p r o d u c t of these e x p e r i ences and s o c i a l expectations w h i c h i m p i n g e upon h i m b e c a u s e he o c c u p i e s 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 b a c k g r o u n d v a r i a b l e s (age, s e x , ethnic a f f i l i a t i o n ) a r e therefore i n d i c e s of the p r e s u m e d p r o b a b i l i t i e s of s i m i l a r p a t t e r n s of r e s p o n s e in the future". S h e r w o o d and h i s a s s o c i a t e s m a i n t a i n e d that i t i s p o s s i b l e to a s s e r t that a l a r g e s e g m e n t of the v a r i a b i l i t y i n the i n d i v i d u a l ' s r e s p o n s e s to and functioning w i t h i n r e a l l i f e s i t u a t i o n s can be e x p l a i n e d by h i s s o c i a l  61  position.  " . . .the m o r e ' p o s i t i o n s ' and e x p e r i e n c e s an i n d i v i d u a l has  in c o m m o n w i t h another i n d i v i d u a l , the g r e a t e r the p r o b a b i l i t y that they w i l l be l i k e one another w i t h r e s p e c t to o t h e r v a r i a b l e s " .  They  m a i n t a i n e d that i f the groups matched on v a r i a b l e s of this type a r e i n fact e q u i v a l e n t , they should m a n i f e s t s i m i l a r i t y in r e s p o n s e to the pre~ m e a s u r e s of the outcome v a r i a b l e s to be used i n the a s s e s s m e n t of the intervention.  Once the s a m p l e s e l e c t i o n p r o c e d u r e a s d e s c r i b e d by the  a u t h o r s i s c o m p l e t e d , the a s s u m p t i o n i s that i t has p r o d u c e d e q u i v a l e n t e x p e r i m e n t a l and c o n t r o l g r o u p s .  T e s t i n g f o r the effects of i n t e r v e n -  tion i s then c a r r i e d out in the s a m e w a y as i f the m e m b e r s had been randomly assigned.  T h e a u t h o r s pointed out that w h i l e the a p p l i c a t i o n  of p r o b a b i l i t y 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 , p o s s i b l e j u s t i f i c a t i o n f o r the use of s a m e i s a s f o l l o w s : p r e - i n t e r v e n t i o n e q u i v a l e n c e r e q u i r e s that the s a m p l e s be no m o r e d i s s i m i l a r i n i t i a l l y than "good" r a n d o m s a m p l e s , and a d e c i s i o n in this r e g a r d r e q u i r e s the a p p l i c a t i o n of a s t a t i s t i c a l test on an "as i f they w e r e r a n d o m b a s i s " ; and i f the degree of p r e i n t e r v e n t i o n e q u i v a l e n c e i s r e g a r d e d as a c c e p t a b l e , the judgement of p o s t i n t e r v e n t i o n n o n - e q u i v a l e n c e - the s e a r c h f o r i n t e r v e n t i o n effect - w o u l d s e e m to a l l o w and r e q u i r e the s a m e l o g i c and tests on the s a m e "as if" b a s i s . In the f i r s t instance the question that i s a s k e d i s : Is i t reasonable to conclude that these two s a m p l e s a r e f r o m the s a m e p o p u l a tion? In the second i n s t a n c e , the question a s k e d i s : Is i t reasonable to c o n c l u d e that they a r e no l o n g e r f r o m the s a m e p o p u l a t i o n ? (p.222)  62  C H A P T E R II METHOD  Setting W o m e n p a r t i c i p a t i n g i n the study d e l i v e r e d t h e i r babies at one of three m a j o r h o s p i t a l s i n V a n c o u v e r . One of these h o s p i t a l s offered a f a m i l y c e n t r e d m a t e r n i t y c a r e ' p r o g r a m m e d u r i n g the i m m e d i a t e p o s t p a r t u m p e r i o d , w h i l e the o t h e r two h o s p i t a l s offered a m o r e t r a d i t i o n a l approach. The 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 w a s i n i t i a t e d in N o v e m b e r 1971 .  Its m a j o r a i m s w e r e to p r o v i d e new p a r e n t s w i t h an o p p o r t u n i t y  to p r a c t i s e p a r e n t i n g s k i l l s in a s u p p o r t i v e e n v i r o n m e n t and to enhance the development of p o s i t i v e r e l a t i o n s h i p s a m o n g f a m i l y m e m b e r s . T h e r e a r e s e v e r a l a r e a s of d i f f e r e n t i a t i o n between the 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 and the m o r e t r a d i t i o n a l h o s p i t a l . F i r s t , the s p e c i f i c n u r s e / m o t h e r / i n f a n t a s s i g n m e n t w i t h its i n d i v i d u a l teaching p r o g r a m m e w h i c h r e s u l t s i n g r e a t e r c o n t i n u i t y of c a r e f o r the m o t h e r and infant.  S e c o n d , the g r e a t e r f l e x i b i l i t y of the p o s t p a r t u m  u n i t , the m o t h e r i s free to use the s u p e r v i s e d n u r s e r y a s she w i s h e s ; she d e c i d e s w h e n , and f o r how l o n g , the infant should be i n the n u r s e r y . The n u r s e i n i t i a l l y bathes and c a r e s f o r the infant in the m o t h e r ' s r o o m a c t i n g as a r o l e m o d e l f o r the m o t h e r .  A s the c a p a b i l i t i e s of  63  the m o t h e r i n c r e a s e she undertakes g r e a t e r r e s p o n s i b i l i t y and e s t a b l i s h e s routines f o r h e r s e l f and h e r infant.  T h i r d , fathers  are  encouraged to p a r t i c i p a t e in the infant c a r e p r o c e s s and have c o m p l e t e l y flexible visiting hours.  W i t h the i n i t i a t i o n of the f a m i l y c e n t r e d p r o -  g r a m m e s e v e r a l changes w e r e made in h o s p i t a l p r o c e d u r e s w i t h the a i m of s i m u l a t i n g the home e n v i r o n m e n t .  M o r n i n g t e m p e r a t u r e taking  w a s e l i m i n a t e d ; m e a l t i m e s w e r e changed f o r patient c o m f o r t ; f o r a n o m i n a l c o s t a husband may eat h i s m e a l s w i t h h i s w i f e .  The post-  p a r t u m f l o o r has a lounge w h e r e the m o t h e r s may v i s i t w i t h t h e i r h u s bands, w a t c h T V , talk w i t h . t h e o t h e r w o m e n and eat t h e i r m e a l s . R e f r e s h m e n t s a r e a v a i l a b l e at a l l t i m e s f o r both p a r e n t s .  In a d d i t i o n  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 s o m e s i m i l a r i t i e s a m o n g the three h o s p i t a l s in this study. ery.  A l l a l l o w e d husbands to be p r e s e n t throughout l a b o u r and d e l i v One t r a d i t i o n a l h o s p i t a l e m p h a s i z e d "demand"' feeding and babies  w e r e bathed in the m o t h e r ' s r o o m , i n i t i a l l y by a n u r s e r y n u r s e and subsequently by the m o t h e r u n d e r the n u r s e ' s g u i d a n c e .  This hospital  a l s o offered i n d i v i d u a l i z e d teaching to the m o t h e r . T h e o t h e r t r a d i t i o n a l h o s p i t a l had a s y s t e m of s c h e d u l e d feedings and the "baby bath" w a s d e m o n s t r a t e d to groups of m o t h e r s t w i c e a w e e k , at w h i c h times i n s t r u c t i o n s w e r e given r e g a r d i n g infant c a r e , feeding e t c .  If an i n d i v i d u a l m o t h e r w i s h e d to bathe h e r own baby she  6k  c o u l d do so i n the n u r s e r y u n d e r the guidance of a n u r s e . M o t h e r s i n both t r a d i t i o n a l h o s p i t a l s w e r e a l l o w e d to keep t h e i r b a b i e s a f t e r feeding b e f o r e r e t u r n i n g them to the n u r s e r y a n d c o u l d d i a p e r them i f they d e s i r e d . Subjects T h e w o m e n i n the study w e r e v o l u n t e e r s who w e r e attending e d u c a t i o n f o r c h i l d b i r t h c l a s s e s w i t h t h e i r husbands between S e p t e m b e r 1974 and N o v e m b e r 1975.  T h e s e c l a s s e s a r e offered by h/vo p r i v a t e 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 w o m e n v o l u n t e e r e d to p a r t i c i p a t e i n the s t u d y .  T h e d i s t r i b u t i o n of these w o m e n in e a c h of  the three m a j o r h o s p i t a l s i n V a n c o u v e r and a c o m p a r i s o n w i t h a r e c e n t s u r v e y i n v o l v i n g 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 M e t r o p o l i t a n H e a l t h S e r v i c e s of G r e a t e r V a n c o u v e r ( K h a i r a t . & C o s t a n z o , 1974, note 2 ) , i s shown in T a b l e I. A c h i s q u a r e w a s c o m p u t e d u s i n g the percentage of those w o m e n e n t e r i n g the three m a j o r h o s p i t a l s a t both t i m e p e r i o d s , this w a s not 2 significant, x  (2) = .222 p_ ^ . . 9 0 , i n d i c a t i n g that the p r e s e n t s a m p l e i s  a r e p r e s e n t a t i v e one in t e r m s of the h o s p i t a l s i n w h i c h t h e w o m e n gave b i r t h to t h e i r baby. O f the total 133 who v o l u n t e e r e d to p a r t i c i p a t e i n the s t u d y , 15 w o m e n had t h e i r babies in h o s p i t a l s in c i t i e s o t h e r than V a n c o u v e r and s i x w o m e n d i d not meet the c r i t e r i o n of d e l i v e r y of a s i n g l e f u l l t e r m  65  infant (2 s e t s of t w i n s , 3 p r e m a t u r e b a b i e s , 1 s t i l l b i r t h ) .  A further  s i x w o m e n d i d not c o m p l e t e the r e q u i r e d n u m b e r of q u e s t i o n n a i r e s — a d r o p out r a t e of 4 . 5 % .  T h e final s a m p l e c o n s i s t e d of 106 w o m e n who  d i d meet the s e l e c t i o n c r i t e r i a . (Appendix A )  Table I D i s t r i b u t i o n of tine W o m e n i n the T h r e e M a j o r H o s p i t a l s i n the C i t y of V a n c o u v e r Hospital  '  P r e s e n t study N=133 Percentage  1974 s u r v e y N=-1021 Percentage  A  38  34  !B  30  25  C  21  18  other  11  19  0  4  no r e s p o n s e  66  T h e w o m e n w e r e w h i t e , C a u c a s i a n s ^ w h o s e age range w a s f r o m 19 to 3 7 , w i t h a m e a n of 2 7 . 0 2 y e a r s and a m e d i a n of 2 7 . 0 0 y e a r s .  The  m e a n n u m b e r o f y e a r s of education w a s 1 4 . 5 0 — m e d i a n 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 .  The women were raised i n  N o r t h A m e r i c a . - : o r the B r i t i s h C o m m o n w e a l t h . T h e w o m e n w e r e m a r r i e d and e x p e c t i n g t h e i r f i r s t b a b y . A l l p a r t i c i p a n t s i n the s t u d y l i v e d i n the c i t y of V a n c o u v e r o r the l o w e r m a i n l a n d a r e a , and d e l i v e r e d t h e i r babies i n one of the t h r e e m a j o r h o s p i t a l s i n the m e t r o p o l i t a n a r e a . A . l l w o m e n had a s i n g l e f u l l t e r m infant, and e x p e r i e n c e d no 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 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 the p o s t p a r t u m p e r i o d of e i t h e r t h e m s e l v e s o r of t h e i r i n f a n t s .  Detailed demographic  data a r e in A p p e n d i x B . ;  T w e l v e w o m e n i n the t r a d i t i o n a l h o s p i t a l s e t t i n g who d e l i v e r e d v a g i n a l l y had r o o m i n g - i n w i t h t h e i r i n f a n t s .  G i v e n that this w a s p o s s i -  ble only i f y o u had a p r i v a t e r o o m f o r w h i c h y o u paid e x t r a p e r d a y and g i v e n the p o s s i b 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 c e n t r e d m a t e r n i t y c a r e , the data f r o m these w o m e n w e r e e x c l u d e d f r o m the s t a t i s t i c a l a n a l y s e s .  T h e total n u m b e r of w o m e n u s e d f o r the  statistical analyses i s therefore 94. sections.  O f these w o m e n 21*had c a e s a r i a n  T h e data f r o m w o m e n i n both types of p r o g r a m m e w e r e c o m -  bined f o r the a n a l y s e s i n v o l v i n g the c o m p a r i s o n of v a g i n a l w i t h c a e s a r ian s e c t i o n .  In view of t h i s , the data f r o m the two w o m e n i n the  c a e s a r i a n s e c t i o n group who had r o o m i n g - i n w i t h i n the t r a d i t i o n a l A l l but two w e r e e m e r g e n c y c a e s a r i a n  67  p r o g r a m m e w e r e not dropped f r o m these a n a l y s e s .  T h e total n u m b e r  of w o m e n f o r each group w a s a s f o l l o w s : F a m i l y centred maternity programme vaginal d e l i v e r y caesarian section  20 6  Traditional programme vaginal d e l i v e r y  53  caesarian section  13  Rooming-in caesarian section  2  T h e p r o p o r t i o n of c a e s a r i a n s e c t i o n (excluding tine two i n r o o m i n g 2 in) by type of p r o g r a m m e w a s not s i g n i f i c a n t , _x^(1) = .13 p_i*» . 5 0 . N e i t h e r w a s the p r o p o r t i o n s i g n i f i c a n t i n c l u d i n g the 2 w o m e n who had 2 r o o m i n g - i n , x _ (1) = .0112 £ > 5 0 . Measures T h e s c h e d u l e f o r c o m p l e t i o n of the v a r i o u s q u e s t i o n n a i r e s and c h e c k l i s t s i s set f o r t h i n T a b l e II. A t t i t u d e towards p r e g n a n c y , l a b o u r , d e l i v e r y and Pie baby q u e s t i o n n a i r e s T h e v a r i o u s q u e s t i o n n a i r e s d e a l i n g w i t h attitudes and f e e l i n g s t o w a r d s the p r e g n a n c y and c h i l d b i r t h e x p e r i e n c e and attitude towards the baby a r e based on those used by J o r d a n i n h e r study (1973).  The f o r -  m a t of each q u e s t i o n n a i r e w a s modified s l i g h t l y to c o n f o r m to a L i k e r t  68  II  Table  S c h e d u l e for C o m p l e t i o n of Time Time  P e r i o d and M e a s u r e s  Period  Data Involved  Measures  D e m o g r a p h i c data I  Prenatal Ninth  questionnaire  Feelings and attitudes towards  Month  Depression adjective Pleasant Labour In  Hospital  After at  One  (DACL)  and D e l i v e r y  Questionnaire  the new baby  questionnaire  A r e a s of C o n c e r n D A C L  III  checklist  Events Schedule  Feelings towards II  pregnancy  B e c k D e p r e s s i o n Index  Week  Home  -  each  Greenberg's Maternity  Questionnaire  Feelings towards  baby  questionnaire  Greenberg's follow-up  questionnaire  A r e a s of C o n c e r n D A C L Feelings towards  IV  After at  Five  Weeks  Home  Six  Months  after  Delivery  questionnaire  B e c k D e p r e s s i o n Index Pleasant  V  baby  A r e a s of C o n c e r n  A  Events Schedule  check was  Counselling  m a d e with the Centre  Postpartum  69  type q u e s t i o n n a i r e i n o r d e r to help c o n t r o l f o r r e s p o n s e s e t a n d acquiescence t e n d e n c i e s . a m o r e positive attitude.)  ( A h i g h e r s c o r e on the q u e s t i o n n a i r e i n d i c a t e s A l p h a r e l i a b i l i t y c o e f f i c i e n t s ( W i n e r , 1962)  w e r e computed a s shown i n T a b l e III.  The reliability coefficients i n -  d i c a t e that each q u e s t i o n n a i r e has i n t e r n a l c o n s i s t e n c y and h o m o g e n e i t y .  T a b l e III A l p h a Reliability Coefficients for Attitude Questionnaires Name  N of q u e s t i o n s  N of s u b j e c t s  Alpha  A t t i t u d e to p r e g n a n c y  40  133  .91  A t t i t u d e to l a b o u r and d e l i v e r y  31  121*  .93  Attitude towards Baby T i m e l  28  121  .80  Attitude towards Baby T i m e 2  38  121  .94  Attitude towards Baby T i m e 3  33  121  .90  .  N = 121 e x c l u d e s the s i x w o m e n who d i d not c o m p l e t e the s t u d y a n d the s i x w o m e n who d i d not m e e t 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 C o n c e r n T h e w o m e n a l s o c o m p l e t e d a c h e c k l i s t of p r o b l e m a r e a s f o r both t h e m s e l v e s and t h e i r infants at t h r e e points i n t i m e ; i n h o s p i t a l , a f t e r one w e e k at h o m e and a f t e r five w e e k s at home (Jordan; T973).The p u r pose of these c h e c k l i s t s w a s to l e a r n of the p r o b l e m s the w o m e n e x p e r i e n c e d at these t h r e e t i m e p o i n t s .  Tine total n u m b e r of p r o b l e m s  w a s the f i g u r e u s e d i n the a n a l y s i s . H o s p i t a l E x p e r i e n c e and One W e e k F o l l o w - u p G r e e n b e r g (1973) and h i s a s s o c i a t e s d e v i s e d a q u e s t i o n n a i r e to l e a r n how the new m o t h e r p e r c e i v e d h e r e x p e r i e n c e w h i l e i n h o s p i t a l . T h e y used it i n a s i m i l a r r e s e a r c h s t u d y and c e r t a i n i t e m s w e r e found to differentiate g r o u p s of w o m e n r a n d o m l y a s s i g n e d to r o o m i n g - i n o r traditional w a r d s .  A l t h o u g h the c o m p l e t e q u e s t i o n n a i r e s w e r e  admin-  i s t e r e d , s o m e questions w e r e not a p p r o p r i a t e f o r the p r o p o s e d s t a t i s t i c a l a n a l y s e s , although they w i l l be used f o r d e s c r i p t i v e p u r p o s e s .  Therefore,  o n l y r e l e v a n t i t e m s s c a l e a b l e in the L i k e r t f o r m a t r e l a t i n g to the h o s p i tal e x p e r i e n c e w e r e u s e d i n the s t a t i s t i c a l a n a l y s e s .  Similarly scale-  a b l e i t e m s w e r e s e l e c t e d f r o m the f o l l o w - u p q u e s t i o n n a i r e .  These  q u e s t i o n n a i r e s a r e i n A p p e n d i c e s C and D . T h e h i g h e r s c o r e r e f l e c t s the m o r e p o s i t i v e s t a t e m e n t . '  71 Depressive Affect T w o m e a s u r e s of d e p r e s s i v e affect w e r e chosen that a r e w i d e l y u s e d i n the c l i n i c a l s e t t i n g .  In a d d i t i o n a n e s t i m a t e of b e h a v i o u r a l  a c t i v i t y w a s obtained f r o m the w o m e n , ( B e c k , 1961; 1967; 1970).  (a) T h e B e c k D e p r e s s i o n Index  This is a clinically derived inventory c o n -  c e r n e d w i t h the c h a r a c t e r i s t i c s , attitudes and s y m p t o m s of d e p r e s s e d individuals.  It c o n s i s t s of 21 c a t e g o r i e s d e a l i n g w i t h a f f e c t i v e ,  b e h a v i o u r a l , c o g n i t i v e and s o m a t i c s y m p t o m s .  Each category contains  graded s e l f - e v a l u a t i v e s t a t e m e n t s r a n g i n g f r o m z e r o to t h r e e .  The  h i g h e r the s c o r e o b t a i n e d , the m o r e d e p r e s s e d the i n d i v i d u a l .  Although  the B e c k confounds s t a t e and t r a i t d e p r e s s i o n , a c c o r d i n g to B e c k e r (1974) it i s s e n s i t i v e to change and a p p a r e n t l y 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 a n x i e t y . A n a l y s i s has shown good r e l i a b i l i t y u s i n g the c r i t e r i a of i n t e r n a l c o n s i s t e n c y and s t a b i l i t y and i t has been shown to be v a l i d i n factor analytic studies. L e m p e r i e r e , 1964).  ( C r o p l e y , & W e c k o w i c z , 1966; P i c h o t , &  M e a n s c a l e s c o r e s f o r the c a t e g o r y of no d e p r e s -  s i o n , m i l d , m o d e r a t e and s e v e r e d e p r e s s i o n a r e 1 0 . 9 , 1 8 . 7 , 2 5 . 4 and 30.0 respectively,  (b) 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 ( L u b i n ,  1965). T h i s i s a m e a s u r e of state d e p r e s s i o n a c c o r d i n g to L u b i n and c o n s i s t s of 32 a d j e c t i v e s , 22 i n d i c a t i n g d e p r e s s i v e mood and ten i n dicating non-depressive mood.  T h i s i n s t r u m e n t has the advantage of  being b r i e f and has a l t e r n a t e f o r m s f o r the p u r p o s e of repeated  measures.  72 T h e s c a l e s have good s p l i t h a l f r e l i a b i l i t y and i n t e r c o 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 , n o n d e p r e s s i v e p s y c h i a t r i c patients and diagnosed d e p r e s s i v e s " .  T h e h i g h e r the s c o r e obtained  on the D A C L the m o r e d e p r e s s e d the i n d i v i d u a l .  A r a w s c o r e of 15  w o u l d i n d i c a t e that a p e r s o n i s m i l d l y d e p r e s s e d . A s would be e x p e c t e d , the B e c k D e p r e s s i o n Index and 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 a r e s i g n i f i c a n t l y but not h i g h l y c o r r e l a t e d w i t h each other.  In the p r e s e n t s t u d y , the c o r r e l a t i o n s between these two m e a -  s u r e s in the ninth month of p r e g n a n c y and s i x w e e k s p o s t p a r t u m w e r e £ =  . 4 4 8 £ < . 0 1 and r = .478 p_<i.01 r e s p e c t i v e l y .  Behaviour 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 d e v i s e d by M a c P h i l l a m y and L e w i n s o h n (1971) w a s u s e d .  T h e a u t h o r s stated that the s c h e d u l e w a s  designed to e l i c i t events that people have enjoyed o v e r the past m o n t h . T h e i n s t r u m e n t c o n s i s t s of 320 events and a c t i v i t i e s and has been u s e d by L e w i n s o h n and h i s c o l l e a g u e s i n t h e i r s t u d i e s of the a s s o c i a t i o n between d e p r e s s i v e mood and a c t i v i t i e s ( L e w i n s o h n , L i b e t , 1972; L e w i n s o h n , G r a f , -1973).  In the p r e s e n t study the w o m e n c o m p l e t e d o n l y  P a r t A of the S c h e d u l e responding to the question " H o w often have these events o c c u r r e d  ? ".  n u m b e r of i t e m s c h e c k e d .  T h e total a c t i v i t y s c o r e i s i n d i c a t e d by the.  73  H o s p i t a l Data S h e e t s f o r M o t h e r and Infant T h e s e w e r e factual i n f o r m a t i o n sheets ( J o r d a n , 1973) c o m p l e t e d by the m o t h e r and i n c l u d e d s u c h i t e m s as length of l a b o u r , type of a n a e s t h e t i c , type of f e e d i n g , and s e x of infant. S i x months a f t e r d e l i v e r y a c h e c k w a s made w i t h the 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 to v e r i f y w h e t h e r any w o m e n in the study had sought a s s i s t a n c e f r o m the c e n t r e . T o a s c e r t a i n w h e t h e r the g r o u p s o f w o m e n i n e a c h h o s p i t a l w e r e s i m i l a r r e g a r d i n g the m e a s u r e s c o m p l e t e d w i t h i n the p r e n a t a l  period,  they w e r e c o m p a r e d on (a) the d e m o g r a p h i c data and (b) t h e i r r e s p o n s e s to the q u e s t i o n n a i r e s i n v o l v i n g attitude to p r e g n a n c y , d e p r e s s i v e affect and total a c t i v i t y . O n e - w a y m u l t i v a r i a t e a n a l y s i s of v a r i a n c e of the s e t of d e m o g r a p h i c v a r i a b l e s (age, education of w i f e , i n c o m e of w i f e , education of husband, i n c o m e of husband) r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e a m o n g those w o m e n e n t e r i n g the t h r e e m a j o r h o s p i t a l s (.Likelihood r a t i o c r i t e r i o n , l a m b a = . 9 6 6 , F (10,196) = .34 £ ^ . 5 0 ) . T h e means and s t a n d a r d d e v i a t i o n s of the d e m o g r a p h i c data f o r the total s a m p l e a r e shown in A p p e n d i x E .  T h e r e w a s no s i g n i f i c a n t d i f f e r e n c e  among the three groups of w o m e n in the set of v a r i a b l e s r e l a t i n g to the prenatal p e r i o d '  (attitude towards p r e g n a n c y , d e p r e s s i v e affect o r  the amount of b e h a v i o u r engaged i n ' ) (A £ ^ .50).  = . 9 6 3 , F ( 8 , 1 9 6 ) = .88  T h e means and standard d e v i a t i o n s of. these data a r e i n  74 Appendix F .  It w a s f e l t , t h e r e f o r e , that the w o m e n i n the t h r e e  h o s p i t a l s w e r e c o m p a r a b l e i n t e r m s o f both d e m o g r a p h i c data a n d data c o l l e c t e d d u r i n g the ninth month of p r e g n a n c y .  T h e data f r o m those  w o m e n who d e l i v e r e d t h e i r babies in h o s p i t a l s offering the m o r e t r a d i t i o n a l m a t e r n i t y e x p e r i e n c e w e r e c o m b i n e d f o r subsequent s t a t i s t i c a l analyses.  Procedure T h e e d u c a t i o n - f o i — c h i l d b i r t h c l a s s e s w e r e v i s i t e d a t the p e n u l t i m a t e class.  T h e g r o u p s w e r e told that I w a s s t u d y i n g the n o r m a l w o m a n ,  e x p e c t i n g h e r f i r s t b a b y , and h e r f e e l i n g s and attitudes t o w a r d p r e g n a n c y , c h i l d b i r t h , the h o s p i t a l and e a r l y p o s t p a r t u m e x p e r i e n c e .  The  g r o u p w a s a l s o i n f o r m e d of the c r i t e r i a f o r s e l e c t i o n and w e r e told that they w o u l d r e c e i v e a c o p y of the r e s u l t s of the study w h e n c o m p l e t e d . T h o s e w o m e n who v o l u n t e e r e d s i g n e d a consent f o r m and w e r e g i v e n the f i r s t s e t of q u e s t i o n n a i r e s in a s t a m p e d a d d r e s s e d e n v e l o p e , to be c o m p l e t e d and r e t u r n e d .  Upon r e c e i p t of the f i r s t s e t , the s e c o n d and s u b -  sequent s e t s of q u e s t i o n n a i r e s w e r e m a i l e d to the w o m e n a t the a p p r o p  pnate time.  2 A t the t i m e of the nationwide p o s t a l s t r i k e i n C a n a d a , 21st of O c t o b e r t o - e a r l y D e c e m b e r 1975, the q u e s t i o n n a i r e s w e r e p i c k e d up a n d d e l i v e r e d by h a n d .  75  A l e t t e r w a s a l s o sent to the p h y s i c i a n w h o s e patients w e r e i n v o l v e d i n the s t u d y , d e s c r i b i n g the study and i n v i t i n g questions a n d / o r c o m m e n t s . (Appendix G)  Statistical Analyses A l l a n a l y s e s w e r e c a r r i e d out i n the c o m p u t i n g c e n t r e 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 , V a n c o u v e r , B . C . T h e independent v a r i a b l e s w e r e (a) type of h o s p i t a l p r o g r a m m e and (b) type of d e l i v e r y e x p e r i e n c e d (whether v a g i n a l o r c a e s a r i a n ) .  Several  types of a n a l y s e s w e r e c a r r i e d out. 1.  D i f f e r e n c e s between the groups on the s e t of dependent v a r i a b l e s  at each t i m e p e r i o d w e r e a n a l y z e d u s i n g H o t e l l i n g s T ^ technique f o r two samples.  F o r each t i m e p e r i o d the h y p o t h e s i s w a s that the g r o u p s c a m e  f r o m a population w i t h a c o m m o n mean v e c t o r .  If the h y p o t h e s i s w e r e  r e j e c t e d m u l t i p l e c o m p a r i s o n s w e r e made u s i n g the " s i m u l t a n e o u s c o n fidence i n t e r v a l " to d e t e r m i n e w h i c h i n d i v i d u a l dependent v a r i a b l e means w e r e s i g n i f i c a n t ( M o r r i s o n , 1967). T h e c o n s e r v a t i v e feature of this method of m u l t i p l e c o m p a r i s o n s u s e d m a y w e l l r e s u l t i n an i n c r e a s e i n T y p e 11 e r r o r .  W h i l e this m o r e  s t r i n g e n t a p p r o a c h p r e v e n t s the p o s s i b i l i t y of o v e r i n t e r p r e t a t i o n of one's data i t a l s o p r e v e n t s the g e n e r a t i o n of p o s s i b l e h y p o t h e s e s .  76  2. T o 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 s c e r t a i n the r e l a t i o n s h i p between the m e a s u r e s c o l l e c t e d , tine pooled w i t h i n groups c o r r e l a t i o n m a t r i c e s f o r the s a m p l e (N=94) f o r each point in t i m e w e r e e x a m i n e d .  T h e pooled w i t h i n g r o u p s  m a t r i x w a s chosen i n view of the s i g n i f i c a n t differences between the v a r i o u s groups on c e r t a i n m e a s u r e s .  T h i s m a t r i x of c o r r e l a t i o n s i s  not inflated by these d i f f e r e n c e s . A l t h o u g h c o r r e l a t i o n c o e f f i c i e n t s a m o n g a l a r g e n u m b e r of v a r i a b l e s a r e s u s p e c t in view of the fact that s p u r i o u s c o r r e l a t i o n s o c c u r by c h a n c e , p r o v i d i n g one evaluates, them c a u t i o u s l y such r e l a t i o n s h i p s a r e v a l u a b l e f r o m a h e u r i s t i c point of v i e w .  T h e pooled w i t h i n groups c o r -  r e l a t i o n m a t r i x f o r a l l v a r i a b l e s w a s e x a m i n e d w i t h this in m i n d .  The  s p e c i f i c v a r i a b l e s that w e r e looked at i n t e r m s of t h e i r r e l a t i o n s h i p to o t h e r s w e r e as f o l l o w s :  method of feeding (whether b r e a s t o r bottle  feeding^ n u m b e r of days spent in h o s p i t a l ; n u m b e r of days spent " r o o m i n g - i n " w i t h the b a b y . 6. A p r i n c i p a l components f a c t o r a n a l y s i s with a v a r i m a x r o t a t i o n w a s c a r r i e d out u s i n g the m a j o r v a r i a b l e s in the study.  (Several  a b l e s w e r e o m i t t e d because of the s m a l l n e s s of the s a m p l e . )  vari-  78  C H A P T E R III RESULTS  The d e s c r i p t i v e s t a t i s t i c s f o r the total s a m p l e r e g a r d i n g length of l a b o u r , s e x of infant, type of a n a s t h e s i a , etc., a r e i n A p p e n d i x H . C o m p a r i s o n Between H o s p i t a l P r o g r a m m e s T i m e 1 ~ P r e n a t a l data c o m p l e t e d in the ninth month of p r e g n a n c y T o a s c e r t a i n w h e t h e r the groups who p a r t i c i p a t e d in the two h o s p i tal p r o g r a m m e s w e r e c o m p a r a b l e w i t h r e s p e c t to t h e i r d e m o g r a p h i c c h a r a c t e r i s t i c s and r e s p o n s e s to the q u e s t i o n n a i r e s and c h e c k l i s t s a d  _  2 m i n i s t e r e d at the ninth month of p r e g n a n c y , H o t e l l i n g s T technique w a s c o n d u c t e d .  statistical  T h e r e w a s no difference between the means  f o r e i t h e r 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 .  T h e s e data a r e shown in A p p e n d i x I and A p p e n d i x J r e s p e c t i v e l y .  The  means f o r the B e c k D e p r e s s i o n Index and D A C L i n d i c a t e that the two groups of w o m e n a r e w i t h i n the n o r m a l l i m i t s in t e r m s of t h e i r d e p r e s s i v e affect.  T h e range of s c o r e s on the D A C L and B e c k D e p r e s s i o n  Index f o r both g r o u p s , h o w e v e r , i n d i c a t e that there a r e s o m e Women who m i g h t be c a l l e d m i l d l y d e p r e s s e d . The pooled w i t h i n groups c o r r e l a t i o n m a t r i c e s of these data for the total s a m p l e a r e in T a b l e s I V a n d V r e s p e c t i v e l y .  79  Table I V P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x f o r the d e m o g r a p h i c data. N = 93 *  A g e of Wife Y e a r s of Education Wife Income of Wife Y e a r s of Education Husband  A g e of Wife  Y e a r s of Education -;- Wife  1.000  .432***  Income of W i f e  Y e a r s of Education ..—' Husband  Income of Husband  .152  .112  .341***  .209**  .364***  .125  .069  .070  .117  Income of Husband  ***  p«£.01  **  p<.05  * one s e t of q u e s t i o n n a i r e s f o r this t i m e p e r i o d w a s l o s t d u r i n g the mail strike.  80  Table V P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x f o r the m e a s u r e s c o l l e c t e d in the ninth month of p r e g n a n c y . N - 93*  A t t i t u d e to Pregnancy  A t t i t u d e to Pregnancy Beck Depression Index DACL  1 . GOO  Beck Depression Index  -  .022  DACL  -.325***  Pleasant Events Schedule  -  .448***  .031  .081  -  .103  Pleasant Events Schedule  p<.01  * one s e t of q u e s t i o n n a i r e s f o r this t i m e p e r i o d w a s l o s t d u r i n g the mail strike  81  T i m e II - H o s p i t a l data T h e r e s p o n s e s of the w o m e n on the v a r i o u s m e a s u r e s at this point in t i m e w e r e a n a l y z e d in two p a r t s .  T h e f i r s t a n a l y s i s of the h o s p i t a l  data i n v o l v e d a c o m p a r i s o n of the two groups on the f o l l o w i n g s e t of v a r i a b l e s ; attitude to l a b o u r and d e l i v e r y , attitude to the b a b y , a r e a s of c o n c e r n in h o s p i t a l and amount of d e p r e s s i v e affect e x p e r i e n c e d each day.  T h e means and s t a n d a r d d e v i a t i o n s f o r these data a r e in T a b l e V I .  Hotellings T  2  revealed a s i g n i f i c a n t d i f f e r e n c e between the two groups of  w o m e n a s a function of the h o s p i t a l p r o g r a m m e e x p e r i e n c e d , F ( 7 , 6 5 ) = 3 . 002.  S i m u l t a n e o u s m u l t i p l e c o m p a r i s o n s revealed no d i f f e r e n c e s  in the means of the i n d i v i d u a l v a r i a b l e s .  Subsequent u n i v a r i a t e a n a l y s i s  of v a r i a n c e i n d i c a t e d that the v a r i a b l e s c o n t r i b u t i n g m o s t to the o v e r a l l d i f f e r e n c e s w e r e attitude to baby, F ( 1 , 7 1 ) = 4.179 p_<£ . 0 4 5 , and the n u m b e r of p r o b l e m s , F (1,17)  =7.917  p_<<:.006. T h o s e w o m e n who had  p a r t i c i p a t e d in the 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 appeared to have a m o r e p o s i t i v e attitude to t h e i r baby in h o s p i t a l and a l s o r e p o r t e d m o r e p r o b l e m s than those w o m e n in the t r a d i t i o n a l p r o g r a m m e .  It  s h o u l d be noted that the w o m e n who p a r t i c i p a t e d in the 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 in J o r d a n ' s study r e p o r t e d m o r e p r o b l e m s than d i d those in the t r a d i t i o n a l p r o g r a m m e .  It m a y w e l l be that the s p e c i f i c  n u r s e a s s i g n m e n t and educational p h i l o s o p h y of this type of p r o g r a m m e p r o v i d e s an a t m o s p h e r e conducive to the v e r b a l i z i n g of p r o b l e m s .  82  Table V I M e a n s and s t a n d a r d d e v i a t i o n of the h o s p i t a l data  F a m i l y Centred Maternity P r o g r a m m e N=20 Mean  SD  A t t i t u d e to l a b o u r and d e l i v e r y  146.85  A t t i t u d e to baby  Traditional Programme N = 53 Mean  SD  12.83  147.06  13.79  131.85  13.92  125.02  12.28  A r e a s of c o n c e r n  11 .60  5.46  8.23  4.20  DACL T i m e One  46.20  4.85  4 5 . 19  5.04  DACL Time Two  46.80  6.25  46.77  7.95  DACL Time Three  50.65  8.84  49.85  10.10  DACL Time Four  50.90  9.96  48.68  8.63  83  T h e pooled w i t h i n groups c o r r e l a t i o n m a t r i x f o r the total s a m p l e f o r these data i s i n T a b l e V I I . T h e second m a j o r a n a l y s i s of the h o s p i t a l data w a s c a r r i e d out on the r e s p o n s e s to 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 .  Hotellings T  2  shows no d i f f e r e n c e between the means of the two g r o u p s on this s e t of v a r i a b l e s , F ( 1 5 , 5 7 ) = .964 p _ > . 5 0 . W h i l e G r e e n b e r g and a s s o c i a t e :  T h e s e data a r e i n A p p e n d i x K .  had r e p o r t e d s i g n i f i c a n t diffei—  ences between w o m e n in t h e i r study this m a y have been due to the c u l t u r a l d i f f e r e n c e s in s t u d y i n g a S w e d i s h s a m p l e o r to the s t a t i s t i c a l techniques e m p l o y e d to a n a l y z e the r e s p o n s e s to t h e i r q u e s t i o n n a i r e s w h i c h may have r e s u l t e d in T y p e I e r r o r s .  T h e p r e s e n t study used  m u l t i v a r i a t e techniques to c o n t r o l f o r this and the f i n d i n g s do not s u p p o r t those of G r e e n b e r g and h i s a s s o c i a t e . . T h e pooled w i t h i n c o r r e l a t i o n m a t r i x f o r the r e s p o n s e s of the total s a m p l e f o r the above data i s in T a b l e VIII. T i m e 111 - A f t e r one week at home When the w o m e n had'been home f o r one w e e k they c o m p l e t e d the attitude to baby q u e s t i o n , a r e a s of c o n c e r n , D A C L and G r e e n b e r g ' s follow-up questionnaire.  Hotellings T  2  revealed a significant difference  between the two groups on this s e t of v a r i a b l e s , F ( 1 0 , 6 2 ) = 3 . 6 2 , £.<£..0008.  T h e means and s t a n d a r d d e v i a t i o n s f o r these m e a s u r e s  shown in T a b l e I X . S i m u l t a n e o u s m u l t i p l e c o m p a r i s o n s , h o w e v e r ,  are  84  T a b l e VII Pooled within groups c o r r e l a t i o n m a t r i x f o r those m e a s u r e s c o m p l e t e d w h i l e in h o s p i t a l .  Attitude to l a b o u r and delivery  Attitude to l a b o u r and Delivery Attitude to B a b y A r e a s of Concern DACL Time 1  DACL Time 2  DACL Time 3  DACL Time 4  *** p «£..01 p «C.02  1.000  Attitude to Baby  .431***  N = 94  Areas DACL DACL DACL DACL of "> Concern Time 1 T i m e 2 T i m e 3 T i m e 4  .177  -.161  -.105  -.072  -277***  -.113  -.137  -.172  .015  -.247***  .095  .182  .167  .012  .710*** .300***  .378***  .405***  .359***  .313***  Table VIII Pooled within groups correlation matrix of the responses to Greenberg's Maternity Questionnaire N=94  Self confidence (1) re: child care .  Perception of amount  (1)  (2)  (3)  (4)  1.000  ,a40*  .197  .143  ..220*  .131  .155  .127  .180  .173  -.046  .320*** .090  -.084  .055  .137  .130  -.004  .150  ..143  .180  .222*  -.037  .194  .085  -.065  '  (5)  (6)  (7)  .377*** .239*  (8) .158  (9) ;  (10)  (11)  (12)  (13)  .046  .-.172  -.084  .003  .022  .081  -.083  .134  .020  .109  .027  .631***.083  (14)  (15)  .019  .075  .013  -.039  -.008  .052  .090  .144  .240*  .073  .159  -.038  .096  .053  .107  -.040  -.035  -.014  -.153  of help needed at home (3) Happiness in hospital (4) Present energy level  •  (5) Absence of anxiety regarding responsibility for baby (6) Confidence regarding role of motherhood (7) Present feelings of gladness v s . depression  .328*** .488*** .522***.272*** . 137  . 095  . 032  . 202  . 067  .275*** .294***.323*** . 130  .117  -.150  .162  -.156  .362*** .254** -.001  .004  . 231*  -.018  008  .125  .018  -.118  .000  .006  - . 128  .086  - 093  .048  -.151  -.022  .160  .080  (8) Maternal feeling to baby  .231*  (9) Competence re childcare  .277*** .172  (10)Immediacy of understanding baby's needs (11)Lack of restriction in usual activities (12)Energy level after delivery (13y\mount of help from nursing personnel (14) Fee!ings of gladness/vs depression after delivery (15) Amount of help received from hospital personnel ***p<:.01 * * p 4 .02 *p<.05  .118  '  -.078  -.085  356**  210*  CO \J1  86  T a b l e EK M e a n s and s t a n d a r d d e v i a t i o n s of the M e a s u r e s c o m p l e t e d a f t e r one week at home  F a m i l y Centred Maternity P r o a r a m m e N = 20 Mean  Traditional Programme N = 53  SD  Mean  163.25  18.67  160.45  18.28  11 . 5 0  8.59  8.58  6.78  Self-Confidence regarding child care  3.50  .89  3.47  E a s e of adjustment from Hospital  3.50  1.15  3.06  1.00  Experience received in H o s p i t a l  3.50  .83  2.60  .97  Preparation for mothering role  3.70  .98  2.96  1.07  I m m e d i a c y of understanding infant  3.95  .94  3.62  1.15  Certainty regarding child care  3.40  .99  2.92  .92  A m o u n t of help needed  3.30  .73  3.17  .73  48.55  8.05  48.55  7.24  A t t i t u d e to B a b y A r e a s of C o n c e r n  DACL  SD  .77.  87  i n d i c a t e d no d i f f e r e n c e s between the i n d i v i d u a l m e a n s .  T h e subsequent  u n i v a r i a t e a n a l y s i s of v a r i a n c e i n d i c a t e d that two v a r i a b l e s c o n t r i b u t i n g m o s t to the o v e r a l l d i f f e r e n c e s w e r e the amount of help r e c e i v e d f r o m the h o s p i t a l in p r e p a r i n g f o r the m o t h e r i n g r o l e , F ( 1 , 7 1 ) = 7.18 £.£•009,  and the amount of e x p e r i e n c e gained w h i l e in h o s p i t a l in  taking c a r e of the baby  F ( 1 , 7 1 ) = 1 3 . 4 3 p_  0004 .  T h e pooled w i t h i n c o r r e l a t i o n m a t r i x f o r the above data f o r the total s a m p l e i s in T a b l e X . T i m e I V - A f t e r f i v e w e e k s at home A f t e r the w o m e n had been home f o r five w e e k s they c o m p l e t e d the following measures:  attitude towards baby; a r e a s of c o n c e r n , B e c k  D e p r e s s i o n Index; the 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 . H o t e l l i n g s 2 T  r e v e a l e d no d i f f e r e n c e s between the two groups on this s e t of  v a r i a b l e s , F ( 5 , 6 7 ) = .654  p_> . 5 0 .  T h e means and s t a n d a r d d e v i a t i o n s  f o r these m e a s u r e s a r e in A p p e n d i x L . T h e pooled w i t h i n c o r r e l a t i o n m a t r i x of these data f o r the total s a m p l e i s in T a b l e X I . T i m e V - S i x months after d e l i v e r y A c h e c k w i t h the 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 of G r e a t e r V a n c o u v e r , indicated that,based on t h e i r r e c o r d s , no w o m e n in the p r e s e n t study had sought the a s s i s t a n c e of the c e n t r e w i t h i n s i x months a f t e r the b i r t h of t h e i r baby.  Table X P o o l e d w i t h g r o u p s c o r r e l a t i o n m a t r i x of the m e a s u r e s completed a f t e r one w e e k at home  (1) A t t i t u d e to B a b y (2) A r e a s of C o n c e r n (3) S e l f confidence re childcare (4)  E a s e of adjustment from hospital  (5) E x p e r i e n c e r e c e i v e d in h o s p i t a l r e : c a r e of baby (6)  Preparation for mothering role  (7)  Length of t i m e to understand infant  (8) C e r t a i n t y r e c h i l d c a r e (9) A m o u n t of help needed (10) D A C L * * * p <.01 ** p ^ . 0 2  (1)  (2)  1.000  -.253**  (3) .534*** -.072  (4) .490***  (5)  (5)  (7)  .274***. .257** ..364**  -.337*** - . 0 6 2  -.096  -.013  .455*** .405*** .416*** .270***  (8)  (9)  .452*** -.090  .303*** -.141  .558*** .354***  (10) .057 .286* .077  .330*** .289*** ,.410*** .453*** .345*** - . 0 5 9  .794*** .336*** .362***  ,287***  ,318***  188  .139  .075  .175 '  .007  .106  .067  .424***  .021 .089  89  Table X I P o o l e d w i t h i n groups c o r r e l a t i o n m a t r i x for the m e a s u r e s c o m p l e t e d a f t e r f i v e w e e k s at h o m e . N = 94  Attitude to B a b y  A t t i t u d e to Baby A r e a s of Concern Beck Depression Index  1 .000  A r e a s of Concern  393  Beck Depression Index  -.168  198  DACL  .243**  148  ,478***  Pleasant Events Schedule  .218*  -.061  .026  -.198  DACL Pleasant Events Schedule  ***  p-C.02 p<*1.05  90 A c r o s s T i m e - Depressive Affect T h e s u m m a r y o f the repeated m e a s u r e s a n a l y s i s of v a r i a n c e f o r d e p r e s s i v e affect i s p r e s e n t e d i n T a b l e X I I .  A s can be s e e n , w h i l e  there i s not a s i g n i f i c a n t d i f f e r e n c e between the two g r o u p s in t e r m s of d e p r e s s i v e affect, t h e r e i s a s i g n i f i c a n t d i f f e r e n c e i n the l e v e l of d e p r e s s i v e affect r e p o r t e d o v e r trie t i m e p e r i o d i n v o l v e d . o v e r t i m e a r e i l l u s t r a t e d in F i g u r e 2 .  These differences  Note that the l e v e l o f d e p r e s s i v e  affect peaks at day 3 f o r those w o m e n in the t r a d i t i o n a l h o s p i t a l and day 4 f o r those in the 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 .  B y the s i x t h  w e e k p o s t p a r t u m , the l e v e l of d e p r e s s i v e affect has r e t u r n e d to the p r e n a t a l l e v e l f o r both g r o u p s .  T h e peaking at the t h i r d and fourth day  p a r a l l e l s tine r e p o r t s i n the c l i n i c a l l i t e r a t u r e of 3 day " b l u e s " , f o u r day " b l u e s " o r " m i l k blues" ( P i t t , 1973; B a k e r , 1967). E v a l u a t i o n of the effectiveness of the 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 c o m p a r e d w i t h the t r a d i t i o n a l p r o g r a m m e U s i n g a n a l y s i s of v a r i a n c e three s p e c i f i c v a r i a b l e s w e r e a n a l y z e d i n o r d e r to a s s e s s the effectiveness of the f a m i l y c e n t r e d m a t e r n i t y programme. a.  S e l f confidence  T h e r e w a s no d i f f e r e n c e in the l e v e l of s e l f confidence of m o t h e r s b e t w e e n the two h o s p i t a l p r o g r a m m e s e i t h e r w h i l e in h o s p i t a l o r a f t e r one w e e k at h o m e w i t h the baby, F ( 1 , 7 1 ) = .733  p_> . 3 0 and F ( 1 , 7 1 ) = . 0 1 8 p _ > . 8 0 .  91  Table X I I Repeated m e a s u r e s a n a l y s i s of v a r i a n c e — l e v e l of d e p r e s s i v e affect o v e r t i m e  Source  dfs  Mean  1  Hospital  1  Error  J2_  6254.24 -CL1  .CO  .001  .536  71  Time  6  3.80  ,001  Time/hospital  6  <L1.00  ,987  Error  426  T I M E PERIOD  Figure 2. Means of D A C L scores at seven points in time: between hospital programs.  Comparison  93 b.  E x p e r i e n c e gained i n h o s p i t a l i n how to c a r e for the baby  T h e r e s p o n s e s of the w o m e n i n the two p r o g r a m m e s to 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 i n v o l v i n g the amount of e x p e r i e n c e gained i n h o s p i t a l i n c a r i n g for the new baby w e r e a n a l y z e d .  A highly significant  difference was found between the h o s p i t a l p r o g r a m m e s i n the amount o f e x p e r i e n c e r e c e i v e d , i n favour of those w o m e n in the f a m i l y c e n t r e d maternity programme, c.  F_ ( 1 , 7 1 ) = 13.42 p  <. . 0 0 0 4 .  A m o u n t of help r e c e i v e d f r o m the h o s p i t a l to p r e p a r e m o t h e r for the m o t h e r i n g r o l e  the  A h i g h l y s i g n i f i c a n t d i f f e r e n c e w a s found between the two g r o u p s o f w o m e n i n the amount of help they r e c e i v e d f r o m the h o s p i t a l to t h e m for the r o l e of m o t h e r h o o d .  T h o s e w o m e n in the f a m i l y  prepare centred  m a t e r n i t y p r o g r a m m e p e r c e i v e d that they obtained m o r e help f o r t h i s r o l e than did those in the t r a d i t i o n a l p r o g r a m m e , d.  F (1,71) = 7 . 1 8 p  <C  .009.  A t t i t u d e t o w a r d s baby w h i l e i n the h o s p i t a l , after one week at home and after five w e e k s at home  A s the attitude t o w a r d s baby q u e s t i o n n a i r e s w e r e not d e s i g n e d f o r a repeated m e a s u r e s a n a l y s i s of v a r i a n c e , o n e - w a y a n a l y s i s of v a r i a n c e w a s used to a n a l y z e the d a t a .  The results indicate a significant dif-  ference in attitude t o w a r d s baby between the two g r o u p s .  T h e w o m e n in  the 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 had a m o r e p o s i t i v e attitude t o w a r d s t h e i r baby w h i l e they w e r e i n h o s p i t a l , F_ ( 1 , 7 1 ) = 4 . 1 7 9 p < A f t e r the women had been home f o r one week and i n t e r a c t i n g w i t h and  .045.  94 c a r i n g f o r t h e i r infante there w e r e no d i f f e r e n c e s i n t h e i r attitude t o w a r d the infant, n o r w e r e t h e r e any d i f f e r e n c e s after f i v e w e e k s at h o m e , F" ( 1 , 7 1 ) = .334 £ > , 5 0 and F (1,71) = 2 . 1 9  £>-.143  respectively.  C o m p a r i s o n Between v a g i n a l D e l i v e r i e s and C a e s a r i a n S e c t i o n s F o r the f o l l o w i n g a n a l y s e s the data w e r e pooled a c r o s s h o s p i t a l and the independent v a r i a b l e w a s type of d e l i v e r y e x p e r i e n c e d — v a g i n a l o r caesarian section.  T h e data w e r e a n a l y z e d in e x a c t l y the s a m e  manner  as w e r e the data f o r h o s p i t a l p r o g r a m m e s . T i m e 1 - p r e n a t a l data  ( c o m p l e t e d i n the ninth month of pregnancy)  T o a s c e r t a i n w h e t h e r the two groups w e r e c o m p a r a b l e w i t h r e s p e c t to both t h e i r d e m o g r a p h i c c h a r a c t e r i s t i c s and responses to the q u e s t i o n n a i r e s and c h e c k l i s t s i n the ninth month of p r e g n a n c y , the data w e r e 2 analyzed using Hotellings T .  T h e r e w a s no difference between the means  f o r e i t h e r set of d a t a , F" (5,87) = 0 . 5 2 p_> . 5 0 and F (4,88) = 1 .44 p_>.20 i n that o r d e r .  T h e means and s t a n d a r d deviations f o r these two  a n a l y s e s a r e i n A p p e n d i x M and N r e s p e c t i v e l y . W h i l e the means f o r the m e a s u r e s of d e p r e s s i o n f o r both groups indicate that the two g r o u p s of w o m e n a r e w i t h i n the n o r m a l l i m i t in t e r m s of t h e i r d e p r e s s i v e affect, the range of s c o r e s on the D A C L and B e c k f o r b o t h groups i n d i c a t e that t h e r e a r e s o m e w o m e n w i t h i n both groups who might be c o n s i d e r e d to be m i l d l y d e p r e s s e d at this t i m e .  95 T i m e II - H o s p i t a l data 2 Hotellings T  showed that t h e r e w a s a s i g n i f i c a n t d i f f e r e n c e between  the two groups of w o m e n i n t h e i r r e s p o n s e s to the q u e s t i o n n a i r e s c o m pleted w h i l e i n h o s p i t a l , F ( 7 . 8 6 ) = 4 . 4 3 p_  . 0 0 0 3 . T h e m e a n s and  s t a n d a r d d e v i a t i o n s f o r this set of v a r i a b l e s a r e shown i n T a b l e X I I I .  The  m u l t i p l e c o m p a r i s o n u s i n g s i m u l t a n e o u s confidence i n t e r v a l s i n d i c a t e d that there w e r e s i g n i f i c a n t l y different group means f o r two v a r i a b l e s — attitude t o w a r d l a b o u r and d e l i v e r y and l e v e l of d e p r e s s i v e affect on the f i r s t day p o s t p a r t u m .  T h o s e w o m e n who had a c a e s a r i a n s e c t i o n e x -  p r e s s e d a l e s s p o s i t i v e attitude t o w a r d t h e i r l a b o u r and d e l i v e r y e x p e r i e n c e and e x p e r i e n c e d m o r e d e p r e s s i v e affect the f i r s t day p o s t p a r t u m than d i d w o m e n who d e l i v e r e d t h e i r babies v a g i n a l l y . T h e m e a n s and s t a n d a r d d e v i a t i o n s f o r r e s p o n s e s to G r e e n b e r g ' s q u e s t i o n n a i r e a r e in T a b l e X I V .  Hotellings T  2  demonstrated a significant  d i f f e r e n c e between tine r e s p o n s e s of w o m e n a s a f u n c t i o n of t h e i r d e l i v e r y e x p e r i e n c e , on this set of v a r i a b l e s , F (15,78) — 2 . 0 5  p_<<.02, although  tine m u l t i p l e c o m p a r i s o n i n d i c a t e d no d i f f e r e n c e between the v a r i o u s g r o u p m e a n s of the i n d i v i d u a l v a r i a b l e s .  Subsequent u n i v a r i a t e a n a l y s i s  of v a r i a n c e i n d i c a t e d that w o m e n who had c a e s a r i a n s w e r e l e s s happy i n the h o s p i t a l , had l e s s e n e r g y and w e r e m o r e d e p r e s s e d a f t e r the d e l i v e r y than w e r e those w o m e n who had v a g i n a l d e l i v e r i e s , F ( 1 , 9 2 ) = 5.57 p<.02; F (1 ,92) = 3 . 9 6 £ - < . 0 5 ;  F (1 ,92) = 8.44 £ , ^ . 0 0 5 r e s p e c t i v e l y .  96  Table XIII M e a n s and s t a n d a r d d e v i a t i o n s of the hospital data  Vaginal D e l i v e r y N = 73 Mean  SD  Caesarian Section N = 21 Mean  SD  A t t i t u d e to L a b o u r and Delivery  147.00  13.45  120.14  47.88  A t t i t u d e to Baby  126.89  13.02  122.14  15.89  9.15  4.78  8.52  5.10  DACL T i m e One  45.47  4.98  50.95  7.08  DACL T i m e Two  46.78  7.48  51 .38  10.10  DACL Time Three  50.07  9.72  53.86  9.66  DACL Time Four  49.29  9.00  51 .48  9.12  A r e a s of Concern  97 Table X I V M e a n s and s t a n d a r d d e v i a t i o n of r e s p o n s e s to G r e e n b e r g ' s q u e s t i o n n a i r e Vaginal Delivery N --= 73 Mean  .Caesarian Section N = 21  SD  Mean  SD  S e l f Confidence regarding childcare  3.30  .78  3.24  .94  P e r c e p t i o n of help needed at home  3.73  .84  3.33  .91  H a p p i n e s s in H o s p i t a l  4.03  .64  3.62  .86  P r e s e n t energy l e v e l  2.18  .90  2.05  .97  A b s e n c e of a n x i e t y r e g a r d i n g r e p o n s i b i l i t y of baby  1.44  .53  1 .48  .60  Confidence r e g a r d i n g the r o l e of motherhood  4.42  .80  4.48  .75  P r e s e n t f e e l i n g s of g l a d n e s s versus depression  4.27  .92  3.81  1 .03  M a t e r n a l f e e l i n g to baby  4.11  1.11  3.62  1 .22  Competence r e g a r d i n g c h i l d c a r e  3.33  .73  3.24  .83  I m m e d i a c y of understanding baby's needs  2.05  1.15  2.19  1 .50  L a c k of r e s t r i c t i o n in usual activities  2.70  1.05  2.61  .92  Energy level after d e l i v e r y  2.66  1.56  1.38  .74  A m o u n t of help f r o m nursing personnel  2.41  .81  2.33  .91  F e e l i n g s of gladness v e r s u s depression after delivery  4.74  .69  4.09  1 .41  A m o u n t of help r e c e i v e d f r o m hospital personnel  3.14  .90  2.90  1.18  98 T i m e 111 - A f t e r one week at home W h e n the w o m e n had been h o m e f o r one w e e k they c o m p l e t e d the attitude t o w a r d s baby 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 and Greenberg's follow-up questionnaire.  Hotellings  c o n d u c t e d on these  data r e v e a l e d that t h e r e w e r e no d i f f e r e n c e s between the two g r o u p s of w o m e n on t h i s s e t of d a t a , F ( 1 0 , 8 3 ) = 1.13 £ ^ . . 5 0 . T h e m e a n s and s t a n d a r d d e v i a t i o n s f o r these m e a s u r e s a r e i n A p p e n d i x O . T i m e I V - after five weeks at home W h e n the w o m e n had been h o m e f o r f i v e w e e k s they c o m p l e t e d the f o l l o w i n g m e a s u r e s ; attitude t o w a r d s baby; a r e a s of c o n c e r n , B e c k D e p r e s s i o n Index; 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 . T^,  Using Hotellings  the a n a l y s i s o f this set of v a r i a b l e s d e m o n s t r a t e d that t h e r e w e r e  no d i f f e r e n c e s between those w o m e n who had v a g i n a l d e l i v e r i e s a n d those who had c a e s a r i a n s e c t i o n , F ( 5 , 8 8 ) = . 8 0 £ « s i . 5 0 .  T h e means and  s t a n d a r d d e v i a t i o n s f o r these data a r e i n A p p e n d i x P . Across Time T o c o m p a r e the two g r o u p s i n t e r m s of d e p r e s s i v e affect o v e r the t i m e p e r i o d i n v o l v e d , a repeated m e a s u r e s a n a l y s i s of v a r i a n c e w a s c a r r i e d out.  T h i s i n d i c a t e d a s i g n i f i c a n t d i f f e r e n c e i n l e v e l of d e p r e s s i v e  affect between the groups i n t e r m s of type of d e l i v e r y , and o v e r t i m e . T h o s e w o m e n who had c a e s a r i a n s e c t i o n s r e p o r t e d a g r e a t e r d e g r e e of d e p r e s s i v e affect than d i d those who had v a g i n a l d e l i v e r i e s . T h e s u m m a r y table f o r this a n a l y s i s  i s shown i n T a b l e X V .  These differences  99 a r e i l l u s t r a t e d g r a p h i c a l l y in F i g u r e 3 .  It should be noted that both  groups peak at day three and that the mean l e v e l of the d e p r e s s i o n affect of the c a e s a r i a n group i n c r e a s e s between the f i r s t w e e k and fifth week at h o m e , m o r e than the mean l e v e l of d e p r e s s i v e affect f o r the vaginal group o v e r the s a m e t i m e p e r i o d .  It s h o u l d be pointed out that  the m e a n s of both groups a r e s t i l l w i t h i n the range obtained d u r i n g the prenatal p e r i o d . Table X V Repeated m e a s u r e s a n a l y s i s of v a r i a n c e L e v e l of d e p r e s s i v e affect o v e r t i m e S u m m a r y table Source Mean Delivery Error Time Time/delivery Error  dfs  _F  1 1 92  7921.34 6.92  .001 .010  3.13 1 .62  .005 .140  6 6 552  £  Specific Comparisons a.  S e l f confidence  In view of S h e a s h o r e ' s findings of l e s s s e l f confidence in m o t h e r s who had been separated f r o m t h e i r infant, the s e l f confidence of the w o m e n w a s a n a l y z e d a c c o r d i n g to type of d e l i v e r y . T h e r e w e r e no d i f f e r e n c e s i n the l e v e l s of s e l f confidence between v a g i n a l d e l i v e r y o r c a e s a r i a n s e c t i o n e i t h e r w h i l e i n the h o s p i t a l o r a f t e r one w e e k at  !  I  1  prenatal  ol  I  2  I 3  4  5  6  7  time 1  time 2  time 3  time 4  2 weeks  6 weeks  i  1  i  i  i  i  _.  I  Hospital TIME  Figure 3.  _ J  Postpartum PERIOD  Means of DACL scores at seven points in time: between types of deliveries.  Comparison  101  home.  F ( 1 , 9 2 ) = .098 £ > . 7 5 5 a n d F ( 1 , 9 2 ) = 2 . 6 6 4 £ . > . 109  respectively. b. A t t i t u d e towards baby i n h o s p i t a l , a f t e r one w e e k at h o m e a n d a f t e r f i v e w e e k s at home A s the q u e s t i o n n a i r e s w e r e not designed f o r repeated  measurement,  d i f f e r e n c e s i n attitudes t o w a r d s the baby a s a function of the type of delivery experienced, were analyzed using . analyses  of variance.  T h e r e w e r e no d i f f e r e n c e s between these two groups a t any of tine t i m e points m e a s u r e d . £>.08;  F (1,92) = 2 . 0 5 6 £ > . 1 5 7 ;  F (1,92) = 2.59  F ( 1 , 9 2 ) = 3.131  £;>.113.  T h e pooled w i t h i n g r o u p s c o r r e l a t i o n m a t r i x f o r a l l the v a r i a b l e s i n the study w a s e x a m i n e d to a s c e r t a i n the r e l a t i o n s h i p between (a) method of feeding — w h e t h e r b r e a s t o r b o t t l e , (b) n u m b e r of d a y s s p e n t i n h o s p i t a l and (c) n u m b e r of days r o o m i n g i n w i t h infant to o t h e r v a r i a b l e s i n the s t u d y . (a) B o t t l e feeding s i g n i f i c a n t l y r e l a t e d to the f o l l o w i n g v a r i a b l e s : r  the a m o u n t of a c t i v i t y engaged i n at the ninth month  P  b i  _P_  -.355  .01  the a m o u n t of a c t i v i t y engaged i n s i x w e e k s postpartum  -.251  .02  the amount of e x p e r i e n c e that the w o m e n f e l t they had r e c e i v e d w h i l e i n h o s p i t a l i n c a r i n g f o r t h e i r baby  -.254  .02  102  rpbi s e l f confidence w h i l e in h o s p i t a l  -.243  .02  f e e l i n g of c o m p e t e n c e w h i l e in h o s p i t a l  -.275  .01  f e e l i n g s of gladness w h i l e i n h o s p i t a l  -.245  .02  m o t h e r ' s p e r c e p t i o n of not needing help at home  -.233  .05  .213  .05  -.254  .02  D A C L a f t e r one w e e k at home attitude towards baby a t s i x w e e k s  postpartum  (b) N u m b e r of days spent i n h o s p i t a l a f t e r the b i r t h of the baby i s s i g n i f i c a n t l y r e l a t e d to the f o l l o w i n g v a r i a b l e s : r  P  age of baby at d i s c h a r g e  . 746  .01  f e e l i n g s of happiness i n the h o s p i t a l  .218  .05  -.239  .05  . 287  .01  e n e r g y l e v e l in h o s p i t a l amount of help r e c e i v e d f r o m n u r s i n g personnel  (c) N u m b e r of days spent r o o m i n g - i n w i t h infant w a s s i g n i f i c a n t l y r e lated to the f o l l o w i n g v a r i a b l e s :  _n_  p,  bathing baby  .499  .01  attitude towards baby  .241  .05  f e e l i n g s of s e l f confidence in h o s p i t a l  .227  .05  f e e l i n g s of competence w h i l e in h o s p i t a l  .227  .05  f e e l i n g s of confidence a f t e r one week at home  . 257  .02  103  r  -J2.  e a s e of adjustment f r o m h o s p i t a l to home  .261  .. 02  amount of e x p e r i e n c e r e c e i v e d w h i l e in hospital  .479  .01  amount of help r e c e i v e d f r o m the h o s p i t a l  .390  .01  i m m e d i a c y of understanding the infant's needs  .239  .05  certainty regarding child care  .265  .02  l e s s help needed at home  .214  .05  Factor Analysis F o r h e u r i s t i c purposes the data obtained f r o m trie w o m e n w e r e s u b j e c t e d to a f a c t o r a n a l y s i s p r o c e d u r e in o r d e r to a s c e r t a i n w h i c h v a r i a b l e s c l u s t e r together.  T h e r e s u l t s s h o u l d be i n t e r p r e t e d c a u t i o u s l y in view of  the r e l a t i v e l y s m a l l s a m p l e i n v o l v e d (N=93).  The factor analysis p r o c e -  d u r e used w a s a p r i n c i p a l components technique w i t h a v a r i m a x rotation. F o u r eigen values w e r e g r e a t e r than u n i t y s o f o u r f a c t o r s w e r e e x t r a c ted.  T h e f a c t o r s and t h e i r loadings a r e presented in A p p e n d i x Q .  Items  w i t h l o a d i n g s g r e a t e r than .40 w e r e used to identify the m e a n i n g of each factor. T h e f i r s t f a c t o r w a s l a b e l l e d the h o s p i t a l e x p e r i e n c e f a c t o r . included the f o l l o w i n g v a r i a b l e s w i t h loadings g r e a t e r than .40.'  It Self  confidence w h i l e in the h o s p i t a l , ease of adjustment f r o m h o s p i t a l to h o m e , e x p e r i e n c e r e c e i v e d w h i l e in h o s p i t a l , help r e c e i v e d f r o m the  104  h o s p i t a l i n p r e p a r a t i o n f o r the m o t h e r i n g r o l e , i m m e d i a c y of u n d e r standing the infants' n e e d s .  L e s s help needed at home and certainty-  r e g a r d i n g c h i l d c a r e when f i r s t at home a l s o loaded h i g h l y on t h i s 3 factor.  In a d d i t i o n , n u m b e r of days spent " r o o m i n g - i n " w i t h the i n -  fant and attitude towards the baby a l s o loaded h i g h l y on this f a c t o r . T h e second f a c t o r i n c l u d e d d e m o g r a p h i c v a r i a b l e s s u c h a s the age and education of the m o t h e r and education of the f a t h e r .  The most  h i g h l y loaded i t e m s on the t h i r d f a c t o r w e r e e n e r g y l e v e l and f e e l i n g s of gladness w h i l e in h o s p i t a l .  D e p r e s s i v e affect, bottle feeding and  l o n g e r length of l a b o u r loaded i n the negative d i r e c t i o n o n this f a c t o r . A t t i t u d e towards l a b o u r and d e l i v e r y loaded v e r y h i g h l y on the fourth factor.  It w a s designated thus on the q u e s t i o n n a i r e . In f a c t , the o n l y w o m e n who had " r o o m i n g - i n " w e r e the w o m e n in the f a m i l y c e n t r e d p r o g r a m m e and the two w o m e n w i t h c a e s a r i a n s e c t i o n s who had r o o m i n g - i n in the t r a d i t i o n a l h o s p i t a l .  105  CHAPTER IV DISCUSSION In the t e r m s of R u n k e l and M c G r a t h (1973), this s t u d y i s b a s i c a l l y a natural field experiment.  O b v i o u s l y i t w a s i m p o s s i b l e to a s s i g n  w o m e n r a n d o m l y e i t h e r to h o s p i t a l e x p e r i e n c e o r type of d e l i v e r y . T h i s l e a v e s the p o s s i b i l i t y of unknown s a m p l i n g b i a s e s v e r y m u c h to the fore.  W h i l e the p r e s e n t study has the advantage of b e i n g r e l e v a n t 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 a p p l i e d r e s e a r c h and unknown s a m p l i n g b i a s e s w i l l l i m i t the g e n e r a l i z a b i l i t y of the r e s u l t s .  While  this i s t y p i c a l of e v a l u a t i v e r e s e a r c h , i t s h o u l d be noted that " a p p r o x i m a t e l y 80% of o u r ( p s y c h o l o g y ) r e s e a r c h i s p e r f o r m e d on the 3 p e r cent of the population c u r r e n t l y e n r o l l e d in c o l l e g e " w i t h a n o v e r - r e p r e s e n t a tion of m a l e s u b j e c t s ( S c h u l t z , 1969). T h e u n c o n t r o l l e d s a m p l i n g factors of the p r e s e n t s t u d y i n v o l v e the c h o i c e of p r e n a t a l c l a s s e s by the p a r t i c i p a n t s i n the study; the s e l f s e l e c t i o n of those who c h o s e to p a r t i c i p a t e and the p o s s i b i l i t y of s e l e c tion f a c t o r s o p e r a t i n g i n the h o s p i t a l w h i c h the w o m e n a t t e n d e d .  In  a d d i t i o n , t h e r e i s the i n h e r e n t p r o b l e m of d i f f e r e n c e s between v o l u n t e e r s and those who chose not to v o l u n t e e r .  R o s e n t h a l (1965) has s u m m a r i z e d  s o m e of the r e s e a r c h on t h i s p r o b l e m . It should be noted that a l l data in this study i n v o l v e d s e l f - r e p o r t m e a s u r e s w i t h the l i m i t a t i o n s of s u c h m e a s u r e s , i . e . , a l l f o r m s of s e l f -  106 •  .  r e p o r t a r e s u s c e p t i b l e to r e a c t i v e b i a s .  ••  F i r s t , the s u b j e c t knows that  she i s the focus of r e s e a r c h ; s e c o n d , the respondent m a y w e l l change i n the attitude being m e a s u r e d because of'the m e a s u r e m e n t p e r s e ; t h i r d , s u b j e c t i v e r e p o r t s a r e v u l n e r a b l e to c e r t a i n types of r e s p o n s e s e t s a s 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). T h e r e a r e s o m e advantages to the use of s e l f - r e p o r t however.  One gets a m o r e d i r e c t m e a s u r e of i n d i v i d u a l f e e l i n g s of the  w o m e n i n v o l v e d r a t h e r than the i n t e r p r e t a t i o n s of what the w o m e n w e r e e x p e r i e n c i n g and f e e l i n g .  A s Nunnalty (1975) c o n c l u d e d , " g e n e r a l l y tine  m o s t v a l i d , e c o n o m i c a l , s o m e t i m e s the o n l y , w a y to l e a r n about a p e r s o n s ' s e n t i m e n t s i s s i m p l y to a s k h i m " . A n o t h e r i m p o r t a n t a d v a n tage of s e l f - r e p o r t m e a s u r e s i s that they a r e not a s o b t r u s i v e a s o t h e r techniques.  A l t h o u g h i t would have been useful to have e m p l o y e d o t h e r  m e a s u r e s , s u c h a s b e h a v i o u r a l o b s e r v a t i o n s , p e e r r e p o r t s , and input f r o m n u r s e s , the p r e s e n t data a r e not a s c o n t a m i n a t e d by r e a c t i v e effects and e x p e c t a n c y effects a s they m i g h t have been had these v a r i o u s o t h e r m e a s u r e s been u t i l i z e d . T h e w o m e n who p a r t i c i p a t e d i n the study w e r e w e l l e d u c a t e d , and f r o m intact f a m i l y s i t u a t i o n s .  T h e y w e r e a w e l l m o t i v a t e d group who  paid to attend p r e n a t a l c l a s s e s and whose d r o p - o u t r a t e f r o m the p r e s e n t  107  study w a s very s m a l l (4.5%). It w a s not p o s s i b l e to c o n t r o l the t i m e at w h i c h the w o m e n c o m p l e t e d the q u e s t i o n n a i r e s although a v e r y c l o s e c o n t r o l w a s kept i n t e r m s o f the date o f r e c e i p t . A n o t h e r f a c t o r w h i c h m a y affect the study w a s 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 w i t h i n each h o s p i t a l o v e r the d u r a t i o n of the s t u d y ; h o w e v e r , f r o m d i s c u s s i o n w i t h h o s p i t a l staffs and the w o m e n i n the s t u d y , J it w a s m y u n d e r s t a n d i n g that the h o s p i t a l e n v i r o n m e n t r e m a i n e d f a i r l y s t a b l e o v e r the 16 month t i m e p e r i o d of the s t u d y . B e f o r e d i s c u s s i n g the i m p l i c a t i o n s of the findings o f the p r e s e n t s t u d y , i t s h o u l d be pointed out that although o n l y the o v e r a l l m u l t i v a r i a t e F" w a s s i g n i f i c a n t i n s e v e r a l of the a n a l y s e s , i t i s not u n c o m m o n "to find that no s i n g l e p a i r w i s e d i f f e r e n c e between any two g r o u p m e a n s i s s i g n i f i c a n t " ( H a r r i s , 1975).  T h i s l a c k of s i g n i f i c a n t p a i r w i s e d i f f e r e n c e s m a y  be a r e f l e c t i o n of the s m a l l but a c c u m u l a t i v e effects of the f a m i l y c e n t r e d maternity programme.  It m a y a l s o suggest that the effects of s u c h a  p r o g r a m m e a r e m o r e g l o b a l and thus not a m e n a b l e to the m o r e s p e c i f i c m e a s u r e s u s e d i n the s t u d y . It had been planned o r i g i n a l l y to c o m p a r e those w o m e n who had r e c e i v e d anaesthetic w i t h those w o m e n who d i d not to s e e i f t h e r e w e r e any d i f f e r e n c e in t h e i r attitude t o w a r d t h e i r baby w h i l e i n h o s p i t a l . Upon a n a l y s i s of the d a t e , h o w e v e r , i t w a s found that 93% of the w o m e n  108  r e c e i v e d s o m e type of a n a e s t h e t i c , (Appendix H) thus m a k i n g s u c h 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% o f those w o m e n i n the 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 had r e c e i v e d a n e p i d u r a l a n a e s t h e t i c c o m p a r e d w i t h 80% of the w o m e n i n the t r a d i t i o n a l p r o g r a m m e . 2  This is a significant difference, x  (1) = 11 . 3 8  .001 .  It i s t h e r e f o r e  p o s s i b l e that the m o r e p o s i t i v e attitude of the w o m e n i n the f a m i l y c e n t r e d m a t e r n i t y c a r e toward t h e i r baby i n h o s p i t a l i s confounded w i t h the use of a n a e s t h e t i c .  Inspection of the pooled w i t h i n g r o u p s c o r r e l a t i o n  m a t r i x , h o w e v e r , r e v e a l e d a c o r r e l a t i o n of o n l y —.05 i n d i c a t i n g an a b s e n c e of a s s o c i a t i o n between attitude toward baby and u s e of anaesthetic. Implications F r o m Major Findings — Hospital P r o g r a m m e H o f e r (1975) stated that in the United S t a t e s , the r e s e a r c h of e a r l y p a r e n t / c h i l d r e l a t i o n s h i p s has been entwined i n a s o c i a l m o v e m e n t involving obstetric c a r e .  Q u e s t i o n s a r e being a s k e d  such as  " S h o u l d m e d i c a l and n u r s i n g p r a c t i s e , h o s p i t a l d e s i g n , o b s t e t r i c and p e d i a t r i c p r o c e d u r e s be a l t e r e d on the b a s i s of r e s e a r c h e v i d e n c e now available".  H a i r e and H a i r e (1968) stated that " T h e h o s p i t a l r i t u a l that  s u r r o u n d s c h i l d b i r t h in the U n i t e d S t a t e s does m u c h to d e s t r o y that c o h e s i v e effect that c h i l d b i r t h s h o u l d have on the f o r m i n g f a m i l y u n i t a n d t h w a r t s n a t u r e ' s n o r m a l p l a n f o r the c h i l d b e a r i n g e x p e r i e n c e " . T h e y stated that " f a m i l y c e n t r e d m a t e r n i t y c a r e w o u l d do m u c h to c o r r e c t  109  the f l a w s in o u r concept of c o n v e n t i o n a l m a t e r n i t y c a r e " and t h e i r book d e s c r i b e d how to i m p l e m e n t s u c h a p r o g r a m m e . T h e f i n d i n g s f r o m the p r e s e n t study i n d i c a t e that the type of h o s p i t a l p r o g r a m m e i n w h i c h a w o m a n spends h e r f i r s t p o s t p a r t u m days does m a k e a d i f f e r e n c e in t e r m s of a m o r e p o s i t i v e attitude towards h e r new baby, and in t e r m s of the amount of e x p e r i e n c e she r e c e i v e s in how to take c a r e of a new baby and in the a m o u n t of help that she r e c e i v e s i n h o s p i t a l to p r e p a r e h e r f o r the m o t h e r i n g r o l e .  T h i s study  c o m p l e m e n t s the w o r k done by K l a u s and h i s c o l l e a g u e s i n a s m u c h a s they found s i g n i f i c a n t d i f f e r e n c e s i n b e h a v i o u r of p r i m i p a r o u s m o t h e r s towards t h e i r f u l l - t e r m infants a s a function of the amount of contact they e x p e r i e n c e d i n h o s p i t a l .  It w a s found in the p r e s e n t study that the  w o m e n who p a r t i c i p a t e d i n the 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 and thus d e t e r m i n e d the amount of contact w i t h t h e i r infants had a m o r e p o s i t i v e attitude towards the baby w h i l e i n h o s p i t a l than d i d w o m e n in a t r a d i t i o n a l p r o g r a m m e in w h i c h n u r s i n g p o l i c y d i c t a t e d when the m o t h e r should have the baby.  Once w o m e n had been home f o r one Week,  handling and i n t e r a c t i n g w i t h t h e i r b a b i e s , these d i f f e r e n c e s d i s a p p e a r e d . T h e fact that the w o m e n w e r e a w e l l educated, w e l l m o t i v a t e d group m a y have s e r v e d to w o r k a g a i n s t finding l o n g e r t e r m d i f f e r e n c e s between the two h o s p i t a l p r o g r a m m e s .  no  T h e fact that there w e r e no d i f f e r e n c e s i n the l e v e l of s e l f c o n f i dence of the w o m e n i n both p r o g r a m m e s s u g g e s t s that this m o r e p o s i tive attitude towards the baby w a s not r e l a t e d to the f e e l i n g s of confidence and competence gained w h i l e c a r i n g f o r t h e i r baby by t h o s e i n the family centred maternity p r o g r a m m e .  T h e components of the f a m i l y  c e n t r e d p r o g r a m m e that r e l a t e to this m o r e p o s i t i v e attitude r e m a i n to be d e t e r m i n e d e m p i r i c a l l y .  It i s p o s s i b l e that the s p e c i f i c n u r s e / m o t h e r /  baby a s s i g n m e n t has-an effect on the m o t h e r ' s attitude t o w a r d s h e r baby.  It m a y be that being r e s p o n s i b l e f o r and c a r i n g f o r h e r own infant  d u r i n g this t i m e r e s u l t s i n a m o r e p o s i t i v e attitude on the p a r t of the m o t h e r in the f a m i l y c e n t r e d p r o g r a m m e .  T h i s w o u l d be p r e d i c t e d  f o r e x a m p l e , by B e r n ' s theory of s e l f p e r c e p t i o n ( B e r n , 1970). S u p p o r t f o r the benefits of f a m i l y c e n t r e d m a t e r n i t y c a r e c o m e s f r o m the s i g n i f i c a n t c o r r e l a t i o n s between attitude t o w a r d s baby and the amount of help r e c e i v e d f r o m the h o s p i t a l and the amount of e x p e r i e n c e gained w h i l e i n h o s p i t a l c a r i n g f o r the b a b y .  In a d d i t i o n , the s i g n i f i c a n t  c o r r e l a t i o n s between v a r i a b l e s s u c h a s f e e l i n g s of s e l f confidence and c o m p e t e n c e , ease of adjustment f r o m h o s p i t a l to h o m e , f o r e x a m p l e , and the n u m b e r of days spent " r o o m i n g - i n " w i t h the i n f a n t a s opposed to the n u m b e r of days spent i n h o s p i t a l p e r s e ) i s s u p p o r t f o r the p o s i t i v e effects of the 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 .  111  T h e r e s u l t s of the f a c t o r a n a l y s i s indicate that attitude t o w a r d l a b o u r and d e l i v e r y w a s u n r e l a t e d to the h o s p i t a l e x p e r i e n c e f a c t o r .  This implies  that the p e r c e p t i o n of the h o s p i t a l e x p e r i e n c e w a s u n r e l a t e d to w h e t h e r the w o m e n had a good o r p o o r d e l i v e r y e x p e r i e n c e . T h e type of h o s p i t a l p r o g r a m m e e x p e r i e n c e d a p p e a r e d 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 p o s t p a r t u m adjustment of the w o m e n in the study.  A t s i x w e e k s p o s t p a r t u m t h e r e w e r e no d i f f e r e n c e s between the  w o m e n in the two p r o g r a m m e s in t e r m s of d e p r e s s i v e affect, b e h a v i o u r o r attitude toward b a b y . T y p e of d e l i v e r y — V a g i n a l C o m p a r e d to C a e s a r i a n S e c t i o n It s h o u l d be noted that the d i f f e r e n c e i n attitude toward baby w h i l e in h o s p i t a l only held f o r the c o m p a r i s o n of w o m e n i n the two h o s p i t a l programmes.  T h e r e w a s no difference when c o m p a r i s o n s w e r e  between the w o m e n i n t e r m s of t h e i r d e l i v e r y e x p e r i e n c e .  made  There  w e r e no d i f f e r e n c e s in attitudes toward baby at the three t i m e points m e a s u r e d between those w o m e n who had had v a g i n a l d e l i v e r i e s and those who had had c a e s a r i a n s e c t i o n s .  T h i s f i n d i n g i s the a n t i t h e s i s of  what might have been p r e d i c t e d given the r e s e a r c h conducted by K l a u s and a s s o c i a t e s .  W o m e n who undergo a c a e s a r i a n s e c t i o n u s u a l l y s u f f e r  more "deprivation  11  (to use B a r n e t t ' s t e r m i n o l o g y ) of t h e i r infant than  do those w o m e n having a v a g i n a l d e l i v e r y . In a d d i t i o n , t h e r e i s the o p e r a t i v e p r o c e d u r e i t s e l f and the fact that they have had m a j o r s u r g e r y .  112  T h e r e s u l t s of the f a c t o r a n a l y s i s suggest that i n fact a p o s i t i v e attitude towards the baby i s u n r e l a t e d to w h e t h e r the w o m e n had a p o s i t i v e e x p e r i e n c e d u r i n g l a b o u r and d e l i v e r y . P o s s i b l y the p r o c e d u r e s i n v o l v e d w i t h c a e s a r i a n s e c t i o n s enable w o m e n to a c c e p t s u c h d e p r i v a t i o n m o r e e a s i l y and perhaps m o t h e r s m a y a c c e p t the d e p r i v a t i o n of t h e i r infant, given the need f o r i n t e n s i v e c a r e , m o r e r e a d i l y than those who have vaginal d e l i v e r y . B o t t l e feeding A finding that s h o u l d be i n t e r p r e t e d c a u t i o u s l y w a s the s i g n i f i c a n t negative r e l a t i o n s h i p between bottle feeding and other v a r i a b l e s s u c h a s the amount of experience, w o m e n f e l t that they had r e c e i v e d w h i l e i n tine h o s p i t a l , the f e e l i n g s of s e l f confidence and competence and attitude toward the baby at s i x w e e k s p o s t p a r t u m .  T h i s i s an i n t e r e s t i n g f i n d i n g  in l i g h t of the e m p h a s i s on breastfeeding in l o c a l w o m e n (85% of p r e s e n t s a m p l e b r e a s t fed t h e i r baby; 75% of K h a i r a t & C o s t a n z o (1974) s a m p l e breastfed t h e i r babies)..  It m a y w e l l be that the w o m e n who breastfeed  t h e i r babies r e c e i v e d m o r e attention i n i t i a l l y f r o m the n u r s i n g s t a f f i n o r d e r that the m o t h e r and c h i l d have a good b e g i n n i n g . T h i s i n t u r n m a y be related to the amount of p e r c e i v e d e x p e r i e n c e being gained i n hospital.  T h e fact that bottle feeding r e l a t e s to l e s s s e l f confidence and  competence i s perhaps e x p l a i n a b l e in l i g h t of the e m p h a s i s in the m e d i a  113  and p r e n a t a l c l a s s e s on the p o s i t i v e a s p e c t s of b r e a s t feeding f o r both m o t h e r and c h i l d .  T h e w o m e n who bottle feed t h e i r baby f e e l m o r e  d e p r e s s e d and have l e s s confidence in t h e i r own a b i l i t i e s , i n a d d i t i o n to going a g a i n s t the ' n o r m ' of t h e i r p e e r g r o u p . Depressive Affect F r i e d m a n (1974) suggested that the t e r m d e p r e s s i o n be e m p l o y e d i n three w a y s .  F i r s t as an affect, second a s a c l i n i c a l s t a t e and t h i r d a s  a character style.  He stated that although this i s not a new w a y of c o n -  c e p t u a l i z i n g d e p r e s s i o n it has been r a t h e r n e g l e c t e d u n t i l now.  Friedman  m a i n t a i n e d that l i k e a n x i e t y , d e p r e s s i o n c a n r e f e r both to a b a s i c f e e l i n g and a m o r e defined c l i n i c a l s t a t e .  D e p r e s s i v e affect r e f e r s to a b a s i c  f e e l i n g of s a d n e s s w h i c h i s p a r t of the f a b r i c i n l i f e and w h i c h i s noted i n s t a t e s of g r i e f and p e r i o d of d i s a p p o i n t m e n t .  C l i n i c a l d e p r e s s i o n , on  the o t h e r hand, r e f e r s to a c o m p l e x of s y m p t o m s i n c l u d i n g the affect of d e p r e s s i o n and a l s o  . . o t h e r affects s u c h a s a n x i e t y , g u i l t , h o s t i l i t y  a s w e l l a s m o t i v a t i o n a l , vegetative and c o g n i t i v e d i s t u r b a n c e s " . M i l l e r ' s (1975) r e v i e w of the p s y c h o l o g i c a l d e f i c i t s in d e p r e s s i o n showed that s u c h d e f i c i t s depend l a r g e l y on s e v e r i t y of d e p r e s s i o n r a t h e r than type of d e p r e s s i o n , and that d e p r e s s e d s u b j e c t s i n n o r m a l p o p u l a t i o n s a r e g e n e r a l l y c h a r a c t e r i z e d by d e f i c i t s s i m i l a r i n n a t u r e but s m a l l e r i n d e g r e e to those of d e p r e s s e d T h e repeated  measures  patients. a n a l y s i s of the d e p r e s s i v e affect i n d i c a t e d  114  that t h e r e w a s no d i f f e r e n c e o v e r t i m e between the group of w o m e n who delivered vaginally.  T h i s finding s u p p o r t s c l i n i c a l o b s e r v a t i o n s , (and  p r e v i o u s s t u d i e s of p o s t p a r t u m d e p r e s s i o n a n d / o r b l u e s ) i n s o f a r a s the l e v e l of d e p r e s s i v e affect peaks on the t h i r d and f o u r t h d a y .  The present  data are c o n s i s t e n t w i t h the a r g u m e n t f o r a h o r m o n a l b a s i s f o r depressive, affect d u r i n g this t i m e p e r i o d as the peaking w a s d e m o n s t r a t e d in a l l groups (vaginal and c a e s a r i a n w i t h i n each h o s p i t a l p r o g r a m m e ) . T h e w o m e n who had e x p e r i e n c e d a c a e s a r i a n s e c t i o n w e r e s i g n i f i c a n t l y m o r e d e p r e s s e d than those who had v a g i n a l d e l i v e r i e s .  Given  that t h e r e w e r e no s i g n i f i c a n t d i f f e r e n c e s between the two groups i n i t i a l l y F ( 1 , 9 2 ) = 3 . 5 3 5 p_^>.063, this suggests that h a v i n g a baby by caesai— ian s e c t i o n i s a l e s s p o s i t i v e e x p e r i e n c e than h a v i n g a baby v a g i n a l l y . T h i s i s s u p p o r t e d i n the p r e s e n t study by the f i n d i n g that these w o m e n a l s o had a s i g n i f i c a n t l y l e s s p o s i t i v e attitude t o w a r d t h e i r l a b o u r and d e l i v e r y e x p e r i e n c e than those who d e l i v e r e d v a g i n a l l y .  It i s unfortunate  that a l o n g - t e r m f o l l o w - u p w a s not f e a s i b l e i n o r d e r to obtain m o r e i n f o r m a t i o n r e g a r d i n g the l e v e l of d e p r e s s i v e affect of w o m e n who had caesarian section.  It i s p o s s i b l e that the i n c r e a s e i n l e v e l of d e p r e s -  s i v e affect seen at s i x w e e k s p o s t p a r t u m i n this group w a s the b e g i n ning of a c o n t i n u i n g t r e n d .  115  W h i l e the p r e s e n t s a m p l e of w o m e n w e r e not c l i n i c a l l y d e p r e s s e d t h e r e a r e s o m e s i g n i f i c a n t c o r r e l a t i o n s between a m o u n t of d e p r e s s i v e affect a s m e a s u r e d by the D A C L and o t h e r v a r i a b l e s a t e a c h t i m e period.  F o r e x a m p l e , i n the ninth month of p r e g n a n c y d e p r e s s i v e a f -  f e c t w a s r e l a t e d to a l e s s p o s i t i v e attitude t o w a r d s p r e g n a n c y ; i n h o s p i t a l d e p r e s s i v e affect w a s r e l a t e d to l e s s p o s i t i v e attitude t o w a r d s l a b o u r 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 ' p o s t p a r t u m p e r i o d d e p r e s s i v e affect w a s a g a i n r e l a t e d to l e s s p o s i t i v e attitude t o w a r d s the baby.  In a d d i t i o n , the l e v e l of d e p r e s s i v e affect w a s p o s i t i v e l y r e l a t e d  to bottle feeding and to the n u m b e r of p r o b l e m s e n c o u n t e r e d by the w o m e n d u r i n g t h e i r f i r s t w e e k at h o m e .  The positive relationship bet-  w e e n d e p r e s s i v e affect and bottle feeding to s o m e extent s u p p o r t s the f i n d i n g s o f P i t t (1973) who stated that w o m e n w h o had the " b l u e s " d i f f e r e d f r o m those who d i d not o n l y i n that they e x p e r i e n c e d m o r e d i f f i c u l t y i n breast feeding.  T h e r e s p o n s e s to G r e e n b e r g ' s h o s p i t a l m a t e r n i t y  q u e s t i o n n a i r e i n d i c a t e d that the m o t h e r ' s f e e l i n g s of d e p r e s s i o n r e l a t e d 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 e n e r g y w h i l e i n h o s p i t a l ; l e s s confidence r e g a r d i n g the r o l e of m o t h e r h o o d and an i n c r e a s e d length of t i m e taken to understand the need of the b a b y . T h e above r e l a t i o n s h i p between d e p r e s s i v e affect and o t h e r v a r i a b l e s i:S. c o n s i s t e n t w i t h s e v e r a l p s y c h o l o g i c a l t h e o r i e s of d e p r e s s i o n .  116  B e c k (1967, 1971, 1974) postulated a c o g n i t i v e theory of d e p r e s s i o n i n w h i c h d e p r e s s i o n i s seen a s a r e s u l t of a t r i a d of c o g n i t i v e d i s t u r bances w h i c h p r e d i s p o s e an i n d i v i d u a l to v a r i o u s f o r m s of thought and b e h a v i o u r a l c h a r a c t e r i s t i c s of d e p r e s s i o n .  T h e components of this  t r i a d a r e "a negative view of the f u t u r e , of the e n v i r o n m e n t and of h i m self".  It could be m a i n t a i n e d that the w o m e n who e x p e r i e n c e d e p r e s -  s i v e affect therefore tend to see t h e i r e x p e r i e n c e s i n a l e s s p o s i t i v e l i g h t , have a l e s s p o s i t i v e attitude t o w a r d s t h e i r baby and s e e t h e m s e l v e s as l e s s a b l e to c a r e f o r the baby c o m p e t e n t l y . T h e p r e s e n t findings a r e a l s o c o n s i s t e n t w i t h the b e h a v i o u r a l t h e o r i e s of d e p r e s s i o n of C o s t e l l o (1972), L e w i n s o h n and his. a s s o c i a t e s (1976) and S e l i g m a n and h i s a s s o c i a t e s (1976). C o s t e l l o ' s (1972) theory of d e p r e s s i o n w o u l d s u g g e s t that the w o m e n who had c a e s a r i a n s e c t i o n s w e r e d e p r e s s e d b e c a u s e "the r e i n f o r c e m e n t e f f e c t i v e n e s s of a l l the components of a c h a i n of b e h a v i o u r s i s c o n t i n gent upon the c o m p l e t i o n of the c h a i n at e i t h e r an o v e r t o r c o v e r t level".  C a e s a r i a n s d i d not c o m p l e t e the c h a i n of c h i l d b i r t h f o r w h i c h  they had tra i n e d . L e w i n s o h n (1976) pointed out that the concept of r e i n f o r c e m e n t i s c e n t r a l to the a n a l y s i s " o f d y s p h o r i a and the o t h e r events w h i c h a r e f r e q u e n t l y encountered among p e r s o n s diagnosed a s d e p r e s s e d " , and to the d e v e l o p m e n t and maintenance of the d e p r e s s i v e s y n d r o m e .  117  A c c o r d i n g to L e w i n s o h n , the b e h a v i o u r a l m o d e l "focuses on the effects w h i c h a r e d u c t i o n i n the rate of response contingent p o s i t i v e r e i n f o r c e ment i s a s s u m e d to have on the b e h a v i o u r of the i n d i v i d u a l " . duction can o c c u r i n three w a y s .  This re-  F i r s t , events contingent on b e h a v i o u r  m a y not be r e i n f o r c i n g . S e c o n d , events w h i c h a r e r e i n f o r c i n g m a y become u n a v a i l a b l e and t h i r d , the i n d i v i d u a l i s unable to e l i c i t r e i n f o r c i n g b e h a v i o u r because of the l a c k of s k i l l .  A c c o r d i n g to L e w i n s o h n  (1974) the total amount of response contingent p o s i t i v e r e i n f o r c e m e n t i s a function of three v a r i a b l e s . 1.  T h e n u m b e r of p o t e n t i a l l y r e i n f o r c i n g 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 i n f o r c e r s i n the e n v i r o n m e n t .  3.  T h e i n s t r u m e n t a l b e h a v i o u r of the i n d i v i d u a l — the extent to w h i c h he p o s s e s s e s the s k i l l s to e l i c i t r e i n f o r c e m e n t f r o m the environment.  L e w i n s o h n pointed out that the b e h a v i o u r a l theory would p r e d i c t d e p r e s s i o n f o r an i n d i v i d u a l who a c h i e v e d a goal f o r w h i c h he has w o r k e d h a r d i f tine r e w a r d turns out to be a w e a k r e i n f o r c e r . T h e findings f r o m the study a r e a l s o c o n s i s t e n t w i t h the l e a r n e d h e l p l e s s n e s s m o d e l postulated by S e l i g m a n (1971) who p r o p o s e d t h i s concept a s a l a b o r a t o r y m o d e l of d e p r e s s i o n i n h u m a n s .  In h i s o p i n i o n ,  d e p r e s s i o n i s caused by e x p e r i e n c e i n w h i c h an i n d i v i d u a l ' s r e s p o n s e s cannot c o n t r o l the a p p r o p r i a t e r e i n f o r c e r s .  S e l i g m a n stated that  118  r e a c t i v e d e p r e s s i o n m a y have i t s roots in the l o s s of c o n t r o l o v e r g r a t i f i c a t i o n and the a l l e v i a t i o n of s u f f e r i n g . A c c o r d i n g to S e l i g m a n (1976) the m o d e l c l a i m s that many d e p r e s s i o n s , a r e caused by u n c o n t r o l l a b l e s i t u a t i o n s w h i c h lead the subject to b e l i e v e that h i s / h e r a r e g e n e r a l l y ineffective i n obtaining r e i n f o r c e m e n t . h i s l a t e s t study s u p p o r t •  responses  T h e r e s u l t s of  the above m o d e l w h i c h c l a i m s that "(a) u n C  •  •  •  c o n t r o l l a b l e events induce d i s t o r t e d p e r c e p t i o n s of r e s p o n s e - r e i n f o r c e ment independence in n o n - d e p r e s s e d people w h i c h c a u s e p e r f o r m a n c e d e f i c i t s p a r a l l e l to those found in n a t u r a l l y o c c u r r i n g d e p r e s s i o n and (b) that e x p e r i e n c e w i t h c o n t r o l l a b l e events r e v e r s e s the p e r c e p t i o n s of this independence and the p e r f o r m a n c e d e f i c i t s a s s o c i a t e d w i t h both h e l p l e s s n e s s and d e p r e s s i o n . " G i v e n the l a c k of d i f f e r e n c e s i n l e v e l of d e p r e s s i v e affect before the b i r t h of the baby, the findings of s i g n i f i c a n t l y m o r e d e p r e s s i v e a f f e c t a f t e r d e l i v e r y s u g g e s t s that c a e s a r i a n s e c t i o n w a s a w e a k r e i n f o r c e r f o r these w o m e n .  T h e w o m e n in the p r e s e n t study t r a i n e d as a team w i t h  t h e i r husbands f o r the b i r t h of t h e i r baby.  T h i s b e h a v i o u r w a s not c o m -  pleted and the w o m e n found that a l l they had l e a r n e d c o u l d not be put to use.  T h e b i r t h of t h e i r baby w a s suddenly taken out of t h e i r c o n t r o l ,  s o m e t h i n g f o r w h i c h the w o m e n w e r e not p r e p a r e d , a n d , in a d d i t i o n , there w e r e the s t r e s s f u l a s p e c t s of s u r g e r y and p o s t - o p e r a t i v e p r o c e dures.  It r e m a i n s to be i n v e s t i g a t e d e m p i r i c a l l y w h e t h e r the w o m e n  119  a c t i v e l y see t h e m s e l v e s as having l e s s c o n t r o l .  T h e l e v e l of d e p r e s s i v e  affect m a y have i n c r e a s e d due to feelings of t i r e d n e s s , l e t h a r g y e t c . due to the o p e r a t i o n ; o r because t h e i r husbands c o u l d not be p r e s e n t a t the d e l i v e r y . M c L e a n (1976) p r o p o s e d a theory in w h i c h d e p r e s s i o n i s seen a s the "consequence of ineffective c o p i n g techniques used to r e m e d y s i t u a tional life p r o b l e m s " .  F i g u r e 4 i s M c L e a n ' s s c h e m a to i l l u s t r a t e h i s  proposition.  Figure 4 Time  0) repeated goal f r u s t r a t i o n s in a v a r i e t y of significant areas  (2)  (3)  f e e l i n g of little control over environment  (4)  anticipations of c h r o n i c failure  depression symptomatology  F i g u r e 5 i s a m o d i f i c a t i o n of tine above u s i n g the p e r c e p t i o n of having a c a e s a r i a n s e c t i o n a s the i n e f f e c t i v e coping technique,  ( c o u r t e s y of  M c L e a n , 1976). Figure 5 .Time (1) expectancy of v a g i n a l delivery sha ttered  (2) woman relinquishes c o n t r o l of birth process  (3) l o s s of confidence in a b i l i t y  (4) higher scores on the D A C L  120  It w o u l d be i n t e r e s t i n g to s p e c u l a t e w h e t h e r the s a m e r e l a t i o n s h i p between d e p r e s s i v e affect and l e s s p o s i t i v e attitude t o w a r d p r e g n a n c y , t o w a r d the baby and to o t h e r v a r i a b l e s w o u l d be found i n a c l i n i c a l l y depressed population. W h a t i s the r e l a t i o n s h i p between d e p r e s s i v e affect and d i s o r d e r s of m o t h e r i n g , the m o s t s e v e r e of w h i c h r e s u l t i n c h i l d a b u s e ?  Is t h e r e a  r e l a t i o n s h i p between d e p r e s s i v e affect i n p r e g n a n c y , c a e s a r i a n s e c t i o n and c h i l d abuse?  T h i s r e m a i n s to be e m p i r i c a l l y d e t e r m i n e d but the  p r e s e n t r e s e a r c h suggests the need f o r f u r t h e r r e s e a r c h to c l a r i f y s u c h relationships.  A s H e i f e r pointed out the p r e c i p i t a t i n g event f o r c h i l d  abuse m a y be a d i f f i c u l t p r e g n a n c y a n d / o r d e l i v e r y ; that a b u s e d c h i l d r e n have a c a e s a r i a n s e c t i o n rate m u c h h i g h e r than that of the g e n e r a l p o p u lation. M c L e a n (1976) a s k e d , " W h a t effect, i f a n y , does p a r e n t a l d e p r e s s i o n have on effective p a r e n t i n g ? " He stated that although t h e r e a r e no e m p i r i c a l s t u d i e s i n the l i t e r a t u r e , i n f o r m a t i o n f r o m s e v e r a l s o u r c e s i n d i c a t e s that effective p a r e n t i n g and a b s e n c e of d e p r e s s i o n a r e r e l a t e d .  According  to M c L e a n , e v i d e n c e f r o m s t u d i e s of s e l f r e p o r t , effect of p a r e n t a l m o d e l l i n g and s e l f e s t e e m i n p r e ~ a d o l e s c e n t s suggest two hypotheses r e g a r d i n g the p r e s e n c e of p a r e n t a l d e p r e s s i o n .  F i r s t , that p a r e n t a l  d e p r e s s i o n m a y r e n d e r p a r e n t s l e s s c a p a b l e of e f f e c t i v e p a r e n t i n g and s e c o n d , that p a r e n t a l d e p r e s s i o n p r o v i d e s a n o p p o r t u n i t y f o r c h i l d r e n to  121  a c q u i r e ineffective i n t e r p e r s o n a l c o p i n g s t r a t e g i e s through p a r e n t a l modelling. T h e low but c o n s i s t e n t r e l a t i o n s h i p s o f d e p r e s s i v e affect to s u c h v a r i a b l e s a s confidence in m o t h e r i n g a b i l i t y , i n c r e a s e d length o f t i m e taken to " k n o w " the b a b y , l e s s s e l f c o n f i d e n c e i n c a r i n g f o r the baby i n a s a m p l e of w o m e n who a r e not c l i n i c a l l y d e p r e s s e d s u g g e s t s the e f f i c a c y of a p r e v e n t i v e a p p r o a c h . C l i n i c a l Implications S e l i g m a n (1976) found that the b e h a v i o u r a l i m m u n i z a t i o n techniques p r o v i d e d a n e a r l y and effective means of p r e v e n t i n g l e a r n e d h e l p l e s s n e s s in a n i m a l s .  T h e r e i s evidence in the p s y c h o l o g i c a l l i t e r a t u r e d e a l i n g  w i t h s t r e s s that s u c h techniques w o r k w e l l f o r h u m a n s . J o h n s o n and L e v e n t h a l (1974) state that m a n y t h e o r i e s suggest that negative affect i s "a p r o d u c t of d i s c r e p a n c i e s between c u r r e n t e x p e r i e n c e and p r i o r e x p e c t a t i o n " .  J o h n s o n (1973) s u g g e s t s that i n a c c u r a t e e x p e c t a -  t i o n s r e g a r d i n g s e n s a t i o n s p r o d u c e d by n o x i o u s s t i m u l i a r e the c r i t i c a l s o u r c e of negative affective r e s p o n s e s .  T h u s , Johnson considers  that i f a p e r s o n a c c u r a t e l y a n t i c i p a t e s how a n o x i o u s s t i m u l u s w i l l f e e l h e / s h e w i l l be l e s s f e a r f u l .  S h e found that a c c u r a t e e x p e c t a t i o n s about  the p h y s i c a l s e n s a t i o n s to be e x p e r i e n c e d , r e d u c e d the s t r e s s c a u s e d by painful s t i m u l i .  T h e r e s u l t s of h e r study s u p p o r t e d the h y p o t h e s i s  that p r e p a r a t o r y i n f o r m a t i o n w h i c h r e d u c e d ' t h e i n c o n g r u i t i e s between  122  expected and a c t u a l l y e x p e r i e n c e d s e n s a t i o n s w a s a s s o c i a t e d w i t h l e s s i n t e n s e e m o t i o n a l r e s p o n s e s d u r i n g painful s t i m u l i .  Johnson and  L e v e n t h a l (1974) c i t e s t u d i e s of f e a r c o m m u n i c a t i o n s u g g e s t i n g that " . . . b e h a v i o u r a l p r e p a r a t i o n , d e t a i l e d i n s t r u c t i o n s on how and w h e n to a c t , and p r i o r r e h e a r s a l of s p e c i f i c a c t i o n s a r e n e c e s s a r y f o r s u b j e c t s to s u s t a i n c o n t r o l o v e r e x t e r n a l t h r e a t s " .  T h e y c o n c l u d e by s t a t i n g  that t h e i r s t u d i e s have shown that " s p e c i f i c types of i n f o r m a t i o n c a n be u s e d to reduce  -  a v e r s i v e r e s p o n s e s and to s t r e n g t h e n effective c o p i n g  responses . . . " M e i c h e n b a u m and T u r k (1976) s t a t e that b e h a v i o u r t h e r a p y i s s h i f t i n g i t s e m p h a s i s to a coping s k i l l s m o d e l and d e s c r i b e the s t r e s s i n n o c u l a t i o n t r a i n i n g p r o c e d u r e s in w h i c h s u b j e c t s a r e p r o v i d e d w i t h a p r o s p e c t i v e defense, o r set of s k i l l s , to d e a l w i t h future s t r e s s f u l situations, using cognitive manipulations such a s imagery r e h e a r s a l , s e l f i n s t r u c t i o n a l t r a i n i n g , and r e l a x a t i o n t r a i n i n g t e c h n i q u e s .  They d i s -  c u s s s t u d i e s showing the s u c c e s s f u l a p p l i c a t i o n of s u c h i n n o c u l a t i o n t r a i n i n g i n c o n t r o l of p h o b i a s , i n t e r p e r s o n a l a n x i e t y and c o n t r o l of a n g e r in the p s y c h o l o g i c a l r e a l m .  T h e s e p r o c e d u r e s have a l s o been  u s e d i n the p h y s i c a l r e a l m of pain c o n t r o l .  T h e y d i s c u s s the c l i n i c a l  p o t e n t i a l of s u c h a p r e v e n t i v e a p p r o a c h f o r h a n d l i n g both p h y s i c a l and psychological stresses.  L a n g e r , J a n i s and W o l f e r (1975) r e p o r t e d on  the r e d u c t i o n of p s y c h o l o g i c a l s t r e s s in s u r g i c a l patients u s i n g two  123  s t r e s s reduction strategies in a field s e t t i n g .  It w a s found that the  coping d e v i c e ( c o g n i t i v e r e a p p r a i s a l of anxiety—provoking e v e n t s , c a l m i n g s e l f - t a l k and c o g n i t i v e c o n t r o l ) w h i c h w a s p o r t r a y e d a s a w a y of c o n t r o l l i n g o n e ' s e m o t i o n s  w a s m o r e e f f e c t i v e i n r e d u c i n g pre~and  p o s t o p e r a t i v e s t r e s s than the technique o f g i v i n g p r e p a r a t o r y c o m m u n i c a t i o n s about what to e x p e c t , c o m b i n e d w i t h  reassurance.  K l u s m a n (1975) showed that p r e n a t a l a n x i e t y w a s r e d u c e d i n a n education-for-childbirth c l a s s which used e x e r c i s e s , breathing t e c h niques and gave w o m e n a s e n s e of p a r t i c i p a t i n g i n and c o n t r o l o v e r the childbirth process.  A n x i e t y w a s not r e d u c e d i n the c o n t r o l p r e n a t a l  c l a s s w h i c h e m p h a s i z e d baby c a r e and i n w h i c h p r e p a r a t i o n f o r c h i l d b i r t h w a s l i m i t e d to i n f o r m a t i o n r e g a r d i n g l a b o u r and d e l i v e r y . In o r d e r to teach c o p i n g s k i l l s and to e m p h a s i z e the i n d i v i d u a l ' s a b i l i t y to c o n t r o l the s i t u a t i o n , the p r e n a t a l c l a s s e s w h i c h the w o m e n i n the p r e s e n t study attended u s e d s t r e s s i n n o c u l a t i o n t e c h n i q u e s .  G i v e n the  r e s e a r c h on pain and a n x i e t y one m i g h t p r e d i c t that these c l a s s e s w o u l d be e f f e c t i v e .  ( T h e r e a r e , h o w e v e r , few s y s t e m a t i c s t u d i e s o f the ef-  f i c a c y of education f o r c h i l d b i r t h c l a s s e s . ) D i s c u s s i o n w i t h p r e n a t a l c l a s s t e a c h e r s i n d i c a t e s that c a e s a r i a n s e c t i o n s a r e r e g a r d e d a s an a b n o r m a l a s p e c t of c h i l d b i r t h a n d , although mentioned a s a p o s s i b i l i t y , they a r e not d i s c u s s e d i n any s i g n i ficant d e t a i l . G i v e n that the p r e s e n t r a t e of c a e s a r i a n s e c t i o n i n  )2h  V a n c o u v e r i s a p p r o x i m a t e l y 20% and given the p o s s i b i l i t y that the n u m b e r of c a e s a r i a n s w i l l tend to r i s e i n view of the i n c r e a s i n g use of fetal m o n i t o r i n g equipment, it does not m a k e s e n s e to i g n o r e c a e s a r i a n sections.  T h e p r e s e n t findings of s i g n i f i c a n t l y m o r e d e p r e s s i v e affect  i n w o m e n who have had c a e s a r i a n s e c t i o n s together w i t h the findings of r e s e a r c h into s t r e s s innoculation and b e h a v i o u r a l i m m u n i z a t i o n techniques and coping s k i l l s , indicate the need f o r g r e a t e r attention focused on c a e s a r i a n s e c t i o n i n p r e n a t a l c l a s s t r a i n i n g . The M y t h of M a t e r n a l Instinct J a n e w a y (1971) s t a t e s the f o l l o w i n g :  ,:  W o m e n a r e not t r a i n e d to be m o t h e r s i n o u r s o c i e t y , o r indeed in any s o c i e t y . . . T h e v e r y fact that o u r s o c i e t y does t r a i n i n i t i a t e s f o r m a l l y f o r most jobs . . .makes woman's role a r c h a i c and a t y p i c a l in that w o m e n s t i l l l e a r n by d o i n g . T h e y take on the v i t a l , c r e a t i v e , i m p o r t a n t , c e n t r a l c o n c e r n of t h e i r l i v e s (they a r e assured), with very little advice o r background. New m o t h e r s a r e expected to a c t by i n s t i n c t ; and this expectation in i t s e l f s e t s them a p a r t f r o m the r e s t of s o c i e t y , w h e r e people a s s u m e that they w i l l be taught the b a s i c r u l e s of the j o b s they have to d o . The expectation that they w i l l be a b l e to a c t by i n s t i n c t s e t s w o m e n a p a r t , a l s o by suggesting that they o p e r a t e on a m o r e p r i m i t i v e l e v e l than is n o r m a l f o r the r e s t of o u r w o r l d . O n l y v e r y r e c e n t l y has attention been p a i d to the needs of the w o m a n  in p r e p a r a t i o n f o r motherhood as opposed to p r e p a r a t i o n f o r c h i l d b i r t h . (The s a m e m a y be s a i d f o r f a t h e r s who r e c e i v e even l e s s a t t e n t i o n . )  125 S t a n d a r d p r o c e d u r e has been p r e n a t a l c l a s s e s w i t h l i t t l e o r no e m p h a s i s on the postnatal p e r i o d and " l i f e w i t h b a b y " .  T h i s m a y have been due i n  p a r t to the myth of m a t e r n a l i n s t i n c t w h i c h a s s u m e s that l o v e i s enough and that because a w o m a n has had a baby she both l o v e s i t and knows what to d o .  O f the p a r t i c i p a n t s in the study (N=106) 46% stated that they  developed a s t r o n g m a t e r n a l f e e l i n g t o w a r d t h e i r baby i m m e d i a t e l y a f t e r the b i r t h ; 33% developed this f e e l i n g w i t h i n t h r e e d a y s , w h i l e the r e m a i n i n g 21% d i d not have this f e e l i n g b y the t i m e they l e f t the h o s p i t a l . R e g a r d i n g the length of t i m e that the w o m e n thought that i t w o u l d take to " k n o w " the baby, e . g . , t h e r e a s o n f o r w h i c h h e / s h e c r i e d , the frequency was as follows: I know h i m / h e r a l r e a d y 3 days one w e e k one month m o r e than one month  43%  27% 19% 3% 8%  T h e finding that those w o m e n i n the 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 had a m o r e p o s i t i v e attitude t o w a r d t h e i r baby a n d g a i n e d m o r e e x p e r i e n c e and a s s i s t a n c e f r o m the h o s p i t a l i n t h e i r new m o t h e r i n g r o l e s u g g e s t s that components of m o t h e r i n g b e h a v i o u r can be l e a r n e d ( i n a d d i t i o n to the c o r r e l a t i o n between p o s i t i v e attitude t o w a r d the b a b y , and e a s e of a d j u s t m e n t , f e e l i n g s of c o m p e t e n c e and s e l f confidence;) that w i t h l e a r n i n g c o m e i n c r e a s e d confidence a n d f e e l i n g s o f c o m p e t e n c e , a m o r e p o s i t i v e attitude toward the baby and a d e c r e a s e i n d e p r e s s i v e  126  affect.  T h e s i g n i f i c a n t c o r r e l a t i o n s between d e p r e s s i v e affect and  n u m b e r of p r o b l e m s e x p e r i e n c e d a f t e r one w e e k and five w e e k s at h o m e support  t h i s , as does tine r e l a t i o n s h i p between d e p r e s s i v e affect and  l e s s p o s i t i v e attitude towards the b a b y .  T h i s is consistent with.Bern's  t h e o r y of s e l f p e r c e p t i o n w h i c h p r e d i c t s that attitudes f o l l o w b e h a v i o u r ( B e r n 1965; 1967; 1970; Jones & G e r a r d 1967; C a l d e r and R o s s 1973), and that a p e r s o n i n f e r s h i s attitude by o b s e r v i n g h i s own b e h a v i o u r and the context in w h i c h it o c c u r s . P r e n a t a l c l a s s t e a c h e r s b e l i e v e that the p r e n a t a l t i m e i s not the m o s t p r o p i t i o u s f o r teaching p a r e n t i n g s k i l l s .  One s u g g e s t i o n b a s e d on  the p r e s e n t study i s that p o s t p a r t u m c l a s s e s f o r p a r e n t s and t h e i r i n fants be i n c o r p o r a t e d into the education f o r c h i l d b i r t h c l a s s e s a s s o o n a s f e a s i b l y p o s s i b l e a f t e r the b i r t h of a b a b y .  These classes could i n -  c l u d e s u c h i t e m s as parenting s k i l l s a s w e l l a s d e a l i n g w i t h the e m o t i o n s and f e e l i n g s of the new p a r e n t s .  S u c h c l a s s e s could a l s o s e r v e as a  v e h i c l e f o r the detection of p a r e n t s who have p a r t i c u l a r d i f f i c u l t i e s i n t h e i r r e l a t i o n s h i p w i t h t h e i r infant w i t h a v i e w .to the p r e v e n t i o n of mothering disorders. Conclusion S e a r c h f o r the H o l y G r a i l In d i s c u s s i n g the concept of " h e a l t h " , K i s s i c k (1972) stated that i t i s both a c o m m o n p l a c e w o r d and an i l l u s i v e concept f r u s t r a t i n g  127 d e s c r i p t i o n and q u a n t i f i c a t i o n . H e s t a t e s , "In a s e n s e h e a l t h i s a n a b s t r a c t i o n that m a y be viewed a s the 20th c e n t u r y e q u i v a l e n t of the H o l y G r a i l — the n e v e r - t o - b e - a t t a i n e d object of a r e l e n t l e s s s e a r c h " . C o w e n (1973) stated that p r i m a r y p r e v e n t i o n in m e n t a l h e a l t h s e e k s (a) to f o r e s t a l l dysfunction by r e d u c i n g the r a t e o f o c c u r r e n c e of d i s o r d e r in the population a t l a r g e and (b) to p r o m o t e p s y c h o l o g i c a l h e a l t h and w e l l b e i n g .  Cowen s a w p r i m a r y p r e v e n t i o n a s a "bonafide c o n c e p -  tual a l t e r n a t i v e to mental health p r o b l e m s ' ' a n d stated that to be effective p r i m a r y p r e v e n t i o n s h o u l d be a c t i v e l y o r i e n t e d to the effects of e n v i r o n ments and the settings on d e v e l o p m e n t .  P r i m a r y prevention typically  does not o c c u r u n t i l a c h i l d r e a c h e s p r e - s c h o o l age ( t h r e e ) .  The years  f r o m b i r t h to s c h o o l age have often been d e s c r i b e d a s the " s i l e n t y e a r s " ( S t e p h e n s o n , 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 i n the c o m m u n i t y , i . e . the youngest age o t h e r than b i r t h at w h i c h n a m e s and a d d r e s s a r e k n o w n " . T h i s m a y be s o ; h o w e v e r , there i s a c o n v e r g e n c e i n the l i t e r a t u r e i n d i c a t i n g that p r e g n a n c y , c h i l d b i r t h and subsequent m o t h e r h o o d s h o u l d be the f o c u s of 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 and i n t e r v e n t i o n a c t i o n s . Chandler  (1972) make an eloquent plea in this v e i n .  Murphy and  T h e y s t a t e that  in a g r i c u l t u r e " p r e v e n t i o n " of d i s e a s e o r of g r o w t h f a i l u r e i s seen l a r g e l y in t e r m s of p r o v i d i n g f o r h e a l t h and s t u r d y g r o w t h .  "Scientific  data r e l e v a n t to the total development a r e m a d e a c c e s s i b l e f r o m f e d e r a l ,  128  s t a t e and county a g e n c i e s and a r e r e a d i l y a p p l i e d to g r o w t h of c a t t l e , h o g s , wheat and c o r n " .  T h e y d i s c u s s the s i t u a t i o n i n the a u t o m o b i l e  f i e l d , w h e r e the c o n s u m e r s ' a d v o c a t e , i f not the c o n s u m e r ,  demands  r e p a i r of r e c o g n i z e d defects in c a r s , the development of safety c h e c k s , finding w a y s of i m p r o v i n g the roads and d e v e l o p i n g b e t t e r c o n t r o l of t r a f f i c w i t h the u l t i m a t e a i m of r e d u c i n g p e r c e n t a g e of deaths and i n j u r i e s that o c c u r each y e a r .  M u r p h y and C h a n d l e r c o m p a r e this w i t h  the f a i l u r e to produce healthy c h i l d r e n . T h e y state that the u t i l i z a t i o n of a l l s c i e n t i f i c knowledge r e l e v a n t to the o p t i m u m development i n the a r e a of c h i l d r e n i s spotty and inadequate.  T h e y c i t e the 161 , 0 0 0 infant  deaths each y e a r ( U . S . ) and the r e l a t e d b i r t h h a z a r d s w h i c h p r e d i s p o s e the infant to d i s t u r b a n c e of functioning i n a l l a r e a s . M u r p h y and C h a n d l e r c i t e the w o r k of P a s a m a n i c k and h i s a s s o c i ates as d e m o n s t r a t i n g the c l o s e r e l a t i o n of m a j o r f o r m s of d i s t u r b a n c e i n development on the one hand w i t h p r e g n a n c y and b i r t h on the o t h e r . T h e y a s k " C a n we think i n t e r m s of a c o m p r e h e n s i v e p r o g r a m m e to p r o d u c e s t r o n g e r b a b i e s , b e t t e r equipped f o r s u r v i v a l in a changing s t r e s s f u l c u l t u r e , c o m p a r a b l e to the p r o g r a m m e s f o r a g r i c u l t u r a l productivity? " H o f e r (1975), C h a i r m a n of the C i b a Foundation P a r e n t - I n t e r a c t i o n S y m p o s i u m w r i t e s . . . " w e have c o m e to r e c o g n i z e that the e a r l y - p a r e n t infant r e l a t i o n s h i p has a profound i m p a c t on the development of  129  emotional  b e h a v i o u r , c o g n i t i v e f a c u l t i e s , even b i o l o g i c a l o r g a n i z a t i o n  and r e s i s t a n c e 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): T h e 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 has p r e p a r e d one of the m o s t s p e c i f i c b l u e p r i n t s f o r a c t i o n in p r i m a r y p r e v e n t i o n . It g i v e s a c t u a l s t e p s to be taken by c i t i z e n s ' g r o u p s in t h e i r c o m m u n i t y to a c h i e v e the goal of the p r e v e n t i o n of l a t e r emotional disturbance. The N A M H proposal focuses s p e c i f i c a l l y on p r e n a t a l and p e r i n a t a l c o n d i t i o n s a s a r e a s w h e r e definite a c t i o n should be t a k e n . T h e t i m e f r o m c o n c e p t i o n to 6 months a f t e r b i r t h w a s chosen a s the a c t i o n p e r i o d . A m o n g the a c t i o n s r e c o m m e n d e d a r e - p r e n a t a l and p e r i n a t a l c a r e affecting the e x p e c t i n g m o t h e r and the d e v e l o p i n g f e t u s , w a y s of c o p i n g w i t h l i f e c r i s i s s i t u a t i o n s affecting the m o t h e r p a r t i c u l a r l y , the d e v e l o p m e n t of b e t t e r parenting s k i l l s , the m o d i f i c a t i o n of the s o c i a l s y s t e m w h i c h m a y be expected to be a s o u r c e of s t r e s s i f u n m o d i f i e d ( w e l f a r e , m e d i c a l c a r e , day c a r e e t c . ) and the i n s u r a n c e of adequate m e d i c a l c a r e f o r m o t h e r and infant following birth . (p.573) T h e w r i t e r f e e l s that w e should stop s e a r c h i n g f o r the i l l u s i v e H o l y G r a i l and s t a r t putting into effect s o m e of the p r e s e n t 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 n c r e a s i n g a w a r e n e s s of the  importance, physically, developmentally, mentally, e m o t i o n a l V c o g n i t i v e l y f o r both p a r e n t s and c h i l d r e n of the w h o l e t i m e p e r i o d of pregnancy, c h i l d b i r t h and e a r l y i n f a n c y .  Instead of the r e l e n t l e s s s e a r c h w e need  r e l e n t l e s s m u l t i - d i s c i p l i n a r y a c t i o n and focus on this p e r i o d . done.  It c a n be  F i n l a n d f o r e x a m p l e has a s t r o n g and f r e e p r e v e n t i v e s e r v i c e f o r  antenatal c a r e , h o s p i t a l d e l i v e r y , postnatal c a r e and p r e s c h o o l c h i l d health c a r e (Wynne and W y n n e , 1974), a l o n g w i t h h o m e m a k e r s and h o m e helps which a r e considered essential preventive s e r v i c e s .  Finnish law  130  e s t a b l i s h e d one C h i l d H e a l t h C e n t r e i n e v e r y l o c a l a u t h o r i t y i n 1944. T h e r e is a schedule for developmental assessment requiring e x a m i n a t i o n at monthly i n t e r v a l s f o r those b a b i e s u n d e r 12 m o n t h s .  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 e a s t one d e v e l o p m e n t a l e x a m i n a tion p e r y e a r up to s c h o o l a g e .  T h e W y n n e r e p o r t s t a t e s that " T h e  c o v e r a g e of these c h i l d r e n i s c o v e r a g e of t h e i r h o m e s and o f t h e i r parents.  T h e C h i l d H e a l t h C e n t r e s teach p a r e n t s n u t r i t i o n , the m a n -  a g e m e n t of m i n o r a i l m e n t s and o f b e h a v i o u r p r o b l e m s , the i m p o r t a n c e of p l a y and of s t i m u l a t i o n i n the h o m e " .  T h e r e is delegation downwards  f o r the o p e r a t i o n of the m a t e r n a l and c h i l d h e a l t h s e r v i c e s f r o m the p r o v i n c i a l g o v e r n m e n t s to the l o c a l g o v e r n m e n t s .  T h i s d e l e g a t i o n of  a u t h o r i t y is a c c o m p a n i e d by o b l i g a t i o n s that e n s u r e that the l o c a l g o v e r n m e n t s have s t r o n g p r e v e n t i v e s e r v i c e s .  In a d d i t i o n , t h e r e i s a c c o u n t -  a b i l i t y of two kinds on the p a r t of the l o c a l a u t h o r i t y , to the M i n i s t e r of H e a l t h ; a c c o u n t a b i l i t y f o r the f i n a n c i a l e x p e n d i t u r e s a n d , m o r e s i g n i f i cantly, accountability for performance.  A s a r e s u l t F i n l a n d has b e c o m e .  one of the w o r l d l e a d e r s i n m a t e r n a l and c h i l d h e a l t h . elsewhere.  It c a n be done  A s S t a l l w o r t h y (1972) pointed o u t , " O b s t e t r i c s i s no l o n g e r  a n e x e r c i s e in m e c h a n i c s but an o p p o r t u n i t y f o r p r a c t i s i n g p r e v e n t i v e m e d i c i n e at i t s b e s t " .  131  Notes 1.  S t o v e l , S . N u t r i t i o n in P r e g n a n c y : L i t e r a t u r e R e v i e w . Prepared f o r the P a c i f i c Health E d u c a t i o n A s s o c i a t i o n w i t h a s s i s t a n c e of the V a n c o u v e r C i t y Health D e p a r t m e n t and B r i t i s h C o l u m b i a P r o v i n c i a l D e p a r t m e n t of H e a l t h .  2.  K h a i r a t , L . and C o s t a n z o , G . A p r o j e c t to evaluate the e f f e c t i v e ness of an educational p r o g r a m m e f o r expectant p a r e n t s . V a n c o u v e r , B . C . M e t r o p o l i t a n Health S e r v i c e of G r e a t e r V a n c o u v e r , M a y 1974.  3.  S t e p h e n s o n , S . Bonding and A t t a c h m e n t d u r i n g the P u e r p e r i u m . P a p e r presented at N u r s i n g C a r e in the P u e r p e r i u m . Continuing E d u c a t i o n in the Health S c i e n c e s . T h e 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 M a t e r n a l A n a l g e s i a on the N e w b o r n . C l i n i c s in o b s t e t r i c s and gynaecology, J . J . B o n i c a , ( e d . ) 1975, 2 ( 3 ) , 6 6 1 - 6 7 1 . Baker, M . , Dorzab, J . , Winokur, G . & Cadoret. Deoressive Disease: T h e E f f e c t of the P o s t p a r t u m S t a 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. Barnett, C.R-., Leiderman, P . H . , Grobstein, R . , & Klaus, M . Neonatal s e p a r a t i o n : The m a t e r n a l s i d e of i n t e r a c t i o n a l d e p r i v a t i o n . P e d i a t r i c s , 1970, _4_5, (2), 1 9 7 - 2 0 5 . B e c k , A . T . , D e p r e s s i o n : C a u s e s and t r e a t m e n t . U n i v e r s i t y of P e n n s y l v a n i a , 1967, 1970.  Philadelphia:  Beck, A . T . W a r d , C . H . , Mendelson, M . , Mock, J . & Erbaugh, J . , A n i n v e n t o r y f o r m e a s u r i n g d e p r e s s i o n . A r c h i v e s of G e n e r a l P s y c h i a t r y , 1961, 4 , 5 6 1 - 5 7 1 . Becker, J . Depression; & S o n s , 1974.  T h e o r y and r e s e a r c h .  New Y o r k : J o h n W i l e y  B e r n , D . J . B e l i e f s , attitudes., and human a f f a i r s . B r o o k s - C o l e , 1970. Benedek, T .  P s y c h o s e x u a l functions i n w o m e n .  Belmont, California;  New Y o r k :  R o n a l d , 1952  B i b r i n g , G . L . S o m e c o n s i d e r a t i o n s of the p s y c h o l o g i c a l p r o c e s s e s in p r e g n a n c y . P s y c h o a n a l y t i c S t u d y of the C h i l d , 1959, 14, 1 1 3 - 1 2 1 . B i b r i n g , G . L . A study of the p s y c h o l o g i c a l p r o c e s s e s i n pregnancy and of the e a r l i e s t m o t h e r / c h i l d r e l a t i o n s h i p . P s y c h o a n a l y t i c S t u d y of the C h i l d , 1961, _16, 9 - 7 2 . Bratfos, O . & Haug. J . O . Puerperal disorders in manic depressive f e m a l e s . A c t a P s y c h i a t r i c a S c a n d i n a v i c a , 1966, 4 2 , 2 8 5 . B r a z e l t o n , T . B . Effect of p r e n a t a l d r u g s on the behaviour of the neonate. A m e r i c a n J o u r n a l of P s y c h i a t r y , 1970, 126, 1261-1266.  133  B r i t i s h M e d i c a l J o u r n a l , P u e r p e r a l P s y c h o s e s , 1966, 2, 1342. B r o n f e n b r e n n e r , U . Is e a r l y i n t e r v e n t i o n e f f e c t i v e . In Handbook'of E v a l u a t i o n R e s e a r c h , E . L . S t r u e n i n g and M . Guttentag ( E d s . ) V o l u m e 2 . London: S a g e P u b l i c a t i o n s , 1975. B r o u s s a r d , E . R . , H a r t n e r , M . S . M a t e r n a l p e r c e p t i o n of the neonate as r e l a t e d to development. C h i l d P s y c h i a t r y and" Human D e v e l o p m e n t , 1970, J_(1), 1 6 - 2 5 . B r o w n , W . A . & S h e r e s h e f s k y , P . S e v e n w o m e n : a p r o s p e c t i v e study of p o s t p a r t u m p s y c h i a t r i c d i s o r d e r s . P s y c h i a t r y , 1972, 3J5, 139. C a l d e r , B . J . and R o s s , M . A t t i t u d e s and B e h a v i o u r . N . J . : G e n e r a l L e a r n i n g P r e s s , 1973. C a m p b e l l , D . T . Reforms as E x p e r i m e n t s . . 1969, 24, 4 0 9 - 4 2 9 .  Morristown,  American Psychologist,  C a m p b e l l , D . T . , & R o s s , H . L . T n e C o n n e c t i c u t c r a c k d o w n cn s p e e d i n g : T i m e - s e r i e s data i n q u a s i - e x p e r i m e n t a l a n a l y s i s . In E . R . Tuft ( e d . ) , T h e quantitative a n a l y s i s of s o c i a l p r o b l e m s . Reading, M a s s : A d d i s o n - W e s l e y , 1970. C a m p b e l l , D . T . & S t a n l e y , J . C . E x p e r i m e n t a l and q u a s i - e x p e r i m e n t a l designs f o r r e s e a r c h . C h i c a g o : Rand M c N a l l y , 1966. C a t t e l l , R . B . Handbook f o r the I P A T A n x i e t y S c a l e : Institute f o r P e r s o n a l i t y and A b i l i t y T e s t i n g . C h a m p a i g n , I l l i n o i s , 1957. C l i f f o r d , E . E x p r e s s e d attitudes i n pregnancy of unwed w o m e n and m a r r i e d p r i m i g r a v i d a and m u l t i g r a v i d a . C h i l d D e v e l o p m e n t , 1962, 33 (4), 945-951 . C o s t e l l o , C . G . D e p r e s s i o n : L o s s of R e i n f o r c e r s o r l o s s of r e i n f o r c e r effectiveness? B e h a v i o u r T h e r a p y , 1972, 3 , 2 4 0 - 2 4 7 . C o w e n , E . L . S o c i a l and C o m m u n i t y I n t e r v e n t i o n s . In A n n u a l R e v i e w of P s y c h o l o g y , 1973, v o l u m e 2 4 , P . H . M u s s e n and M . R . R o s e n z w e i g ( e d s . ) A n n u a l R e v i e w Inc: P a l o A l t a , C a l i f o r n i a , U . S . A . Cox, B . S . Rooming-In.  N u r s i n g T i m e s , 1974, 7 0 ,  1246-1247.  134  C r o p l e y , A . J . & W e c k o w i c z , T . E . T h e D i m e n s i o n a l i t y of c l i n i c a l d e p r e s s i o n , A u s t r a l i a n J o u r n a l pf P s y c h o l o g y , 1966, _1_8 (1), 197-201. C r u i k s h a n k , W . H . P s y c h o s e s a s s o c i a t e d w i t h pregnancy and the p u e r p e r i u m . Canadian M e d i c a l A s s o c i a t i o n J o u r n a l , 1940 , 43 , 571 . D a v i d s , A . & De V a u l t , S . M a t e r n a l a n x i e t y d u r i n g p r e g n a n c y and c h i l d b i r t h a b n o r m a l i t i e s . P s y c h o s o m a t i c M e d i c i n e , 1962,_24, (5), 4 6 4 - 4 6 9 . D a v i d s , A . , De V a u l t , S . , & T a l m a d g e , M . A n x i e t y , p r e g n a n c y and childbirth abnormalities. J o u r n a l of C o n s u l t i n g P s y c h o l o g y , 1961a, 2 5 , (1), 7 4 - 7 7 . D a v i d s , A . , De V a u l t , S . , & T a l m a d g e , M . P s y c h o l o g i c a l study of emotional factors in pregnancy; a p r e l i m i n a r y report. P s y c h o s o m a t i c M e d i c i n e , 1961b, 2 3 , (2), 9 3 - 1 0 3 . D a v i d s o n , J . R . T . , P o s t p a r t u m mood change in J a m a i c a n W o m e n : A d e s c r i p t i o n and d i s c u s s i o n on i t s s i g n i f i c a n c e , B r i t i s h J o u r n a l of P s y c h i a t r y , 1972, 121 , 6 5 9 - 6 3 . D e u t s c h , H . The p s y c h o l o g y of w o m e n . G r u n e & S t r a t t o n , 1945.  V o l u m e 2 , New Y o r k ;  D o t y , B . A . R e l a t i o n s h i p s among attitudes i n p r e g n a n c y and o t h e r m a t e r n a l c h a r a c t e r i s t i c s . T h e J o u r n a l of G e n e t i c P s y c h o l o g y , 1967, JMM, 2 0 3 - 2 1 7 . E d w a r d s , K . R . P s y c h o l o g i c a l changes a s s o c i a t e d w i t h p r e g n a n c y and o b s t e t r i c c o m p l i c a t i o n s . D i s s e r t a t i o n A b s t r a c t s , 1970, 30 ( 8 B ) , 3864. E d w a r d s , K . R . & J o n e s , M . R . P e r s o n a l i t y changes r e l a t e d to p r e g n a n c y and o b s t e t r i c c o m p l i c a t i o n s . P r o c e e d i n g s of the 78th A n n u a l Convention of the A m e r i c a n P s y c h o l o g i c a l A s s o c i a t i o n , 1970, 3 4 1 342. Engel, E . L . F a m i l y Centred maternity c a r e . 1960, _41, 9 5 - 9 7 .  Hospital Progress,  135 E n g e l , E . L . F a m i l y centred h o s p i t a l m a t e r n i t y c a r e , A m e r i c a n J o u r n a l of O b s t e t r i c s and G y n e c o l o g y , 1963, S5_(2), 2 6 0 - 2 6 6 . E r i c k s o n , M . T . R e l a t i o n s h i p between p s y c h o l o g i c a l attitudes d u r i n g pregnancy and c o m p l i c a t i o n s of p r e g n a n c y , l a b o u r and d e l i v e r y . P r o c e e d i n g s of the 67th A n n u a l Convention of the A m e r i c a n P s y c h o l o g i c a l A s s o c i a t i o n , 1965, 2 1 3 - 2 1 4 . F a l e t t o , J . T e n y e a r s of f a m i l y c e n t r e d m a t e r n i t y c a r e . T o p i c s , 1963, 41_, 5 5 .  Hospital  F r i e d m a n , R . J . The P s y c h o l o g y of D e p r e s s i o n : A n o v e r v i e w . In R . J . Fried nd M . M . K a t z , ( t d s . ) T h e P s y c h o l o g y of D e p r e s s i o n : C o n t e m p o r a r y T h e o r y and R e s e a r c h . New Y o r k : J o h n W i l e y & S o n s , 1974. G o r d o n , R . E . & G o r d o n , K . K . S o c i a l f a c t o r s in the p r e d i c t i o n and t r e a t m e n t of e m o t i o n a l d i s o r d e r s of p r e g n a n c y . A m e r i c a n J o u r n a l of O b s t e t r i c s and G y n e c o l o g y , 1959, 77, (5), 1074-1083. G o r d o n , R . E . & G o r d o n , K . K . S o c i a l f a c t o r s in p r e v e n t i o n of p o s t p a r t u m e m o t i o n a l p r o b l e m s . O b s t e t r i c s and G y n e c o l o g y , 1960, 15, (4), 4 3 3 - 4 3 8 . G o r d o n , R . E . K a p o s t i n s , E . E . & G o r d o n , K . K . F a c t o r s in p o s t p a r t u m e m o t i o n a l a d j u s t m e n t . O b s t e t r i c s and G y n e c o l o g y , 1965, _25, (2), 158-166. G o r s u c h , R . L . & K e y , M . K A b n o r m a l i t i e s of p r e g n a n c y a s a function of a n x i e t y and life s t r e s s , P s y c h o s o m a t i c M e d i c i n e , 1974, 3 6 , (4), 352-361 . 0  Greenberg, M . Rosenberg, I . , Lind, J . , F i r s t mothers rooming-in w i t h t h e i r n e w b o r n s : i t s i m p a c t upon the m o t h e r . A m e r i c a n J o u r n a l of O r t h o p s y c h i a t r y , 1973 , 4 3 , (5), 7 8 3 - 7 8 8 . G r i m m , E . P s y c h o l o g i c a l tension in p r e g n a n c y , M e d i c i n e , 1961, _23, (6), 5 2 0 - 5 2 7 .  Psychosomatic  G r i m m , E . & Venet, W . R . T h e r e l a t i o n s h i p of e m o t i o n a l adjustment and attitudes to the c o u r s e and outcome of p r e g n a n c y . P s y c h o s o m a t i c M e d i c i n e , 1966, _28, (1), 3 4 - 4 9 .  136  G r i m m , E . R . P s y c h o l o g i c a l and s o c i a l f a c t o r s i n p r e g n a n c y , d e l i v e r y and o u t c o m e . In S . A . R i c h a r d s o n and A . F . G u t t m a c h e r , (eds) C h i l d b e a r i n g — Its s o c i a l and p s y c h o l o g i c a l a s p e c t s . T h e W i l l i a m s and W i l k i n s C o m p a n y , 1967. H a l l , D . E . & M o h r , G . T . P r e n a t a l attitudes of p r i m i p a r a e , M e n t a l H y g i e n e , 1933, 17_, 2 2 6 - 2 3 4 . H a i r e , D . & H a i r e , J . Implementing f a m i l y c e n t r e d m a t e r n i t y c a r e with a central n u r s e r y . H i l l s i d e , N . J . : Childbirth Education A s s o c i a t i o n , 1968. Hamilton, J . A . Postpartum psychiatric problems. C . V . M o s b y C o . , 1962 .  St. Louis:  The  Hathaway, S . and M c K i n l e y , C . M i n n e s o t a M u l t i p h a s i c P e r s o n a l i t y Inventory, New Y o r k : T h e P s y c h o l o g i c a l C o r p o r a t i o n , 1 951 . H e i f e r , R . T h e r e l a t i o n s h i p between l a c k of bonding and c h i l d abuse and n e g l e c t . In M . H . K l a u s , T . L e g e r , & M . A . T r a u s e , (eds) M a t e r n a l attachment and m o t h e r i n g d i s o r d e r s : A round t a b l e . J o h n s o n and J o h n s o n Baby P r o d u c t s C o : S a u s a l i t o , C a l i f o r n i a , 1975. H i g g i n s , A . C . N u t r i t i o n a l status and the o u t c o m e of p r e g n a n c y . P a p e r p r e s e n t e d at the m e e t i n g of the C a n a d i a n D i e t e t i c A s s o c i a t i o n A n n u a l C o n v e n t i o n , M o n c t o n , New B r u n s w i c k , J u n e , 1975. H o f e r , M . A . I n t r o d u c t i o n . In M . A . H o f e r ( C h a i r ) , P a r e n t - I n f a n t I n t e r a c t i o n . S y m p o s i u m on the p a r e n t - i n f a n t r e l a t i o n s h i p held at the C i b a F o u n d a t i o n , L o n d o n , E n g l a n d , N o v e m b e r , 1974. H o o k e , J . F . & M a r k s , P . A . M M P I c h a r a c t e r i s t i c s of p r e g n a n c y . J o u r n a l of C l i n i c a l P s y c h o l o g y , 1962, J_8, (3), 3 1 6 - 3 1 7 . H o o s e r , R . L . A study of the effects of p r e n a t a l health education c l a s s e s . D i s s e r t a t i o n A b s t r a c t s , 1973, 3 3 - B , 4 3 4 9 . H o r s l e y , S . P s y c h o l o g i c a l Management of the P r e n a t a l P e r i o d . In J . H o w e l l s (ed) M o d e r n p e r s p e c t i v e s i n p s y c h o - o b s t e t r i c s , E d i n b u r g h : O l i v e r and B o y d , 1972  137  J a c k s o n , E . B . S h o u l d m o t h e r and baby r o o m together? J o u r n a l of N u r s i n g , 1946, 4 6 , 1 7 - 1 9 .  American  Jacobson, L . , K a i j , L . , N i l s s o n , A . Postpartum mental d i s o r d e r s in an unselected s a m p l e : F r e q u e n c y of s y m p t o m s and p r e d i s p o s i n g f a c t o r . B r i t i s h M e d i c a l J o u r n a l , 1965, J_, 1640-1643. J a n e w a y , E . M a n ' s w o r l d w o m a n ' s p l a c e . A study i n s o c i a l m y t h o l o g y . New Y o r k : D e l l P u b l i s h i n g C o . I n c . , 1971. J a r r a h i - Z a d e h , A . , K a n e , F . J . , Van de C a s t l e , R . L . , L a c h e n b r u c h , P . A . , & E w i n g , J . A . , E m o t i o n a l and C o g n i t i v e changes in pregnancy and e a r l y p u e r p e r i u m , B r i t i s h J o u r n a l of P s y c h i a t r y , 1969, 115, 7 9 7 - 8 0 5 . J o h n s o n , J . E . Effects of a c c u r a t e expectations about s e n s a t i o n s on the s e n s o r y and d i s t r e s s components of p a i n . J o u r n a l of P e r s o n a l i t y and S o c i a l P s y c h o l o g y , 1973, _27, (2), 2 6 1 - 2 7 5 . J o h n s o n , J . E . & L e v e n t h a l , H . Effects of a c c u r a t e expectations and b e h a v i o u r a l i n s t r u c t i o n s on r e a c t i o n s d u r i n g a noxious m e d i c a l e x a m i n a t i o n . J o u r n a l of P e r s o n a l i t y and S o c i a l P s y c h o l o g y , 1974, 2 9 , (5), 7 1 0 - 7 1 8 . J o r d a n , A . D . E v a l u a t i o n of a F a m i l y C e n t r e d M a t e r n i t y C a r e P r o g r a m m e . P a r t 1: I n t r o d u c t i o n , design and t e s t i n g . J O G N N u r s i n g , 1973, 2 , (1), 1 3 - 3 5 . J o r d a n , A . D . E v a l u a t i o n of a f a m i l y c e n t r e d m a t e r n i t y c a r e p r o g r a m m e . P a r t II: A n c i l l a r y f i n d i n g s and p a r e n t s c o m m e n t s . J O G N N u r s i n g , 1973,_2, (2), 1 5 - 1 2 7 . J o r d a n , A . D . E v a l u a t i o n of a f a m i l y c e n t r e d m a t e r n i t y c a r e p r o g r a m m e . P a r t III: I m p l i c a t i o n s and r e c o m m e n d a t i o n s . JOGN N u r s i n g , 1973, 2 (3), 1 5 - 2 3 . K a i j , K . & N i l s s o n , A . E m o t i o n a l and p s y c h o t i c i l l n e s s f o l l o w i n g c h i l d b i r t h . I n j . H o w e l l s (ed.) M o d e r n 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 , E d i n b u r g h : O l i v e r and B o y d , 1972. Kane, F . J . , H a r m a n , W . J . , K e e l e r , M . H . , Ewing, J . A . Emotional and c o g n i t i v e d i s t u r b a n c e in the e a r l y p u e r p e r i u m . B r i t i s h J o u r n a l of P s y c h i a t r y , 1968, 114, 9 9 - 1 0 2 .  138  K e l l a m , S . G . , B r a n c h , J . D . , A g r a w a l , K . C . , G r a b i l l , M . E . Wpodlawn M e n t a l H e a l t h C e n t r e : A n e v o l v i n g s t r a t e g y f o r planning i n c o m m u n i t y mental h e a l t h . In S . Golann and C . E i s d o r f e r ( E d s . ) Handbook o f C o m m u n i t y M e n t a l H e a l t h , New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1972. K e l l y , D . H . , W a l t e r , C . J . The r e l a t i o n s h i p between c l i n i c a l d i a g n o s i s and a n x i e t y , a s s e s s e d by f o r e a r m blood flow and o t h e r m e a s u r e m e n t s . B r i t i s h J o u r n a l of P s y c h i a t r y , 1968, 114, 6 1 1 . K e n n e l l , J . , G o r d o n , D . & K l a u s , M . T h e effects of e a r l y m o t h e r infant s e p a r a t i o n on l a t e r m a t e r n a l p e r f o r m a n c e , c i t e d i n K l a u s , M . H . , & K e n n e l l , J . H . M o t h e r s s e p a r a t e d f r o m thei r newborn i n f a n t s . P e d i a t r i c C l i n i c s of N o r t h A m e r i c a , 1970, J_7, (4), 1015-1037. K e n n e l l , J . H . & K l a u s , M . H . C a r e of the m o t h e r of the h i g h - r i s k i n fant. C l i n i c a l O b s t e t r i c s and G y n e c o l o g y , 1971, 1_4, 9 2 6 - 9 5 4 . Kennell, J . H . , Jerauld, R . , Wolfe, H . , Chesler, D . , K r e g e r , N . C . , M c A l p i n e , W . , Steffa, M . , K l a u s , M . H . Maternal Behaviour one y e a r after e a r l y and extended p o s t - p a r t u m c o n t a c t . D e v e l o p m e n t a l M e d i c i n e and C h i l d N e u r o l o g y , 1974, J_6, 1 7 2 - 1 7 9 . Kennell, J . H . , Trause, M . A . & Klaus, M . H . Evidence for a sensitive p e r i o d i n the human m o t h e r . In M . A . H o f e r ( c h a i r ) , P a r e n t - I n f a n t I n t e r a c t i o n . S y m p o s i u m on t h e p a r e n t infant r e l a t i o n s h i p h e l d at the C i b a F o u n d a t i o n , L o n d o n , N o v e m b e r , 1974, 1975. K e s s l e r , M . A l b e e , G . W . P r i m a r y p r e v e n t i o n , i n A n n u a l R e v i e w of P s y c h o l o g y , 1975, volume 2 6 . M . R „ R o s e n w e i g , L . W . P o r t e r , ( E d s . ) A n n u a l R e v i e w s I n c . , P a l o A l t o , C a l i f o r n i a , 1975. K i s s i c k . W . L . T h e health s y s t e m . In S . G o l a n n and C . E i s d o r f e r , ( E d s . ) Handbook of C o m m u n i t y M e n t a l H e a l t h , New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1972. Klaus, M . , Jerauld, K . , K r e g e r , N . , McAlpine, W . , Steffa, M . , K e r n e l l , J . H . M a t e r n a l attachment — i m p o r t a n c e of the f i r s t p o s t p a r t u m d a y s . New E n g l a n d J o u r n a l of M e d i c i n e . 1972, 2 8 6 , 460-463.  139  Klaus, M . H . , Leger, T . , & Trause, M . A . (Eds.) Maternal Attachment and M o t h e r i n o D i s o r d e r s : A Round T a b l e . J o h n s o n and —  _ ~  Sri..—  ,  .—  J o h n s o n B a b y P r o d u c t s C o : S a u s a l i t o , C a l i f o r n i a , 1975. K l a u s , M . H . , & K e n n e l l , J . H . , M o t h e r s s e p a r a t e d f r o m t h e i r new b o r n infants. P e d i a t r i c C l i n i c s of N o r t h A m e r i c a , 1970, J_7, (4), 1015-1037. K l a u s , M . H . & K e n n e l l , J . H . P a rent-to-Infant A t t a c h m e n t , In V . C . Vaughan & T . B e r r y B r a z e l t o n ( E d s . ) T h e f a m i l y — C a n i t be s a v e d . Y e a r Book M e d i c a l P u b l i s h e r s , I n c . , 1976. Klaus, M . H . & Kennell, J . H . Parent-to-infant A d v . P e d i a t r i c (in p r e s s ) .  attachment.  Recent  K l a u s , M . H . , K e n n e l l , J . H . , P l u m b , N . , Z u e h l k e , S . Human m a t e r nal behavour at the f i r s t contact w i t h h e r y o u n g . P e d i a t r i c s , 1970, 4 6 , (2), 1 8 7 - 1 9 2 . K l e i n , H . R . , P o t t e r , H . W . , & D y k , R . B . , A n x i e t y in P r e g n a n c y and c h i l d b i r t h . New Y o r k : P a u l M . H o e b e r , 1950. K l e i n , D . C . , & S e l i g m a n , M . E . P . R e v e r s a l of p e r f o r m a n c e d e f i c i t s and p e r c e p t u a l d e f i c i t s in l e a r n e d h e l p l e s s n e s s and d e p r e s s i o n . J o u r n a l of A b n o r m a l P s y c h o l o g y , 1976, 8 5 , (1), 11-26. K l e i n , M . , & S t e r n , L . L o w b i r t h w e i g h t and the battered c h i l d s y n d r o m e . A m e r i c a n J o u r n a l of D i s e a s e s of the C h i l d , 1971, 122, 15-18. K l u s m a n , L . E . Reduction of P a i n i n c h i l d b i r t h by the a l l e v i a t i o n of a n x i e t y d u r i n g p r e g n a n c y , J o u r n a l of C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1975, 4 3 , (2), 1 6 2 - 1 6 5 . Krugman, A . D . , Ross, S . , Vincino, F . L . & Clyde, D . J . A research note: effects of d e x t r o - a m p h e t a m i n e and m e p r o b a m a t e on p r o b l e m s o l v i n g and mood of aged s u b j e c t s . J o u r n a l of G e r o n t o l o g y , 1960, J_5, (4). L a n g e r , E . J . , J a n i s , I. L . , & W o l f e r , J . A . Reducation of p s y c h o l o g i c a l s t r e s s i n s u r g i c a l p a t i e n t s . J o u r n a l of E x p e r i m e n t a l S o c i a l P s y c h o l o g y , 1975, 1_L, 1 5 5 - 1 6 5 .  140  L a p i d u s , L . B . , C o g n i t i v e c o n t r o l and r e a c t i o n s to s t r e s s : C o n d i t i o n f o r m a s t e r y in the a n t i c i p a t o r y p h a s e . P r o c e e d i n g s o f the 77th A n n u a l Convention of the A m e r i c a n P s y c h o l o g i c a l A s s o c i a t i o n , 1969.  L a p i d u s , L . B . , T h e r e l a t i o n between c o g n i t i v e c o n t r o l and r e a c t i o n s to s t r e s s . A study of m a s t e r y i n the a n t i c i p a t o r y phase of c h i l d b i r t h . D i s s e r t a t i o n A b s t r a c t s , 1969, 3 Q - B , 384. L e i d e r m a n , P . H . M o t h e r s at R i s k : A P o t e n t i a l consequence of the h o s p i t a l c a r e of the p r e m a t u r e infant. In E . J a m e s A n t h o n y and C . K o u p e r n i k ( E d s . ) T h e c h i l d in h i s f a m i l y : C h i l d r e n at p s y c h i a t r i c r i s k . V o l u m e III, L o n d o n : J o h n W i l e y and S o n s , 1974. Leiderman, P . H . , Leifer, A . D . , Seashore, M . J . Barnett, C . R . and G r o b s t e i n , R . M o t h e r - i n f a n t i n t e r a c t i o n : Effects of e a r l y d e p r i v a t i o n , p r i o r e x p e r i e n c e and sex of infant. E a r l y D e v e l o p m e n t , R e s . P u b l . A s s o c i a t i o n f o r R e s e a r c h i n N e r v o u s and M e n t a l D i s e a s e , 1973, 5 1 , 154-175. L e i d e r m a n , P . H . & S e a s h o r e , M . J . M o t h e r - i n f a n t neonatal s e p a r a t i o n : s o m e delayed c o n s e q u e n c e s . In M . A * H o f e r ( C h a i r ) , P a r e n t Infant I n t e r a c t i o n . S y m p o s i u m on the parent-infant r e l a t i o n s h i p held at the C i b a F o u n d a t i o n , L o n d o n , E n g l a n d , N o v e m b e r , 1974. Leifer, A . D . - , Leiderman, P . H . , Barnett, C . R. , W i l l i a m s , J . A . , Effects of mothei—infant s e p a r a t i o n on m a t e r n a l a t t a c h m e n t b e h a v i o r . C h i l d D e v e l o p m e n t , 1972, 4 3 , 1203-1218. L e w i n s o h n , P . M . C l i n i c a l and t h e o r e t i c a l a s p e c t s of d e p r e s s i o n . In K . S . C a l h o u n , H . E . A d a m s and K . M . M i t c h e l l , ( E d s . ) Innovative t r e a t m e n t methods in p s y c h o p a t h o l o g y . New Y o r k : W i l e y , 1973. L e w i n s o h n , P . M . A b e h a v i o u r a l a p p r o a c h to d e p r e s s i o n . In R J . F r i e d m a n and M . M . K a t z ( E d s . ) T h e p s y c h o l o g y of d e p r e s s i o n C o n t e m p o r a r y T h e o r y and R e s e a r c h . New Y o r k : J o h n W i l e y & S o n s , 1974. 0  Lewinsohn, P . M . , Biglan, A . & Z e i s s , A . M . Behavioural treatment of d e p r e s s i o n . In the b e h a v i o u r a l management of a n x i e t y , d e p r e s s i o n and p a i n . P . O . D a v i d s o n , ( E d . ) New Y o r k : B r u n n e r / M a z e l , 1976.  141  L e w i n s o h n , P . M . and G r a f , M . P l e a s a n t a c t i v i t i e s and d e p r e s s i o n . J o u r n a l of C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1973, 4 1 , (2) 261 - 2 6 8 . " L e w i n s o h n , P . M . and L i b e t , J . , P l e a s a n t E v e n t s , a c t i v i t y s c h e d u l e s and d e p r e s s i o n , J o u r n a l of A b n o r m a l P s y c h o l o g y , 1972, 7 9 , (3), 291 - 2 9 5 . Lubin, B . L . Adjective checklist f o r measurement of depression. A r c h i v e s of G e n e r a l P s y c h i a t r y , 1965, _1_2, 5 7 - 7 0 . L u b i n , B . L . , G a r d e n e r , S . H . , & R o t h , A . , M o o d and s o m a t i c s y m p t o m s d u r i n g p r e g n a n c y . P s y c h o s o m a t i c M e d i c i n e , 1975, 3 7 , (2), 136-145. L y e r l y , S . B . , R o s s , S . , K r u g m a n , A . D . & C l y d e , D . J . D r u g s and p l a c e b o s : the effects of i n s t r u c t i o n s upon p e r f o r m a n c e and m o o d • u n d e r a m p h e t a m i n e sulphate and c h l o r a l h y d r a t e . J o u r n a l of A b n o r m a l and S o c i a l P s y c h o l o g y , 1964, 6 8 , (3). M a c P h i l l a m y , D . J . , & Lewinsohn, P . M . Pleasant Events Schedule, E u g e n e : U n i v e r s i t y of O r e g o n , 1971. ( M i m e o ) . M e a r e s , R . , G r i m w a d e , J . , B i c k l e y , M . , & W o o d , C . P r e g n a n c y and N e u r o t i c i s m . T h e M e d i c a l J o u r n a l of A u s t r a l i a , 1972, J _ , 5 1 7 - 5 2 0 . M c B r y d e , A . C o m p u l s o r y r o o m i n g in i n the w a r d and p r i v a t e newborn s e r v i c e at Duke H o s p i t a l , J . A . M . A . , 1951 , 145, 6 2 5 . M c D o n a l d , R . L . T h e r o l e of e m o t i o n a l f a c t o r s i n o b s t e t r i c c o m p l i c a t i o n s : A r e v i e w . P s y c h o s o m a t i c M e d i c i n e , 1968, 3 0 , (2), 222-237. McDonald, R . L . , Gynther, M . D . , & C h r i s t a k o s , A . C . Relations between m a t e r n a l a n x i e t y and o b s t e t r i c c o m p l i c a t i o n s . P s y c h o s o m a t i c M e d i c i n e , 1963, 2 5 , (4), 3 5 7 - 3 6 3 . M c L e a n (1976)  personal communication.  M c L e a n , P . P a r e n t a l D e p r e s s i o n : Incompatible w i t h e f f e c t i v e pa r e n t i n g . In E . J . M a s h , L . C . H a n d y , & L . A . H a m e r l y n c k , ( E d s . ) B e h a v i o u r M o d i f i c a t i o n a p p r o a c h e s to p a r e n t i n g . New Y o r k : B r u n n e r M a z e l , I n c . , 1976.  142  M c L e a n , P . T h e r a p e u t i c d e c i s i o n - m a king in the b e h a v i o u r t r e a t m e n t of d e p r e s s i o n . In P . O . D a v i d s o n (ed) T h e B e h a v i o u r a l M a n a g e m e n t of A n x i e t y D e p r e s s i o n and P a i n . New Y o r k : B r u n n e r / M a z e l , I n c . , 1976. Medwar, P .  T h e a r t of the s o l u b l e .  L o n d o n : M e t h u e n , 1967.  M e i c h e n b a u m , D . & T u r k s , M . T h e c o g n i t i v e - b e h a v i o u r a l management of a n x i e t y , a n g e r and p a i n . In P . O . D a v i d s o n ( E d . ) T h e B e h a v i o u r a l Management of A n x i e t y , D e p r e s s i o n and P a i n . New Y o r k : B r u n n e r / M a z e l , I n c . , 1976. M i l l e r , W . R . Psychological deficit in depression . Psychological B u l l e t i n , 1975, 8 2 , 2 3 8 - 2 6 0 . M o r r i s o n , D . F . Multivariate Statistical Methods. C a l i f o r n i a : M c G r a w - H i l l , 1967.  San Francisco,  M o s s , H . A . S e x , age and state a s d e t e r m i n a n t s of m o t h e r infant i n t e r a c t i o n . M e r r i l l P a l m e r Q u a r t e r l y , 1967, 13, 1 9 - 2 4 . M o y e r , L . N . , Collette, J . P . & Ludtke, R . L . F a m i l y Centred Care H e l p s New P a r e n t s . T h e M o d e r n H o s p i t a l , 1966, 130-174. M u r p h y , L . B . and C h a n d l e r , C . A . B u i l d i n g Foundations f o r S t r e n g t h in the P r e s c h o o l Y e a r s : P r e v e n t i n g D e v e l o p m e n t a l D i s t u r b a n c e s . In Handbook of C o m m u n i t y M e n t a l H e a l t h , S t u a r t E . G o l a n n and C a r l E i s d o r f e r ( E d s . ) New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s , 1972. M u r r a y , H . A . Thematic Apperception Test. U n i v e r s i t y P r e s s , 1943.  Cambridge:  Harvard  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 1973 P r e v e n t i o n of M e n t a l D i s o r d e r s in P r e n a t a l and P e r i n a t a l P e r i o d s — A c t i o n G u i d e l i n e s 1 - 2 5 . N i l s s o n , A . Paranatal emotional adjustment. A prospective investigation of 165 w o m e n . 1 . A g e n e r a l account of background v a r i a b l e s , attitudes to c h i l d b i r t h and an a p p r e c i a t i o n of p s y c h i a t r i c m o r b i d i t y . A c t a P s y c h i a t r i c a S c a n d i n a v i a , 1970, 220 s u p p l e m e n t . N i l s s o n , A . & A l m g r e n , P . E . Paranatal emotional adjustment. A p r o s p e c t i v e i n v e s t i g a t i o n of 165 w o m e n . II. T h e influence of b a c k ground f a c t o r s , p s y c h i a t r i c h i s t o r y , p a r e n t a l r e l a t i o n s and p e r s o n a l i t y c h a r a c t e r i s t i c s . A c t a P s y c h i a t r i c a S c a n d i n a v i a , 1970, s u p p l e m e n t .  143  N o w l i s , V . R e s e a r c h w i t h the mood a d j e c t i v e check l i s t . In S . S . T o m k i n s , & C . E . l z a n d ( E d s . ) A f f e c t , C o g n i t i o n and P e r s o n a l i t y , New Y o r k : S p r i n g e r , 1965. N u n n a l l y , J . C , T h e study of change i n e v a l u a t i o n r e s e a r c h : P r i n c i p l e s c o n c e r n i n g m e a s u r e m e n t , e x p e r i m e n t a l d e s i g n , and a n a l y s i s . In E . L . S t r u e n i n g and M . Guttentag ( E d s . ) Handbook of E v a l u a t i o n R e s e a r c h . London: S a g e P u b l i c a t i o n s , 1975. O l i v e r , W . A . C h i l d b i r t h e x p e c t a n c i e s and e x p e r i e n c e s a s a function of l o c u s of c o n t r o l and L a m a z e t r a i n i n g . D i s s e r t a t i o n A b s t r a c t s , 1972, 3 3 , 4 B , 1802-1803. P i c h o t , P . & L e m p e r i e r e , T . A n a l y s e f a c t o r i e l l e d'un questionnaire, d ' a u t o - e v a l u a t i o n des s y m p t o m e s d e p r e s s i f s . Revue P s y c h o l o g i q u e A p p l i q u e , 1964, _14, 1 5 - 2 9 . C i t e d by J . B e c k e r D e p r e s s i o n : T h e o r y and R e s e a r c h . New Y o r k : J o h n W i l e y & S o n s . 1974. P i t t , M . A t y p i c a l depression following childbirth. P s y c h i a t r y , 1968, 1 14, 1 3 2 5 - 1 3 3 5 . Pitt, B . Maternity Blues. 431-433.  B r i t i s h J o u r n a l of  B r i t i s h J o u r n a l P s y c h i a t r y , 1973, 122,  Ratsoy, M . B . Maternity Patients make decision, N u r s e , 1974, 4 2 - 4 4 .  The Canadian  R i n g l e r , N . M . , K e n n e l l , J . H . , H a r v e l l a , R . , N a v o j o s k y , B . J . , and Klaus^ M . H . , M o t h e i — t o - c h i l d s p e e c h a t 2 y e a r s effects of e a r l y p o s t - n a t a l c o n t a c t . J o u r n a l of P e d i a t r i c s , 1975, 8 6 , 141 . Rosenthal, R . 389-406.  T h e volunteer s u b j e c t .  H u m a n R e l a t i o n s , 1965, 18,  R u n k e l , P . J . & M c G r a t h , J . E . R e s e a r c h on H u m a n B e h a v i o u r . A s y s t e m a t i c guide to m e t h o d . New Y o r k : H o l t , R i n e h a r t & W i n s t o n , I n c . , 1972. R y l e , A . T h e p s y c h o l o g i c a l d i s t u r b a n c e s a s s o c i a t e d w i t h 345 p r e g n a n c i in 137 w o m e n . J o u r n a l of M e n t a l S c i e n c e , 1961, 107, 2 7 9 .  S c h a e f e r , E . S . & M a n h e i m e r , H . D i m e n s i o n s of P e r i n a t a l a d j u s t m e n t . A p a p e r presented at the E a s t e r n P s y c h o l o g i c a l A s s o c i a t i o n M e e t i n g , New Y o r k : A p r i l 1960. S c h a e f e r , E . S . & B e l l , R . , D e v e l o p m e n t of the p a r e n t a l attitude r e s e a r c h i n s t r u m e n t . C h i l d D e v e l o p m e n t , 1958, _29, 3 3 9 - 3 6 2 . S c o t t , E . & T h o m s o n , A . M . A p s y c h o l o g i c a l i n v e s t i g a t i o n of p r i m i g r a v i d a e I V . P s y c h o l o g i c a l f a c t o r s in the c l i n i c a l phenomena of la bo r . J o u r n a l of O b s t r i c s and G y n a e c o l o g y of the B r i t i s h E m p i r e , 1956, 6 3 , 5 0 2 . S c h u l t z , D . P . T h e human subject in p s y c h o l o g i c a l r e s e a r c h . P s y c h o l o g i c a l B u l l e t i n , 1969, 7 2 , 2 1 4 - 2 1 8 . S e a g e r , C . P . A c o n t r o l l e d study of p o s t p a r t u m m e n t a l i l l n e s s . J o u r n a l of M e n t a l S c i e n c e s , 1960, 106, 2 1 5 - 2 3 0 . Seashore, M . J . , Leifer, A . D . Barnett, C . R . , Leiderman, P . H . T h e effects of d e n i a l of e a r l y m o t h e r - i n f a n t i n t e r a c t i o n on m a t e r n a l s e l f c o n f i d e n c e . J o u r n a l of P e r s o n a l i t y and S o c i a l P s y c h o l o g y , 1973, 2 6 , (3), 3 6 9 - 3 7 8 . S e l i g m a n , M . E . P . D e p r e s s i o n and l e a r n e d h e l p l e s s n e s s . In R . J . F r i e d m a n and M . M . K a t z ( e d s . ) T h e P s y c h o l o g y of D e p r e s s i o n New Y o r k : John W i l e y and S o n s , 1974. S e l i g m a n , M . E . P . , M a i e r , S . F . & S o l o m o n , R . L . In F . R . B r u s h ( E d . ) A v e r s i v e c o n d i t i o n i n g and l e a r n i n g . New Y o r k : A c a d e m i c P r e s s , 1971. S h e a , N . K l a t s k i n , E . H . & J a c k s o n , E . B . , H o m e adjustment of r o o m i n g - i n and n o n - r o o m i n g - i n m o t h e r s . A m e r i c a n J o u r n a l of N u r s i n g , 1952, _52, (1), 6 5 - 6 7 . S h e r e s h e f s k y , P . M . , Y a r r o w , L . J . P s y c h o l o g i c a l a s p e c t s of a f i r s t p r e g n a n c y and e a r l y postnatal a d a p t a t i o n . New Y o r k : R a v e n P r e s s , 1973. Sherwood, C . D . , M o r r i s , J . N . & Sherwood, S . A multivariate nonr a n d o m i z e d matching technique f o r studying the i m p a c t of s o c i a l i n t e r v e n t i o n s . IN E . L . S t r u e n i n g & M . Guttentag ( E d s . ) Handbook of E v a l u a t i o n R e s e a r c h , V o l u m e 1, L o n d o n : S a g e P u b l i c a t i o n s , 1975.  145 S h u t t l e w o r t h , M . A n i n v e s t i g a t i o n of the r e l a t i o n s h i p between c e r t a i n p s y c h o l o g i c a l f a c t o r s and c h i l d b i r t h . D i s s e r t a t i o n A b s t r a c t s , 1954, 14, 7 1 6 . S i l v e r m a n , C , T h e e p i d e m i o l o g y of d e p r e s s i o n . H o p k i n s P r e s s , 1968.  B a l t i m o r e : John  S i n g e r , J . E „ , W e s t p h a l , M . & N i s w a n d e r , K . R e l a t i o n s h i p of w e i g h t gain d u r i n g pregnancy to b i r t h w e i g h t and infant growth and d e v e l o p ment in the f i r s t y e a r of l i f e . O b s t e t r i c s and G y n e c o l o g y , 1968, 31 , 4 1 7 - 4 2 3 . S p i e l b e r g e r , C . D . , G o r s u c h , R . L . , L u c h e n e , R . E . S T A I manual f o r the s t a t e - t r a i t anxiety i n v e n t o r y . P a l o A l t o , C a l i f o r n i a : C o n s u l t i n g P s y c h o l o g i s t s P ^ e s s , 1970. S t a l l w o r t h y , J . Management of the H o s p i t a l C o n f i n e m e n t . In J . G . Howells (ed.) Modern Perspectives in P s y c h o - O b s t e t r i c s , Edinburgh: O l i v e r s B o y d , 1972. T a n z e r , D . R . T h e p s y c h o l o g y of p r e g n a n c y and c h i l d b i r t h ; A n i n v e s t i g a t i o n of n a t u r a l c h i l d b i r t h . D i s s e r t a t i o n A b s t r a c t s , 1967, 28, 6 - B , 2615. T a y l o r , J . A . A p e r s o n a l i t y s c a l e of m a n i f e s t a n x i e t y „ J o u r n a l A b n o r m a l and S o c i a l P s y c h o l o g y , 1953, 4 8 , 2 8 5 - 2 9 0 . T h o m p s o n , L . J . A t t i t u d e s of p r i m i p a r a e a s o b s e r v e d i n a p r e n a t a l c l i n i c . M e n t a l H y g i e n e , 1942, 2 6 , 2 4 3 - 2 5 6 . T i m b e r l a k e , B . T h e New L i f e C e n t e r . 1975, 7 5 , ( 9 ) , 1456-1461.  A m e r i c a n J o u r n a l of N u r s i n g ,  Todd, E . D . M . Puerperal Depression. A prospective epidemiological s t u d y , L a n c e t , 1964, 2 , 1264-1266. Webb, D . J . , Campbell, D . T . , S c h w a r t z , R . D . , Sechrest, L . U n o b t r u s i v e M e a s u r e s ; N o n r e a c t i v e r e s e a r c h i n the S o c i a l s c i e n c e s . C h i c a g o : Rand M c N a l l y , 1966. W e i s s , C . H . E v a l u a t i o n R e s e a r c h Methods of A s s e s s i n g P r o g r a m m e E f f e c t i v e n e s s . Englewood C l i f f s , N . J . : P r e n t i c e H a l l , Inc. 1972. W e h g r a f , F . P s y c h o s o m a t i c a p p r o a c h e s to gynecology and o b s t e t r i c s . S p r i n g f i e l d : C h a r l e s C . T h o m a s , 1953.  146  W i l s o n . . J . E . , B a r g l o w , P . and S h i p m a n , W . "1 he p r o g n o s i s of p o s t p a r t u m mental i l l n e s s . C o m p r e h e n s i v e P s y c h i a t r y , 1972, 13, 3 0 5 . W i n e r , B . J . S t a t i s t i c a l p r i n c i p l e s in e x p e r i m e n t a l d e s i g n . M c G r a w H i l l Book C o m p a n y , 1962.  New Y o r k :  Wooden, E . E . F a m i l y Centred Maternity C a r e , Hospital T o p i c s , 1962a, 6 9 - 7 3 . W o o d e n , H . E . T h e f a m i l y c e n t r e d a p p r o a c h to m a t e r n i t y c a r e . N u r s i n g F o r u m , 1962b, _1_, 6 1 - 7 5 . W o r l d H e a l t h O r g a n i z a t i o n . C o n s t i t u t i o n of the W o r l d Health O r g a n i z a t i o n . In Handbook of b a s i c d o c u m e n t s . New Y o r k : A u t h o r . Undated. W y n n , M . & W y n n , A . The p r o t e c t i o n of m a t e r n i t y and infancy: A study of the s e r v i c e s f o r pregnant w o m e n and young c h i l d r e n i n F i n l a n d . London: Council for C h i l d r e n ' s W e l f a r e . 1 9 7 4 . W y n n , M . & W y n n , A . N u t r i t i o n c o u n s e l l i n g i n the prevention of low b i r t h - w e i g h t . L o n d o n : Foundation f o r E d u c a t i o n and R e s e a r c h i n Childbearing, 1 9 7 5 . Y a l o m , . I . D . , Lunde, D . T . , M o o s , R . H . , Hamburg, D . A . Postpartum B l u e s s y n d r o m e . A r c h i v e s of G e n e r a l P s y c h i a t r y , 1 9 6 8 , J _ 8 , 1 6 - 2 7 . Z e m l i c k , M . J . & W a t s o n , R . I. M a t e r n a l attitudes of a c c e p t a n c e and r e j e c t i o n d u r i n g and a f t e r p r e g n a n c y . A m e r i c a n J o u r n a l of Orthopsychiatry, 1 9 5 3 , _23, 5 7 0 - 5 8 4 . Z u c k e r m a n , M . T h e development of an A f f e c t A d j e c t i v e C h e c k L i s t f o r the M e a s u r e m e n t of a n x i e t y . J o u r n a l o f C o n s u l t i n g P s y c h o l o g y , 1960,  24,  457-462.  Z u c k e r m a n , M . & L u b i n , B . , Adjective check l i s t : M a n u a l . San D i e g o , C a l i f o r n i a : E d u c a t i o n a l and I n d u s t r i a l T e s t i n g S e r v i c e , 1965.  Zuckerman, M . , Nurnberger, J . I . , Gardiner, S . H . , Vandiveer, J . M . B a r r e t t , B . H . & Den B r e e i j e n , A . P s y c h o l o g i c a l c o r r e l a t e s o f • s o m a t i c c o m p l a i n t s in p r e g n a n c y and d i f f i c u l t y i n c h i l d b i r t h . J o u r n a l of C o n s u l t i n g P s y c h o l o g y , 1963, _27, 4 , 3 2 4 - 3 2 9 .  147  Appendix A  C r i t e r i a f o r i n c l u s i o n i n the s t u d y : 1.  White,  2.  Live in Lower Mainland o r Vancouver  3.  R a i s e d i n N o r t h A m e r i c a o r the B r i t i s h C o m m o n w e a l t h  4.  M a r r i e d - legally or common-law  .5.  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.  Primiparous  7.  D e l i v e r e d of a s i n g l e infant i n one of t h r e e m a j o r V a n c o u v e r hospitals  8.  No 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 d u r i n g p r e g n a n c y , o r the p o s t p a r t u m of e i t h e r the m o t h e r o r infant.  C a u c a s i a n  delivery  148  Appendix 3 D e s c r i p t i o n of d e m o g r a p h i c c h a r a c t e r i s t i c s f o r s a m p l e of w o m e n in the p r e s e n t study A G E OF WOMEN N=106 Years  N = 94 No.  19-24  23  21  25 - 30  69  60  31 - 35  13  12 •  37  1  1  BIRTHPLACE OF WOMEN N = 94  N= 106 Country  No.  Canada  87  76  Britain  9  9  U.S.A.  5  Australia  2  European  2 Y E A R S OF EDUCATION  Yea rs  N = 106  N = 94 3  U n d e r 12 12  33  26  13  8  8  c a m e to Canada a s infants, r a i s e d i n V a n c o u v e r , B . C .  149  Years  N = 106  N = 94  14  9  6  15  8  8  16  22  21  17  19  19  18  2  2  no r e s p o n s e  1  i  1  MAJOR OCCUPATIONS O F WOMEN N = 106  N = 94  Nurses  20  18  Teachers  19  17  Secretaries  16  14  Housewives  16  15  Other  35  30  E M P L O Y E D DURING 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  8 months  20  17  9 months  7  7  16  14  1  1  not e m p l o y e d no r e s p o n s e  3  4  150  PLANNING TO RETURN TO WORK A F T E R T H E BIRTH O FT H E BABY N=106  N=94  W i t h i n two months  11  11  before s i x months  19  16  7  7  unsure  11  8  not r e t u r n i n g to w o r k  56  50  2  2  a f t e r s i x months  no r e s p o n s e  151  Appendix C Greenberg Maternity Questionnaire ~ Selected Questions 1.  A f t e r h a v i n g been i n the h o s p i t a l f o r about one w e e k , I now f e e l that m y s e l f - c o n f i d e n c e on the q u e s t i o n of c h i l d c a r e i s V e r y l a r g e (5) R a t h e r l a r g e (4) N e i t h e r l a r g e n o r s m a l l (3) R a t h e r s m a l l (2) V e r y l i t t l e (1)  2.  Do y o u think that y o u w i l l need help i n the home the f i r s t t i m e ? N o , not at a l l (5) Y e s , a l i t t l e (4) Y e s , a m o d e r a t e amount (3) Y e s , a l a r g e amount (2)  3.  W h i c h of the f o l l o w i n g i s true f o r y o u ? I have been v e r y happy i n the h o s p i t a l and I a m thus not i n s u c h a h u r r y to go home (5) I have been happy at the h o s p i t a l but I s t i l l w o u l d l i k e to go h o m e a s soon a s p o s s i b l e ( 4 ) I have not been e s p e c i a l l y unhappy i n the h o s p i t a l but I s t i l l want to go home v e r y m u c h (3) I have been unhappy i n the h o s p i t a l and want to go h o m e v e r y m u c h (2)  4.  A t t h i s t i m e how do y o u f e e l ? V e r y t i r e d (1) A l i t t l e t i r e d (2) A s u s u a l (3) Pepped up (4) F u l l o f e n e r g y (5)  5. C h e c k what i s true f o r y o u . I think that t h i s new baby i s a g r e a t a n x i o u s about h i s c a r e ( 1) I think that this new baby i s a g r e a t a n x i o u s about h i s c a r e (2) I don't think that t h i s baby i s s u c h a a m s t i l l a n x i o u s about h i s c a r e (3) I don't think that this baby i s s u c h a a m not a n x i o u s about h i s c a r e ( 4 )  r e s p o n s i b i l i t y and I a m v e r y r e s p o n s i b i l i t y but I a m not g r e a t r e s p o n s i b i l i t y but I g r e a t r e s p o n s i b i l i t y and I  152  6.  How do you feel about y o u r c o m i n g r o l e of being a m o t h e r ? I a m happy about i t and f e e l confident i n 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 a n x i o u s and u n c e r t a i n (2) I a m v e r y anxious (1)  7.  A t this t i m e how do y o u f e e l ? V e r y glad (5) G l a d (4) A s u s u a l (3) A l i t t l e sad (2) D e p r e s s e d (1)  8.  M a n y m o t h e r s don't develop a s t r o n g f e e l i n g t o w a r d s the baby r i g h t a w a y . T h i s i s c o m p l e t e l y n o r m a l . W h e n d i d y o u f i r s t get the f e e l i n g that the baby w a s a l l y o u r s ? I m m e d i a t e l y a f t e r the b i r t h (5) A f t e r the f i r s t 3 d a y s (4) A f t e r the f i r s t w e e k (3) It's c o m i n g but I d o n ' t quite have i t y e t (2)  9.  A f t e r having been in the h o s p i t a l f o r about one w e e k , I now f e e l that m y competence on the q u e s t i o n of c h i l d c a r e i s V e r y l a r g e (5) R a t h e r l a r g e (4) N e i t h e r l a r g e n o r s m a l l (3) R a t h e r s m a l l (2) V e r y l i t t l e (1)  10.  How long do y o u think that it w i l l take y o u to know y o u r infant; the r e a s o n f o r w h i c h he c r i e s e t c . I know h i m a l r e a d y (6) T h r e e days (5) One week (4) Two w e e k s (3) One month(2) M o r e than one month (1)  11.  How much do y o u think that the baby w i l l r e s t r i c t y o u r u s u a l activities? Not at a l l (5) M o d e r a t e l y (2) A l i t t l e (4) G r e a t l y (1) S o m e w h a t (3)  153  12.  How did you feel a f t e r ' t h e d e l i v e r y ? V e r y t i r e d (1) A l i t t l e , t i r e d (2) A s usual (3) Pepped up (4) F u l l of energy (5)  13.  How much help d i d y o u r e c e i v e f r o m the n u r s i n g A l i t t l e (1) R a t h e r much (2) M u c h (3) A g r e a t deal (4)  14.  How did y o u feel i m m e d i a t e l y a f t e r the d e l i v e r y ? V e r y glad (5) G l a d (4) A s u s u a l (3) A l i t t l e sad (2) D e p r e s s e d (1)  15.  personnel?  D i d you f e e l that the help that y o u r e c e i v e d f r o m the h o s p i t a l p e r s o n n e l was M o r e than enough (5) A b o u t right (3) Not enough (1)  154  Appendix D Greenberg's Follow-up — Selected Questions 1. A f t e r having been at home f o r about 1 w e e k , I now f e e l that m y s e l f confidence i n the q u e s t i o n of c h i l d c a r e i s V e r y l a r g e (5) R a t h e r l a r g e (4) N e i t h e r l a r g e n o r s m a l l (3) R a t h e r s m a l l (2) V e r y l i t t l e (1) 2.  3.  4.  D i d y o u feel that y o u r adjustment f r o m the h o s p i t a l to the h o m e w a s V e r y easy (5) E a s y (4) N e i t h e r d i f f i c u l t n o r e a s y (3) D i f f i c u l t (2) V e r y d i f f i c u l t (1) How m u c h e x p e r i e n c e d i d y o u f e e l that y o u r e c e i v e d w h i l e i n the h o s p i t a l ( E x p e r i e n c e i n how to take c a r e of a baby) V e r y l a r g e (5) R a t h e r l a r g e (4) N e i t h e r l a r g e n o r s m a l l (3) R a t h e r s m a l l (2) V e r y l i t t l e (1) I f e l t that the m a t e r n i t y h o s p i t a l helped me V e r y much (5) R a t h e r much (4) N e i t h e r l i t t l e n o r m u c h - to be p r e p a r e d f o r m y r o l e R a t h e r l i t t l e (2) of being a m o t h e r V e r y l i t t l e (1)  5. How long do you think i t w i l l take f o r y o u to know y o u r infant the r e a s o n f o r w h i c h he c r i e s , e t c . I know h i m a l r e a d y (5) T w o w e e k s m o r e (4) One month m o r e (3) T h r e e months m o r e (2) M o r e than three months (1)  155  6.  When I f i r s t c a m e home f r o m the m a t e r n i t y h o s p i t a l I f e l t V e r y c e r t a i n (5) R a t h e r c e r t a i n (4) N e i t h e r c e r t a i n n o r u n c e r t a i n (3) - about the q u e s t i o n of R a t h e r u n c e r t a i n (2) how one s h o u l d take c a r e V e r y u n c e r t a i n (1) of a newborn baby  7« How m u c h help d i d you need when y o u f i r s t a r r i v e d home f r o m the hospital? None (5) A l i t t l e (4) A m o d e r a t e mount (3) A l a r g e amount (2)  Appendix  E  M e a n s and S t a n d a r d D e v i a t i o n s f o r the D e m o g r a p h i c Data of W o m e n who D e l i v e r e d T h e i r B a b i e s in the T h r e e M a j o r H o s p i t a l s in V a n c o u v e r , B r i t i s h C o l u m b i a  Hospital A N=2S  Hospital B N=34*  Hospital C N=45  Mean  SD  Mean  SD  Mean  SD  Age  27.35  3.60  26.88  3.45  26.93  2.90  N u m b e r of Y e a r s of Education — Wife  14.62  1 .81  14.62  2.13  14.33  2.24  A n n u a l Income of W i f e N u m b e r of Y e a r s of E d u c a t i o n — Husband A n n u a l Income of Husband  $5,808 15.69  $13,827  $2,522  $6,147  $2,159  $6,378  $1,946  3.16  15.44  3.16  14.88  2.99  $5,600  $13,706  $4,488  $13,100  $4,609  *The p r e n a t a l data f r o m one w o m a n in this group w e r e l o s t in the m a i l and not r e c o v e r e d .  Appendix  F  M e a n s and S t a n d a r d D e v i a t i o n s of the M e a s u r e s C o l l e c t e d • i n the Ninth Month of P r e g n a n c y f o r the W o m e n Who D e l i v e r e d T h e i r B a b i e s in the T h r e e M a j o r H o s p i t a l s in V a n c o u v e r , B r i t i s h C o l u m b i a  Hospital A N=26  Hospital B N = 34*  Hospital C N=45  Mean  SD  Mean  SD  Mean  SD  165.27  20.49  163.88  15.19  158.98  38.48  5.65  2.90  6.41  3.67  5.84  3.78  DACL  47.50  7.55  47.12  6.67  46.93  6.88  Pleasant Events Schedule  70.88  13.30  67.09  21 .95  67.56  18.87  A t t i t u d e to P r e g n a n c y B e c k D e p r e s s i o n Index  *The p r e n a t a l data f r o m one w o m a n in this group were l o s t i n the m a i l and not r e c o v e r e d .  159  Appendix H  1.  2.  LENGTH OF  GESTATION  N=106  N=94  O v e r 40 w e e k s  38  34  40 w e e k s  30  27  38 - 39 w e e k s  26  24  36 - 37 w e e k s  6  4  l e s s than 36 w e e k s  2  2  no response  4  3  LENGTH OF LABOUR  4.  N=94  Under 5 hours  18  15  5 - 8 hours  25  21  9 - 19  36  34  o v e r 20 h o u r s  23  20  4  4  no r e s p o n s e 3.  N=106  METHOD OF DELIVERY  N=1Q6  N=94  Caesarian  21  21  Vaginal  85  73  ANASTHETIC Spinal  N=106  N=94  7  6  Epidural  63  56  Perineal Block  11  11  160  N=106 Nitrous Oxide Other 5.  6.  7.  S E X OF INFANT  N=94  17  14  8  7  N=106  N=94  Female  49  48  Male  57  46  BIRTHWEIGHT O F INFANT  N=106  N=94  Over 3,600 grammes  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  Over 2,700  14  12  Over 2,475  5  4  METHOD O F FEEDING  N=106  N=94  Breastfeeding  91  80  B o t t l e feeding  11  10  Both  4  4  161  Appendix I M e a n s and s t a n d a r d d e v i a t i o n s f o r the d e m o g r a p h i c data  F a m i l y centred maternity p r o g r a m m e N=20  Traditional Programme N=52 *  Mean  SD  Mean  SD  Age  27.40  3.07  26.79  3.36  Number of Y e a r s Education — Wife  14.40  1 .76  14.40  2.26  A n n u a l Income of W i f e  $5,950  $2,559  $6,105  $2,197  N u m b e r of y e a r s E d u c a t i o n — Husband  15.60  3.32  1 5 . 10  3.02  $6,149  $12,606  $4,793  A n n u a l Income of Husband  $13,550  * T h e p r e n a t a l data f r o m one w o m a n i n this group w e r e l o s t i n the m a i l and not r e c o v e r e d  162  Appendix J M e a n s and s t a n d a r d d e v i a t i o n s of the m e a s u r e s c o l l e c t e d i n the ninth month of p r e g n a n c y  F a m i l y Centred Maternity P r o g r a m m e N=20  Traditional Programme N = 52*  Mean  SD  Mean  SD  166.05  19.19  165.25  15.24  5.55  2.54  5.92  3.00  DACL  47.05  7.06  46.29  6.30  Pleasant Events Schedule  71 . 3 0  13.75  69.63  20.07  A t t i t u d e to P r e g n a n c y • B e c k D e p r e s s i o n Index  * T h e p r e n a t a l data f r o m one w o m a n i n this group w e r e l o s t i n the m a i l and not r e c o v e r e d  163  Appendix K M e a n s and s t a n d a r d d e v i a t i o n of r e s p o n s e s to G r e e n b e r g ' s q u e s t i o n n a i r e F a m i l y Centred Maternity Care Programme N=20 Mean SD  Mean  S e l f Confidence regarding childcare  3.40  .60  3.26  .84  P e r c e p t i o n of help needed at home  3.90  .79  3.66  .85  Happiness in Hospital  4.05  .76  4.01  .60  Present energy level  2.15  1 .04  2.19  .86  A b s e n c e of a n x i e t y r e g a r d i n g r e s p o n s i b i l i t y of baby  1 .40  .50  1 .45  .54  Confidence r e g a r d i n g the r o l e of motherhood  4.30  .80  4.47  .80  P r e s e n t f e e l i n g s of g l a d n e s s versus depression  4.25  .85  4.28  .95  M a t e r n a l f e e l i n g to baby  3.75  1 .29  4.25  1 .02  C o m p e t e n c e r e g a r d i n g c h i l d c a re 3.45  .76  3.28  .72  1.80  1 .06  2.15  1 .18  L a c k of r e s t r i c t i o n in usual activities  2.35  1 .09  2.83  1 .01  Energy level after d e l i v e r y  2.30  1 .42  2.79  1 .60  A m o u n t of help f r o m nursing personnel  2.55  .76  2.36  .83  F e e l i n g s of gladness v e r s u s depression after d e l i v e r y  4.55  .83  4.81  .62  A m o u n t of help r e c e i v e d from hospital personnel  3.30  1.17  3.08  .78  I m m e d i a c y of understanding b a b y ' s needs  Traditional Programme N=53 SD  \6h  Appendix L M e a n s and standard deviations of the m e a s u r e s c o m p l e t e d after five w e e k s at home  F a m i l y Centred Maternity Care Programme N=20  Traditional Programme N=53  Mean  SD  Mean  SD  176.30  16.33  182.17  13.87  A r e a s of C o n c e r n  8.20  4.77  6.06  6.02  B e c k D e p r e s s i o n Index  5.05  3.99  4.72  3.47  DACL  46.35  6.60  45.79  10.77  Pleasant Events Schedule  59.60  18.74  62.09  20.88  A t t i t u d e to B a b y  165  Appendix  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 the d e m o g r a p h i c  Vaginal  Caesarian  Deliveries  Section  N=72*  Age N u m b e r of Y e a r s Education —  Number  of  N=21  Mean  S D  Mean  S D  26.96  3.26  27.62  3.63  14.40  2.12  14.81  $6,063  $2,286  $6,405  $1,729  15.24  3.09  15.81  3.17  $12,868  $5,177  $14,595  of  Wife  Annual Income  data  of  Wife  2.11  Years  Education —  Husband  Annual Income  of Husband  The prenatal m a i l a n d not  data f r o m one w o m a n recovered  in this group w e r e l o s t in  $3,826  the  166  Appendix N M e a n s and s t a n d a r d d e v i a t i o n s of the m e a s u r e s c o l l e c t e d i n the ninth month of p r e g n a n c y  Vaginal Delivery N=72* Mean A t t i t u d e to P r e g n a n c y  Caesa rian Section N=21 SD  Mean  SD  165.47  16.30  158.10  5.82  2.87  5.90  4.21  DACL  46.50  6.48  49.62  7.39  Pleasant Events Schedule  70.10  18.45  63.76  15.68  B e c k D e p r e s s i o n Index  40.15  * T h e p r e n a t a l data f r o m one w o m a n i n this group w e r e l o s t i n the m a i l and not r e c o v e r e d  167  Appendix O M e a n s and standard deviations of the measures c o m p l e t e d after one wee!-; at home  vaginal Delivery N=73 Mean A t t i t u d e to B a b y  161.22  Caesjj r i a n Section N=21 SD 18.30  Mean  SD  150.38  39.12  A r e a s of C o n c e r n  9.38  7,38  7.38  6.18  Self-confidence re: childcare  3.48  .80  3.10  1 .30  E a s e of adjustment f r o m hospital  3.19  1.05  2.86  1 .42  Experience received in Hospital  2.85  1 .00  2.62  1 .47  P r e p a r a t i o n f o r r o l e of Mothering  3.16  1.09  2.81  1 .60  Length of t i m e to understand infant  3.71  1.10  Certainty regarding childbirth  3.05  A m o u n t of help needed DACL  3.43  1 .57  .96  2.90  1 .48  3.21  .73  2.71  1.15  48.55  7.41  46.62  12.85  168  Appendix P M e a n s and s t a n d a r d deviations f o r the m e a s u r e s c o m p l e t e d after five weeks at home  Vaginal Delivery N=73  Caesarian Section N=21  Mean  SD  Mean  SD  180.56  14.70  174.62  14.05  A r e a s of C o n c e r n  6.64  5.76  6.76  6.39  B e c k D e p r e s s i o n Index  4.81  3.59  5.43  3.26  DACL  45.95  9.77  49.05  6.87  Pleasant Events Schedule  61.41  20.22  59.43  17.92  A t t i t u d e to B a b y  163  Key f o r A p p e n d i x Q 25 A i d when 23 Know 10 R o o m 17 Infant 20 A d j u s t 24 C e r t 22 H e l p 19 C o n f i 21 E x p e r  H e l p needed at home I m m e d i a c y of understanding infant N o . of days r o o m i n g - i n attitude towards baby ease of adjustment f r o m h o s p i t a l c e r t a i n t y r e g a r d i n g c a r e of n e w b o r n help r e c e i v e d f r o m h o s p i t a l s e l f confidence r e g a r d i n g c h i l d c a r e e x p e r i e n c e r e c e i v e d in h o s p i t a l  18 7 4 13 3 1 2  no, of p r o b l e m s i n h o s p i t a l S e x of infant Income of husband no. of p r o b l e m s at home education of husband A g e of w i f e education of wife  Cone Sex Incoh Concern Educh Age EducW  15  V12 8 WGT  16 14 9 6  V14 DACLC Feed Lab  12 l a b d e l 11 A t t p r e g 5 Dayspp  e n e r g y l e v e l in h o s p i t a l w e i g h t of infant f e e l i n g s of gladness D A C L in h o s p i t a l bottle feeding length of l a b o u r attitude towards l a b o u r and d e l i v e r y attitude towards pregnancy n u m b e r of days in h o s p i t a l  170  Appendix Q F'actor A n a l y s i s of Data F a c t o r s and f a c t o r loading of s e l e c t e d v a r i a b l e s N = 93 Variable  Factor 1  4  25 A i d w h e n  -0.4386  0.2733  -0.0769  0.1358  23  Know  -0.4437  -0.0031  0.0159  -0.0523  10  Room  -0,4644  -0.1918  -0.2123  -0.0581  17  Infant  -0.5935  0.2055  0.1284  0.2353  20 A d j u s t  -0.6151  0.2215  0.1624  0.0241  24  -0.6513  0.0740  -0.0900  0.1622  22 Help  -0.6731  -0.2547  0.2708  -0.1815  19  Confi  -0.6968  0.2116  0.0701  0.1124  21  Exper  -0.7191  -0.3158  0.1752  -0.1250  0.1618  -0.2639  -0.1332  0.0641  0.1698  -0.2851  0.2198  0.0473  -0.0767  - 0 . 3 060  -0.1528  -0.0862  0.1403  -0.4177  -0.0408  0.1649  -0.0048  -0.4199  0.1937  -0.1265  -0.0907  -0.4907  -0.0790  -0.1560  0.0426  -0.5722  -0.0291  -0.0214  0.1099  0.0266  0.5293  0.1327  -0.0869  -0.0530  0.4323  0.0541  Cert  18 Cone 7  Se&  4  Incoh  13 3  Concern Educh  1 Age 2  EducW  15 V I 2 8 WGT  17)  16 V I 4  0.0143  0.1347  0.4125  0.1673  14  DACLC  0.2395  -0.1047  -0.3296  -0.1252  9  Feed  0.2143  0.0369  -0.3671  0.0310  6  Lab  -0.0603  -0.3481  -0.4717  0.3483  12  labdel  -0.0827  -0.0978  0.1675  0.8169  11  Attpreg  •-0.0952  0.1702  0.1319  0 . 1985  -0.0036  -0.2447  -0.2081  5  Dayspp  -0.3745  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0093925/manifest

Comment

Related Items