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The effects of a nursing intervention on maternal perception of the infant and postpartum adjustment Davidson, Sheena Mary 1978

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THE EFFECTS OF A NURSING INTERVENTION ON MATERNAL PERCEPTION OF THE INFANT AND POSTPARTUM ADJUSTMENT SHEENA MARY DAVIDSON B.Sc.N., Queen's U n i v e r s i t y , K i n g s t o n , Ont., 1960 B.A., Queen's U n i v e r s i t y , K i n g s t o n , Ont., 1961 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING THE FACULTY OF GRADUATE STUDIES School o f Nursing We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA November, 1977 /T\ Sheena Mary Davidson, 1977 by i n In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of Brit ish Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of r.rarlnatP S t i i H I g q . gr»hrv>1 o f N u r s i n g The University of Brit ish Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date November 28 , 1977 i i ABSTRACT The purpose o f t h i s study was to i n v e s t i g a t e the e f f e c t o f a n u r s i n g i n t e r v e n t i o n on the mother's postpartum adjustment and p e r c e p t i o n of her i n f a n t . The i n t e r v e n t i o n was designed to g i v e i n f o r m a t i o n about i n f a n t behaviour p a t t e r n s ; and t o a s s i s t the mother i n i d e n t i f y i n g the b e h a v i o u r a l responses and r e f l e x behaviours c h a r a c t e r i s t i c o f her i n f a n t . A q u a s i - e x p e r i m e n t a l d e s i g n was u t i l i z e d w i t h random assignment o f the t w e n t y - f i v e married p r i m i p a r o u s p a r t i c i p a n t s t o e i t h e r an experimental or a c o n t r o l group. The s u b j e c t s i n the experimental group took p a r t i n the n u r s i n g i n t e r v e n t i o n approximately twelve days f o l l o w i n g t h e i r i n f a n t s ' b i r t h s ; the f a t h e r s o f the i n f a n t s were a l s o present d u r i n g the i n t e r -v e n t i o n . A l l p a r t i c i p a n t s completed the Neonatal P e r c e p t i o n Inventory and the P o s t n a t a l Research Inventory one month p o s t -partum. Data were a l s o obtained from the mothers' h o s p i t a l r e c o r d s . S t a t i s t i c a l a n a l y s i s comparing the scores f o r the two groups i n d i c a t e d t h a t experimental group mothers had a more p o s i t i v e p e r c e p t i o n o f t h e i r i n f a n t s . In a d d i t i o n , they r e p o r t e d l e s s d e p r e s s i o n and i r r i t a b i l i t y and fewer n e g a t i v e f e e l i n g s towards c a r i n g f o r t h e i r b a b i e s . There were no d i f f e r e n c e s between experimental and c o n t r o l group mothers on seven o t h e r s c a l e s o f maternal adjustment. C o r r e l a t i o n s between the p e r c e p t i o n s c a l e and maternal adjustment i n v e n t o r y a c r o s s a l l s u b j e c t s showed t h a t p o s i t i v e p e r c e p t i o n o f the i i i i n f a n t was a s s o c i a t e d w i t h low s c o r e s on s c a l e s o f d e p r e s s i o n , i r r i t a b i l i t y , f e a r or concern f o r the baby, and the mother's need f o r reassurance. These f i n d i n g s were d i s c u s s e d i n r e l a t i o n t o t h e i r i m p l i c a t i o n s f o r c l i n i c a l p r a c t i c e . Suggestions f o r f u r t h e r r e s e a r c h i n t o other v a r i a b l e s t h a t may be i n f l u e n t i a l i n the postpartum p e r i o d were a l s o o u t l i n e d . i v TABLE OF CONTENTS Page LIST OF TABLES v i ACKNOWLEDGEMENTS v i i Chapter I INTRODUCTION 1 Background and Statement o f the Problem 1 Statement o f the Purpose 5 D e f i n i t i o n o f Terms 6 Assumptions 7 Hypotheses 7 M u l t i d i s c i p l i n a r y Approach t o the Problem 8 Overview o f the Study 9 II LITERATURE REVIEW 10 I n t r o d u c t i o n • • • 10 T r a n s i t i o n t o the Maternal Role • 11 Development of the Mother-Infant R e l a t i o n s h i p .... 14 P e r c e p t i o n o f the I n f a n t 17 Summary 23 I I I RESEARCH DESIGN 25 Overview • • • • 25 Independent V a r i a b l e 25 Dependent V a r i a b l e s 27 Neonatal P e r c e p t i o n Inventory 28 P o s t n a t a l Research Inventory 28 / I n t e r v e n i n g V a r i a b l e s • • 29 S e t t i n g 29 P a r t i c i p a n t s • 30 C r i t e r i a f o r S e l e c t i o n 30 Recruitment 31 Procedure f o r C o l l e c t i o n of Data 33 S t a t i s t i c a l A n a l y s i s 35 L i m i t a t i o n s 35 IV FINDINGS AND DISCUSSION 38 D e s c r i p t i o n o f the Sample 38 F i n d i n g s R e l a t i n g t o Hypothesis I 43 F i n d i n g s R e l a t i n g t o Hypothesis I I 45 F i n d i n g s R e l a t i n g t o Hypothesis I I I 47 Summary 50 V Chapter Page V IMPLICATIONS FOR NURSING PRACTICE AND RESEARCH 52 I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e 52 I m p l i c a t i o n s f o r Research 59 SELECTED BIBLIOGRAPHY 63 APPENDIXES A. INFORMATION INCLUDED IN THE NURSING INTERVENTION ... 67 B. BROUSSARD NEONATAL PERCEPTION INVENTORY 77 C. SCHAEFER AND MANHEIMER1S POSTNATAL RESEARCH INVENTORY AND SCORE SHEET 80 D. INFORMATION SHEET 87 E. INFORMED CONSENT FORM 89 v i LIST OF TABLES Tabl e Page 1 B i r t h I n formation f o r F i r s t 32 V o l u n t e e r s 32 2 Mother's Age ( i n years) 38 3 Mother's Educ a t i o n ( i n years) ..................... 39 4 Mother' s E t h n i c Background 39 5 D u r a t i o n o f Labour (hours) 40 6 A n a l g e s i a D u r i n g Labour (number o f women r e c e i v i n g ) 40 7 Anae t h e s i a During D e l i v e r y (number o f women r e c e i v i n g ) 41 8 Use o f Forceps During D e l i v e r y 42 9 Means. Standard D e v i a t i o n s and R e s u l t s o f " t - T e s t s Comparing Average Baby (A) and Your Baby (Y) Scores on the Neonatal P e r c e p t i o n Inventory 43 10 Means, Standard D e v i a t i o n s , and R e s u l t s o f t - T e s t s Between Experimental (E) and C o n t r o l (C) Groups on P o s t n a t a l Research Inventory 46 11 C o r r e l a t i o n C o e f f i c i e n t s Between Neonatal P e r c e p t i o n Inventory and P o s t n a t a l Research Inventory . 49 v i i ACKNOWLEDGEMENTS I have been very f o r t u n a t e t o have the continued support, encouragement and a s s i s t a n c e o f many people w h i l e conducting t h i s study. I would e s p e c i a l l y l i k e t o thank the f o l l o w i n g : My a d v i s o r s . E l a i n e C a r t y and Helen Shore, who shared suggestions and v a l u a b l e c r i t i c i s m which allowed me t o b e g i n and t o f o l l o w through w i t h t h i s p r o j e c t . A mere "thank you" seems r e a l l y inadequate. The women who so w i l l i n g l y took p a r t i n t h i s i n v e s t i g a t i o n ; the p a r t i c i p a t i n g h o s p i t a l , and i n p a r t i c u l a r , L i l a Morrow and the n u r s i n g s t a f f o f 6 South, S t . P a u l ' s H o s p i t a l , whose a s -s i s t a n c e was i n v a l u a b l e to t h e s u c c e s s f u l outcome o f t h i s i n -v e s t i g a t i o n ; Susan P a i n t e r f o r her humour and warmth as we grew i n our knowledge o f c l i n i c a l r e s e a r c h ; Karen Brown f o r the t y p i n g o f t h i s t h e s i s and her v a l u a b l e e d i t o r i a l comments. F i n a l l y , my f a m i l y and, i n p a r t i c u l a r , my f a t h e r - i n - l a w , O l o f Davidson. Without t h e i r continued l o v e , understanding, and i n t e r e s t t h i s p r o j e c t c o u l d not have been completed. CHAPTER I INTRODUCTION Background and Statement o f the Problem T h i s study was conducted because o f the i n v e s t i g a t o r ' s b e l i e f t h a t the postpartum p e r i o d i s o f c o n s i d e r a b l e importance f o r the development of t h e r e l a t i o n s h i p between mother and i n f a n t . Over the l a s t few y e a r s a v a r i e t y o f new programs and s e r v i c e s have been developed t o t r a n s f e r i n f o r m a t i o n t o couples about s k i l l s i n v o l v e d i n the new r o l e s they assume w i t h p a r e n t -hood. On c l o s e i n s p e c t i o n i t i s apparent t h a t these programs g e n e r a l l y f ocus on the p h y s i c a l c a r e t a k i n g a s p e c t s o f p a r e n t i n g . For example* t o p i c s covered i n c l u d e such s u b j e c t s as b a t h i n g , f e e d i n g , and changing - based on the model o f the "average baby." What appears t o be l a c k i n g , i n t h i s i n v e s t i g a t o r ' s o p i n i o n , i s any e x p l a n a t i o n t o the pa r e n t s o f t h e i r i n f a n t ' s unique responses t o h i s / h e r environment and the people i n i t . T h i s would s e n s i t i z e p a r e n t s t o the need t o "tune i n " and respond t o the behaviours o f t h e i r i n f a n t . The way the mother r e l a t e s t o her i n f a n t w i l l be m o d i f i e d by her p e r c e p t i o n o f her i n f a n t ' s behaviour (Broussard and Hartner, 1971). I n d i v i d u a l i z e d assessment o f the i n f a n t should a s s i s t her 1 2 to a c c u r a t e l y p e r c e i v e her i n f a n t ' s needs. A c c u r a t e and s e n s i t i v e ( i . e . "tuned i n " ) p e r c e p t i o n w i l l i n c r e a s e her a b i l i t y t o c a r e f o r t h e c h i l d i n response t o h i s / h e r behaviours -whatever they may be. I f t h e mother i s a b l e t o do t h i s , the baby i n r e t u r n should appear r e c e p t i v e to her c a r e . Thus her f e e l i n g o f accomplishment i n her new r o l e should be enhanced. A d a p t a t i o n t o the maternal r o l e i s not accomplished i n a few hours o r days (Rubin, 1961; Kennedy, 1969). Evidence of t h i s l i e s i n the k i n d s o f q u e s t i o n s mothers have asked the i n v e s t i g a t o r as l a t e as one month postpartum, "Is i t normal f o r the baby t o be awake so much?", "How do I t e l l what the baby's c r y means?", and "Am I doing the r i g h t t h i n g s f o r my baby?" Present day women need help w i t h answers t o th e s e k i n d s o f q u e s t i o n s , p a r t l y because o f changes i n contemporary Western s o c i e t i e s . These changes a r e r e f l e c t e d i n c h i l d -r e a r i n g p r a c t i c e s , and more s p e c i f i c a l l y i n a d a p t a t i o n t o the maternal r o l e . There a r e a t l e a s t four major i n f l u e n c i n g f a c t o r s t h a t a re o f importance t o note here. F i r s t , most of today's p r o s p e c t i v e mothers have been r a i s e d i n r e l a t i v e l y s m a l l , i s o l a t e d two-generation n u c l e a r f a m i l i e s . The n u c l e a r f a m i l y p r o v i d e s l i t t l e o p p o r t u n i t y t o observe or p r a c t i c e mothering r o l e s . Adams (1962) found t h a t o n l y 25 perc e n t o f the pr i m i p a r o u s women i n her study had p r e v i o u s l y cared f o r i n f a n t s under t h r e e months o f age. I t i s o f t e n d i f f i c u l t f o r these mothers t o meet the needs o f t h e i r i n f a n t s , s i n c e most a r e unaware o f the range and d i v e r s i t y 3 o f behaviours t h a t can be expected o f a newborn i n f a n t . Second, the modern f a m i l y i s ve r y mobile. Couples may enter parenthood g e o g r a p h i c a l l y separated from f a m i l y and f r i e n d s . Consequently t h e r e may be a r e d u c t i o n i n a v a i l a b l e s o c i a l networks f o r support d u r i n g the t r a n s i t i o n t o the maternal r o l e . Abernathy (1973) found t h a t a l a c k o f a s s i s t a n c e and feedback from f r i e n d s and r e l a t i v e s , c o n cerning t h e maternal r o l e , r e s u l t e d i n a lowered l e v e l o f maternal c o n f i d e n c e . T h i r d , t he women's l i b e r a t i o n movement has i n f l u e n c e d the a t t i t u d e s o f both men and women towards f a m i l y l i f e . For example, th e r e has been a broadening o f the c u l t u r a l l y approved r o l e behaviours f o r women (Keane, 1970). Women who l e a v e home to e n t e r the marketplace spend i n c r e a s i n g p r o p o r t i o n s o f t h e i r time l e a r n i n g s k i l l s a p p r o p r i a t e t o t h e i r c a r e e r s , r e d u c i n g the time and m o t i v a t i o n e s s e n t i a l f o r d e v e l o p i n g s k i l l s appro-p r i a t e t o maternal r o l e s . C l a r k (1966) r e p o r t s t h a t "an u n b e l i e v a b l e number o f young mothers f a c e motherhood w i t h inadequate s k i l l s and s e l f - c o n f i d e n c e . " F i n a l l y , most women have r o m a n t i c i z e d t h e mothering r o l e (Cronenwett, 1976) and t h e r e f o r e a r e not a t a l l prepared f o r the r e a l i t y o f what i s i n v o l v e d i n meeting the needs o f an i n f a n t . O p p o r t u n i t i e s f o r p r e p a r a t i o n f o r parenthood a r e as sca r c e i n our s o c i e t y o u t s i d e the f a m i l y s t r u c t u r e as the y are w i t h i n . R o s s i (1968) notes the l a c k o f r e s o u r c e s a v a i l a b l e w i t h i n the e d u c a t i o n a l system f o r l e a r n i n g t o d e a l w i t h t h e t r a n s i t i o n t o p a r e n t a l r o l e s . Furthermore, most of the 4 e d u c a t i o n w i t h i n the h e a l t h d e l i v e r y system i s o r i e n t e d t o prepare the mother f o r pregnancy and c h i l d b i r t h , not f o r c h i l d -r e a r i n g . Consequently, many women enter parenthood w i t h an i n t e l l e c t u a l awareness o f the p h y s i c a l changes i n pregnancy, the p h y s i o l o g y o f l a b o u r , and the b i r t h p r o c e s s . However, they may l a c k e x p e r i e n c e i n t r a n s l a t i n g these c o g n i t i v e f a c t s i n t o a c t u a l behaviours i n v o l v e d i n the maternal r o l e . As w e l l as having l i t t l e e xperience w i t h - or knowledge about - behaviours n e c e s s a r y f o r i n f a n t c a r e , and few supports t o help her, the mother may a l s o l a c k a c l e a r i d e a o f the nature o f the r o l e t h a t she i s attempting to f i l l . U n c e r t a i n t y about the mothering r o l e has s e v e r a l r o o t s * The mother h e r s e l f may be v e r y young and s t i l l i n the p r o c e s s o f educating h e r s e l f . She may r e j e c t the model o f c h i l d r e a r i n g which was adopted by her p a r e n t s or may be p u z z l e d because the model o f her p a r e n t s d i f f e r s from the p a t t e r n adopted by her husband's p a r e n t s . I f the mother r e j e c t s the models t h a t she and her husband were r a i s e d w i t h , she must s t a r t t o d e f i n e motherhood i n a way which i s comfortable and meaningful f o r her. F i n d i n g a s u i t a b l e p a t t e r n w i l l l i k e l y be a d i f f i c u l t task (Walker, 1974). With the t r a d i t i o n a l f a m i l y and s o c i a l supports m i s s i n g d u r i n g the " c r i s i s o f parenthood" (Lemasters, 1965), nurses are attempting t o help mothers i n t h e i r a d a p t a t i o n to the maternal r o l e . C u r r e n t l y , nurses a r e w e l l accepted as p r o v i d e r s o f p r e n a t a l and w e l l - c h i l d c a r e ( E l f e r t , 1975). Nursing care 5 i n h o s p i t a l f o l l o w i n g the baby's b i r t h has t o focus on the immediate p h y s i c a l and emotional needs o f the f a m i l y . T h i s i n c l u d e s not o n l y s u p p l y i n g p h y s i c a l c a r e f o r the mother and i n f a n t but a l s o a s s i s t i n g and g u i d i n g the mother i n t h e t a k i n g on o f i n f a n t c a r e t a s k s ; i n b e g i n n i n g to r e s o l v e the experiences of l a b o u r and b i r t h ; and i n the i n i t i a l r e c o g n i t i o n o f the i n f a n t as a separate i n d i v i d u a l (Cronenwett, 1976). S k i l l e d s e n s i t i v e c a r e can meet the immediate needs o f the f a m i l y a t t h i s time; however, Rubin's (1961) d e s c r i p t i o n o f mothers' behaviours d u r i n g the two weeks f o l l o w i n g b i r t h demonstrates t h a t t h e t a k i n g on of the maternal r o l e has not been f u l l y accomplished by the time o f h o s p i t a l d i s c h a r g e . F u r t h e r needs; w i l l occur d u r i n g the next weeks as the mother d e a l s w i t h the d u a l p r o c e s s o f d e v e l o p i n g s k i l l i n the t a s k s i n v o l v e d i n mothering and i n l e a r n i n g what her i n f a n t i s r e a l l y l i k e . Statement o f the Purpose T h i s i n v e s t i g a t o r developed a n u r s i n g i n t e r v e n t i o n t o demonstrate t o b o t h p a r e n t s the b e h a v i o u r a l responses o f t h e i r own i n f a n t and t o e x p l a i n t o them o t h e r a s p e c t s o f i n f a n t b e h a v i o u r s t h a t have been r e p o r t e d i n the l i t e r a t u r e t o be o f concern t o p a r e n t s . The purpose of t h i s study was t o e v a l u a t e the e f f e c t o f t h i s i n t e r v e n t i o n on the mother's p o s t n a t a l adjustment (as measured by the P o s t n a t a l Research Inventory o f Schaefer and Manheimer, 1960) and her p e r c e p t i o n o f her i n f a n t (as measured 6 by Broussard's, 1971, Neonatal P e r c e p t i o n I n v e n t o r y ) . These two measures were used t o compare an experimental group o f mothers, who r e c e i v e d the n u r s i n g i n t e r v e n t i o n , t o an u n t reated c o n t r o l group. D e f i n i t i o n o f T e r m s M a t e r n a l p e r c e p t i o n . A mother's awareness o f her i n f a n t i n the r o l e o f a parent t o t h a t i n f a n t . I n t e r p r e t a t i o n o f b e h a v i o u r a l cues from the i n f a n t t o determine the i n f a n t ' s needs, i n t e r e s t s and i n d i v i d u a l i t y i s p a r t o f t h i s p r o c e s s . M o t h e r - i n f a n t acquaintance p r o c e s s . The i n i t i a l phase o f the m a t e r n a l - i n f a n t i n t e r a c t i o n a l p r o c e s s i n which the mother attempts t o f i n d out what her i n f a n t i s r e a l l y l i k e and by o b s e r v i n g the i n f a n t ' s behaviours d e c i d e s how the i n f a n t r e a c t s to h e r . On the b a s i s o f t h i s i n f o r m a t i o n she may e i t h e r r e i n f o r c e or change her f e e l i n g s towards the i n f a n t . The n u r s i n g i n t e r v e n t i o n . An i n t e r a c t i v e d i s c u s s i o n o f i n f a n t behaviour p a t t e r n s and assessment of the i n f a n t . The purpose was t o a s s i s t the mother i n i d e n t i f y i n g b e h a v i o u r a l responses and r e f l e x b ehaviours c h a r a c t e r i s t i c o f her i n f a n t . P e r c e p t i o n . A p r o c e s s whereby the i n d i v i d u a l s e l e c t s , organ-i z e s and i n t e r p r e t s the sensory d a t a a v a i l a b l e i n o r d e r t o g a i n awareness o f h i m s e l f and/or h i s environment. Postpartum p e r i o d . From b i r t h t o one month f o l l o w i n g d e l i v e r y . P r i m i p a r o u s . B e a r i n g a c h i l d f o r t h e f i r s t time. 7 R o l e . A n o r g a n i z e d s e t o f b e h a v i o u r s t h a t b e l o n g t o a n i d e n t i -f i a b l e s o c i a l p o s i t i o n . A s s u m p t i o n s 1 . T h e e a r l y p o s t p a r t u m p e r i o d i s a c r i t i c a l l y i m p o r t a n t t i m e f o r e s t a b l i s h i n g t h e m o t h e r - i n f a n t r e l a t i o n s h i p . 2 . M o t h e r s n e e d s u p p o r t and a s s i s t a n c e i n o r d e r t o o r i e n t p o s i t i v e l y t o w a r d s t h e i r i n f a n t s d u r i n g t h e e a r l y p o s t -p a r t u m p e r i o d . 3. A n a p p r o p r i a t e way t o a s s i s t m o t h e r s i s t o d e m o n s t r a t e t h e i n f a n t s ' b e h a v i o u r s t o t h e p a r e n t s a b o u t t w e l v e d a y s f o l l o w i n g t h e b i r t h o f t h e i n f a n t . 4 . D e m o n s t r a t i n g t h e i n f a n t ' s b e h a v i o r a l r e s p o n s e s t o b o t h p a r e n t s w i l l i n c r e a s e t h e e f f e c t i v e n e s s o f t h e d e m o n s t r a t i o n f o r t h e m o t h e r . H y p o t h e s e s T h e f o l l o w i n g h y p o t h e s e s w e r e t e s t e d t 1 . T h e m o t h e r s i n a n e x p e r i m e n t a l g r o u p who r e c e i v e t h e d e m o n s t r a t i o n o f t h e i r i n f a n t s ' b e h a v i o u r a l r e s p o n s e s w i l l s c o r e s i g n i f i c a n t l y d i f f e r e n t l y o n p e r c e p t i o n o f t h e i r i n f a n t s ( N e o n a t a l P e r c e p t i o n I n v e n t o r y ) t h a n w i l l a c o n t r o l g r o u p o f m o t h e r s who d o n o t r e c e i v e t h i s d e m o n -s t r a t i o n . 2 . T h e m o t h e r s i n t h e e x p e r i m e n t a l g r o u p who r e c e i v e t h e d e m o n s t r a t i o n o f t h e i r i n f a n t s ' b e h a v i o u r a l r e s p o n s e s 8 w i l l s c o r e s i g n i f i c a n t l y d i f f e r e n t l y on postpartum a d j u s t -ment than those who do not r e c e i v e t h i s demonstration -as measured by the P o s t n a t a l Research Inventory. 3. The mothers who have a more p o s i t i v e p e r c e p t i o n o f t h e i r i n f a n t (as measured by the Neonatal P e r c e p t i o n Inventory) w i l l have a more p o s i t i v e postpartum adjustment (as measured by the P o s t n a t a l Research I n v e n t o r y ) . M u l t i d i s c i p l i n a r y Approach t o the Problem At t h e time t h i s problem was b e i n g c o n c e p t u a l i z e d i t was l e a r n e d t h a t a group o f developmental p s y c h o l o g i s t s a t the U n i v e r s i t y o f B r i t i s h Columbia were a l s o i n t e r e s t e d i n understanding more about mo t h e r - i n f a n t i n t e r a c t i o n s i n the p e r i n a t a l p e r i o d . The i n v e s t i g a t o r t h e r e f o r e d e c i d e d to e x p l o r e the f e a s i b i l i t y o f a m u l t i d i s c i p l i n a r y r e s e a r c h p r o j e c t . I t turned out t h a t the n u r s i n g and psychology i n t e r e s t s i n t h i s a rea were complementary. The f o c u s o f the p s y c h o l o g i s t s was t o develop b e t t e r measures o f the i n f l u e n c e o f p r e n a t a l a t t i -tudes on p o s t n a t a l a t t i t u d e s and behaviours. The n u r s i n g f o c u s was t o use knowledge about neonates, from t h e l i t e r a t u r e , i n order t o develop an i n t e r v e n t i o n which would a s s i s t mothers i n adapting t o t h e i r new maternal r o l e . I t was t h e r e f o r e p o s s i b l e f o r both the psychology and n u r s i n g graduate students t o work on t h e i r own s t u d i e s , although they o f t e n used the same s u b j e c t s and c o l l e c t e d some shared i n f o r m a t i o n , such as demographic data. 9 Overview o f the Study T h i s t h e s i s i s organized i n t o f i v e c hapters and an appendix. The focused review o f the l i t e r a t u r e appears i n the next chapter under t h r e e major headings: t r a n s i t i o n t o the maternal r o l e ; development o f the mother-infant r e l a t i o n s h i p ; and maternal p e r c e p t i o n o f the i n f a n t . Chapter I I I d e s c r i b e s the r e s e a r c h methodology and a r a t i o n a l e f o r the n u r s i n g i n t e r -v e n t i o n . The a n a l y s i s o f the d a t a d e s c r i b i n g the sample o f p a r t i c i p a n t s and the f i n d i n g s r e l a t i n g t o the hypotheses are i n Chapter IV. Chapter V i n c l u d e s i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e and suggestions f o r f u r t h e r r e s e a r c h . CHAPTER I I LITERATURE REVIEW I n t r o d u c t i o n The development o f the mother-infant r e l a t i o n s h i p has been the focus o f much r e s e a r c h i n the l a s t t h i r t y y e a r s . Most o f the e a r l y s t u d i e s o f mother-infant r e l a t i o n s h i p s focused on the i n f a n t ' s r o l e and on f a c t o r s which a f f e c t e d the i n f a n t ' s behaviour and r o l e development (Bowlby, 1958; W o l f f , 1965; B r a z e l t o n , 1963). I t i s o n l y i n the l a s t decade t h a t knowledge has been accumulated about f a c t o r s a f f e c t i n g the r e l a t i o n s h i p from the mother's p o i n t o f view. These f a c t o r s i n c l u d e such t h i n g s as h o s p i t a l p r a c t i c e s which separate mother and i n f a n t f o l l o w i n g b i r t h , s o c i e t a l and c u l t u r a l e x p e c t a t i o n s , and the mother's h i s t o r y o f i n t e r p e r s o n a l r e l a t i o n s w i t h her own p a r e n t s , her husband and o t h e r s (Klaus and K e n n e l l , 1970). T h i s l i t e r a t u r e review f o c u s e s on s t u d i e s r e l a t i n g t o the mother's a d a p t a t i o n d u r i n g the postpartum p e r i o d . R o l e theory has been u t i l i z e d as the co n c e p t u a l framework f o r t h i s study. S e l e c t e d l i t e r a t u r e i s reviewed on problems o f r o l e t r a n s i t i o n i n g e n e r a l , and s p e c i f i c a l l y , on t r a n s i t i o n t o the maternal r o l e . P a r t o f t h e maternal r o l e t r a n s i t i o n i n v o l v e s 10 11 d e v e l o p i n g a p o s i t i v e r e l a t i o n s h i p w i t h the new i n f a n t . T h i s p o s i t i v e mother-infant r e l a t i o n s h i p i s o f t e n r e f e r r e d t o i n the l i t e r a t u r e as "attachment." A number o f s t u d i e s t h a t have examined f a c t o r s which a f f e c t the mother's attachment t o the baby ar e a l s o reviewed. A c c o r d i n g t o r o l e t h e o r y , one o f the c r u c i a l v a r i a b l e s t h a t determines r o l e r e l a t i o n s h i p , i s p e r c e p t i o n o f the o t h e r i n d i v i d u a l i n t h a t r e l a t i o n s h i p . S t u d i e s d e a l i n g w i t h the importance o f the mother's p e r c e p t i o n o f her i n f a n t a r e i n c l u d e d i n t h e f i n a l s e c t i o n o f t h e l i t e r a t u r e review. T h i s f i n a l s e c t i o n a l s o i n c l u d e s s t u d i e s o f methods t h a t have been u t i l i z e d to h e l p mothers o b t a i n a c c u r a t e p e r c e p t i o n o f t h e i r own i n f a n t ' s b e h a v i o u r s . T r a n s i t i o n to the Maternal R o l e Role t h e o r y p r o v i d e s a c o n c e p t u a l o r i e n t a t i o n f o r under-s t a n d i n g how mothers and i n f a n t s f u n c t i o n and a f f e c t one another i n the postpartum p e r i o d . A r o l e i s d e f i n e d as "an o r g a n i z e d s e t o f behaviours t h a t b e l o n g to an i d e n t i f i a b l e p o s i t i o n " ( S a r b i n and A l l e n , 1968). Some r o l e s are d y a d i c . That i s , the e x i s t e n c e and e x p e c t a t i o n s o f the r o l e depend upon the e x i s t e n c e and e x p e c t a t i o n s o f a r o l e o t h e r . One cannot f i l l a mothering r o l e without a c h i l d and the behaviours expected o f t h e mother a r e determined i n p a r t by the demands o f t h e c h i l d . Mothers have to b e g i n f i l l i n g t h e i r r o l e knowing very l i t t l e about the r o l e o t h e r (the i n f a n t ) . 12 Most behaviour i n v o l v e d i n r o l e enactment i s l e a r n e d b e haviour. I t i s u s u a l and expected t h a t when a person i s to engage i n a new r o l e t h e r e w i l l be a p e r i o d o f t r a n s i t i o n , or a t r a n s i t i o n a l r o l e , i n which the o p p o r t u n i t y to a c q u i r e know-ledge, s k i l l s , and values a s s o c i a t e d w i t h the r o l e w i l l be a v a i l a b l e (Schwitzgebel and K o l b , 1974). In a d d i t i o n , the s u c c e s s f u l t r a n s i t i o n to a new r o l e a l s o i n v o l v e s the o r g a n i -z a t i o n o f these b a s i c s k i l l s and a t t i t u d e s i n t o a new s e l f -concept f o r the i n d i v i d u a l . I t has been argued by the p r e s e n t i n v e s t i g a t o r t h a t r e s o u r c e s and o p p o r t u n i t y f o r t r a n s i t i o n t o the mothering r o l e are l a r g e l y l a c k i n g i n our s o c i e t y . Hence, the development t o the maternal r o l e must be accomplished a f t e r the woman has a l r e a d y become a mother. Schwitzgebel and K o l b (1974) suggest t h a t t r a n s i t i o n a l r o l e s a r e u s u a l l y s t r e s s f u l p e r i o d s . There are many s i t u a t i o n a l demands made upon the person i n t r a n s i t i o n . Hence, i t i s i d e a l f o r t h e r o l e l e a r n e r t o be a s s o c i a t e d w i t h o t h e r s who a r e f a c i n g s i m i l a r s t r e s s e s so t h a t peer support and group problem s o l v i n g can be undertaken. I t i s a l s o p r e f e r a b l e t h a t r o l e models who have a l r e a d y a c q u i r e d the behaviours and a t t i t u d e s p r e r e q u i s i t e to the new r o l e be a v a i l a b l e to t e a c h the person i n t r a n s i t i o n . The person i n t r a n s i t i o n should a l s o be g i v e n o p p o r t u n i t i e s t o p r a c t i c e the r o l e i n a s i t u a t i o n t h a t i s s u p e r v i s e d , where a s s i s t a n c e can be g i v e n i n the event i t i s needed. For the new mother these supports a r e u s u a l l y a v a i l a b l e o n l y d u r i n g the f o u r or f i v e days i n h o s p i t a l f o l l o w i n g her i n f a n t ' s b i r t h . 13 Theories and c l i n i c a l research suggest that the mother has not usually adapted to her new maternal r o l e by the time of d i s -charge from the hospital (Robson and Moss, 1970; Rubin, 1961, 1967; Ryan, 1973). These f i r s t four or f i v e days are, probably, simply not enough time fo r the interpersonal r e l a t i o n s h i p of the mother and c h i l d to develop. Interpersonal relationships begin with a process of acquaintance that forms the basis of subsequent interpersonal behaviours. Between adults i t can be seen as having three components! the a c q u i s i t i o n of information about the other; the assessment of the other's attitudes; and either r e i n f o r c e -ment or change i n existing states of o r i e n t a t i o n about the other (Newcomb, 1961). From the mother's point of view, the beginning mother-infant r e l a t i o n s h i p could be described i n s i m i l a r terms, after d e l i v e r y each new mother attempts to f i n d out what her infant i s r e a l l y l i k e , and by observing the infant's behaviours, decides how the infant reacts to her. On the basis of t h i s information, she may either reinforce or change her f e e l i n g s towards the infant (Kennedy, 1969, 1971). This process of developing a close interpersonal r e l a -t ionship with her infant i s generally referred to i n the l i t e r a t u r e as "the attachment process*" Ainsworth (1973) defines attachment as "an a f f e c t i o n a l t i e that one person forms to another person, binding them together i n space and enduring over time." Robson and Moss (1970) have defined 14 maternal attachment as "the extent t o which a mother f e e l s t h a t her i n f a n t o c c u p i e s an e s s e n t i a l p o s i t i o n i n her l i f e . " Thus the m o t h e r - i n f a n t r e l a t i o n s h i p depends on i n t e r a c t i o n s i n which the behaviour o f each p a r t n e r a f f e c t s and i s a f f e c t e d by t h a t of the o t h e r . The few s t u d i e s which look a t f a c t o r s t h a t a f f e c t maternal attachment i n the development of the m o t h e r - i n f a n t r e l a t i o n s h i p w i l l be d e s c r i b e d next. Development o f the Mother-Infant R e l a t i o n s h i p One o f the f i r s t s t u d i e s t o f o c u s on the mother i n the mother-infant attachment p r o c e s s was conducted by Robson and Moss (1970). T h i s e x p l o r a t o r y study o f 54 p r i m i p a r o u s mothers looked a t the development o f the mother's f e e l i n g s o f attachment towards her i n f a n t d u r i n g the f i r s t t h r e e months of l i f e . S t r u c t u r e d i n t e r v i e w s , conducted when the i n f a n t s were a p p r o x i -mately t h r e e months o l d , were designed to g a t h e r i n f o r m a t i o n on t h r e e s p e c i f i c q u e s t i o n s i when the mother f i r s t experienced p o s i t i v e f e e l i n g s and l o v e towards the i n f a n t ; when the i n f a n t f i r s t became a person t o her; and when the i n f a n t f i r s t seemed to r e c o g n i z e her. Robson and Moss con s i d e r e d the components of maternal attachment t o i n c l u d e f e e l i n g s o f warmth or l o v e , a sense o f p o s s e s s i o n and d e v o t i o n , p r o t e c t i v e n e s s and concern f o r the i n f a n t ' s w e l l - b e i n g , p o s i t i v e a n t i c i p a t i o n o f prolonged c o n t a c t , and a need and p l e a s u r e i n c o n t i n u i n g t r a n s a c t i o n s . Using t h i s model o f maternal attachment, the authors found t h a t the mothers had l i t t l e or no f e e l i n g s of attachment 15 a t b i r t h or throughout the h o s p i t a l s t a y . Once home the mothers r e p o r t e d f e e l i n g s o f u neasiness which were a t l e a s t p a r t l y due t o the f e e l i n g t h a t they c o u l d not communicate w i t h t h e i r b a b i e s . The f i r s t p o s i t i v e f e e l i n g s came when the i n f a n t began t o make eye c o n t a c t , show v i s u a l f i x a t i o n and s m i l i n g , and t o produce s o c i a l smiles and v o c a l i z a t i o n s . Mothers r e p o r t e d t h a t the baby seemed t o become a person t o them about the time the i n f a n t began t o e x h i b i t i n t e r a c t i v e behaviour. In many ways Robson and Moss were demonstrating t h a t the attachment between mother and i n f a n t grows as they become acquainted. Once the baby began t o r e a c t t o the mother i n a way she could understand (by s m i l i n g , e t c . ) , the mother's f e e l i n g s about th e i n f a n t were i n t e n s i f i e d . A study by Kennedy (1969) a l s o i l l u s t r a t e s the c e n t r a l s i g n i f i c a n c e t o the mother o f her i n f a n t ' s i n t e r a c t i v e responses t o her own b e h a v i o u r s . Kennedy conducted a d e s c r i p t i v e study o f the nature o f the mother-infant acquaintance p r o c e s s d u r i n g the f i r s t two weeks a f t e r the i n f a n t s ' b i r t h s i n ten mother-i n f a n t p a i r s . Her f i n d i n g s were t h a t a p o s i t i v e r e l a t i o n s h i p developed f o r t h e mothers who had planned the b i r t h o f t h e baby and had a problem-free pregnancy, l a b o u r , and b i r t h . T h i s group o f mothers a l s o had adequate help from husbands, r e l a t i v e s and f r i e n d s and were ab l e t o seek and r e c e i v e i n f o r m a t i o n from p r o f e s s i o n a l s . The b a b i e s o f these mothers tended t o be respon-s i v e t o the mother's c a r e t a k i n g attempts. Mothers who experienced d i f f i c u l t y i n a d j u s t i n g t o the i n f a n t i n the f i r s t two weeks postpartum tended not t o have 16 planned the pregnancy and t o have had p h y s i c a l and emotional problems d u r i n g pregnancy, labour and b i r t h o f the i n f a n t . These mothers a l s o lacked an adequate s o c i a l support system. The i n f a n t s i n t h i s group were p e r c e i v e d t o be n e g a t i v e l y r e s p o n s i v e t o the mother's attempts a t i n t e r a c t i o n . D i f f e r e n c e s between the two groups o f mothers were r e p o r t e d i n r e l a t i o n t o the way they r e a c t e d t o the i n f a n t ' s c r y i n g . The mother's c a p a c i t y t o t r u s t , e s p e c i a l l y her a b i l i t y to t r u s t the newborn's behaviour, was suggested to be a f a c i l i -t a t i n g f a c t o r i n the p o s i t i v e acquaintance p r o c e s s . Kennedy's the o r y concerning the f a c t o r s t h a t i n f l u e n c e the mother-infant acquaintance p r o c e s s i s t h a t j C e r t a i n q u a l i t i e s i n the mother f u n c t i o n t o f a c i l i t a t e the mother-infant acquaintance p r o c e s s i n the f i r s t two weeks o f l i f e . They are emotional and p h y s i c a l s t r e n g t h , i n t e r p e r s o n a l s k i l l s and the c a p a c i t y t o t r u s t . These q u a l i t i e s may be enhanced or d i m i n i s h e d by the m a t e r n a l l y p e r c e i v e d rewarding or p u n i s h i n g nature o f the events t h a t occur d u r i n g pregnancy and the ensuing two weeks. B e f o r e the b i r t h o f the baby the rewards and punishments are d e r i v e d mainly from the mother's p h y s i c a l environment, s o c i a l environment and somatic e x p e r i e n c e s . W i t h i n a few weeks a f t e r b i r t h the i n f a n t becomes the most s i g n i f i c a n t mediator o f p l e a s u r e and unpleasure, by v i r t u e o f h i s p a t t e r n o f r e s p o n s i v e n e s s . (Kennedy, 1969, p. 54). In summary, some mothers i n the study seemed t o have been a b l e t o o b t a i n r e a l i s t i c i n f o r m a t i o n about t h e i r i n f a n t s ' behav-i o u r s . I f the mother then assessed the i n f a n t as b eing respon-s i v e and r e c e p t i v e t o her c a r e t a k i n g attempts a p o s i t i v e r e l a t i o n s h i p developed. Thus, the i n f a n t , through h i s or her b e h a v i o u r s , p a r t l y determines the q u a l i t y and q u a n t i t y o f care 17 r e c e i v e d d u r i n g the e a r l y phase o f the mother-infant acquaintance p r o c e s s - although the mother must have the u n d e r l y i n g s k i l l s t o observe and to c o r r e c t l y i n t e r p r e t the i n f a n t ' s b e haviours. Kennedy f e l t t h a t an important f a c t o r i n t h i s p r o c e s s was t h e a b i l i t y o f the mother to t r u s t or have c o n f i d e n c e i n her own judgments. These s t u d i e s h i g h l i g h t the importance t o the mother o f being a b l e to i n t e r a c t i n a p l e a s u r a b l e way w i t h her i n f a n t . That i s , s u c c e s s f u l a d a p t a t i o n t o the maternal r o l e i s dependent on p l e a s u r a b l e i n t e r a c t i o n s w i t h i n the mother-infant dyad. An Important f a c t o r , i f t h i s i s t o occur, i s a p o s i t i v e p e r c e p t i o n o f the i n f a n t by the mother. The next s e c t i o n d e a l s w i t h s t u d i e s which d i s c u s s the mother's p e r c e p t i o n o f her i n f a n t and how t h i s i n f l u e n c e s s u c c e s s f u l t r a n s i t i o n t o the maternal r o l e . P e r c e p t i o n of the I n f a n t Broussard and Hartner (1971) conducted a l o n g i t u d i n a l study o f 318 p r i m i p a r o u s women w i t h h e a l t h y b a b i e s i n which they i l l u s t r a t e d t h a t p e r c e p t i o n o f t h e i n f a n t i s a s s o c i a t e d w i t h the mother's postpartum adjustment t o the maternal r o l e . In t h i s study the mother's concept o f "the average baby's behaviour" was used as an anchor f o r comparison w i t h her own i n f a n t * s behaviour. The mothers were asked t o r a t e the "average baby" and t h e i r own baby a t two separate time points» f i r s t , d u r i n g the f i r s t or second postpartum day; and second, a t approximately 18 one month o f age. The items on which they r a t e d the i n f a n t were c r y i n g , s p i t t i n g - u p , e l i m i n a t i o n , f e e d i n g , s l e e p i n g , and p r e d i c t a b i l i t y . A t one month, i n a d d i t i o n t o r a t i n g her own i n f a n t , the mother was g i v e n Schaefer's P o s t n a t a l Research Inventory. T h i s i n v e n t o r y y i e l d s a s e t o f s c a l e s c o r e s , s i x o f which were used i n the study - d e p r e s s i o n , n e g a t i v e a s p e c t s o f c h i l d - r e a r i n g , i r r i t a b i l i t y , need f o r reassurance, f e a r or concern f o r the baby, and the mother's psychosomatic symptom a n x i e t y . The sample was d i v i d e d i n t o " h i g h - r i s k " and "low-r i s k " i n f a n t s on the b a s i s o f the mother's e v a l u a t i o n o f the baby a t one month. Those i n f a n t s who had been p e r c e i v e d as above average by t h e i r mothers were c o n s i d e r e d t o be low r i s k f o r l a t e r emotional problems; those i n f a n t s who had been r a t e d as below average by t h e i r mothers at one month were c o n s i d e r e d t o be h i g h - r i s k f o r l a t e r emotional problems. The r a t i n g s a t time one (soon a f t e r the i n f a n t ' s b i r t h ) showed t h a t 46.5 p e r c e n t o f the mothers r a t e d t h e i r i n f a n t s as b e t t e r than average. At time two (when the i n f a n t was one month o f age), 61.2 percent o f the mothers r a t e d t h e i r i n f a n t as b e t t e r than average. Those mothers who r a t e d t h e i r i n f a n t s as below average were s i g n i f i c a n t l y more l i k e l y t o score h i g h on s c a l e s o f d e p r e s s i o n , i r r i t a b i l i t y , and n e g a t i v e a s p e c t s o f c h i l d - r e a r i n g from the P o s t n a t a l Research Inventory. The r e s e a r c h e r s suggested t h a t these f i n d i n g s i n d i c a t e d t h a t some o f the mothers and i n f a n t s had a l r e a d y e s t a b l i s h e d poor mother-c h i l d i n t e r a c t i o n s one month f o l l o w i n g the i n f a n t ' s b i r t h . 19 I n a d d i t i o n , t h e r e s e a r c h e r s w e r e c o n c e r n e d a b o u t t h e d e v e l o p -ment o f e m o t i o n a l d i s t u r b a n c e s i n t h e c h i l d w h o s e m o t h e r p e r -c e i v e d h i m a s " l e s s t h a n a v e r a g e " a n d w h o s e m o t h e r was a l s o " d e p r e s s e d " and " i r r i t a b l e . " I t was p o s s i b l e t o f o l l o w e i g h t y - f i v e o f t h e c h i l d r e n u n t i l t h e y w e r e a p p r o x i m a t e l y f o u r a n d o n e - h a l f y e a r s o l d . A t t h a t t i m e t h e y w e r e e v a l u a t e d b y two c h i l d p s y c h i a t r i s t s who h a d n o k n o w l e d g e o f t h e c h i l d r e n ' s p r e v i o u s r a t i n g s . T h e r e w e r e t w o r a t i n g s a s s i g n e d - n e e d f o r t h e r a p e u t i c i n t e r v e n t i o n o r n o n e e d f o r t h e r a p e u t i c i n t e r v e n t i o n . T h e m o t h e r ' s p e r c e p -t i o n s o f t h e c h i l d a t t i m e o n e ( b i r t h ) d i d n o t p r e d i c t t h e l a t e r n e e d f o r t h e r a p e u t i c i n t e r v e n t i o n . H o w e v e r , t h e m o t h e r ' s p e r c e p t i o n o f t h e c h i l d a t t i m e two ( o n e month) d i d . S i x t y - s i x p e r c e n t o f t h o s e i n t h e h i g h - r i s k g r o u p w e r e s e e n a s n e e d i n g t h e r a p y w h i l e o n l y 20 p e r c e n t o f t h e l o w - r i s k g r o u p w e r e r a t e d a s r e q u i r i n g h e l p . T h e n e e d f o r i n t e r v e n t i o n w i t h t h e c h i l d was n o t r e l a t e d t o a n y o f t h e o t h e r v a r i a b l e s t h a t w e r e c o n -s i d e r e d i n t h e s t u d y ( e . g . m a t e r n a l e d u c a t i o n , a g e ) . S i n c e a p r e d i c t i v e e v a l u a t i o n o f t h e c h i l d was o b t a i n e d a f t e r t h e m o t h e r h a d h a d some e x p e r i e n c e i n c a r i n g f o r t h e i n f a n t i t was p o s t u l a t e d t h a t i n t e r a c t i o n s d u r i n g t h e f i r s t p o s t p a r t u m m o n t h a r e o f u t m o s t i m p o r t a n c e t o t h e m o t h e r - i n f a n t r e l a t i o n s h i p . I f t h e m o t h e r s u c c e e d e d i n c o p i n g w e l l d u r i n g t h i s t i m e s h e was m o r e l i k e l y t o h a v e a s e n s e o f a c c o m p l i s h m e n t a n d a h o p e f u l t o n e f o r t h e r e l a t i o n s h i p was s e t . T h i s was l a t e r r e f l e c t e d i n t h e c h i l d ' s d e v e l o p m e n t . T h e r e was a l s o 20 a r e l a t i o n s h i p between the p e r c e p t i o n o f the i n f a n t and the mother's postpartum adjustment. Those mothers who p e r c e i v e d t h e i r i n f a n t s as " b e t t e r than average" were s i g n i f i c a n t l y l e s s l i k e l y t o score h i g h on s c a l e s o f d e p r e s s i o n , i r r i t a b i l i t y , and n e g a t i v e aspects o f c h i l d - r e a r i n g . A c c u r a t e and r e a l i s t i c p e r c e p t i o n o f i n f a n t behaviour can be f a c i l i t a t e d by a c c u r a t e knowledge about how i n f a n t s behave and how they d i f f e r from one another i n t h i s behaviour. B r a z e l t o n (1963) suggests t h a t the a c c u r a t e p r e d i c t i o n and ex-p l a n a t i o n o f each i n f a n t ' s unique behaviour (e.g. a c t i v i t y , c r y i n g p a t t e r n s , r e s p o n s i v e n e s s ) a t b i r t h would a l l e v i a t e maternal a n x i e t y d u r i n g the i n i t i a l p e r i o d o f adjustment (the acquaintance p r o c e s s , as i t has been termed by Kennedy, 1969). B r a z e l t o n (1973) has demonstrated t h a t normal b a b i e s , from the moment o f b i r t h , are very d i f f e r e n t i n such t h i n g s as a c t i v i t y , f e e d i n g and s l e e p i n g p a t t e r n s , and i n r e s p o n s i v e n e s s t o the c a r e t a k i n g o f o t h e r s . He f u r t h e r suggests t h a t the p a r e n t s ' r e a c t i o n s and the i n f a n t ' s e f f e c t on h i s environment are d e t e r -mined i n p a r t by these d i f f e r e n c e s . S h a r i n g t h i s i n f o r m a t i o n -t h a t the newborn i n f a n t can shape h i s environment, as w e l l as be shaped by i t - should f u r t h e r a l l e v i a t e the a n x i e t y f e l t by new p a r e n t s ( E d e l s t e i n , 1975). In a d d i t i o n , demonstrating the i n f a n t ' s behaviours i n response t o a v a r i e t y o f s t i m u l i should a s s i s t the parents t o i d e n t i f y the i n f a n t as an i n d i v i d u a l and help them t o a c c u r a t e l y assess the i n f a n t ' s responses. The B r a z e l t o n Neonatal B e h a v i o u r a l Assessment S c a l e (1973) 21 was developed to e v a l u a t e the behaviour o f the newborn. T h i s s c a l e a s sesses the i n f a n t ' s s t a t e of c o n s c i o u s n e s s , h i s a b i l i t y f o r s e l f - q u i e t i n g a f t e r a v e r s i v e s t i m u l i and a l s o i n c l u d e s an examination o f the i n f a n t ' s r e f l e x e s . A d a p t a t i o n s have been made t o the B r a z e l t o n S c a l e i n order t o make i t s u i t a b l e f o r use w i t h parents i n h e l p i n g them to l e a r n about t h e i r i n f a n t s ' b e h a v i o u r a l responses. Two s t u d i e s have been done a t the U n i v e r -s i t y o f Washington u s i n g a m o d i f i e d B r a z e l t o n Assessment, or "Mother B r a z e l t o n " as they term i t . Ryan (1973) adapted the B r a z e l t o n Neonatal Assessment S c a l e and used i t i n her study o f the maternal p e r c e p t i o n o f neonatal behaviour w i t h a sample o f e l e v e n mothers and t h e i r i n f a n t s . The r e s u l t s o f her study i n d i c a t e d t h a t the group o f mothers who had r e c e i v e d a demonstration of the "Mother B r a z e l -t o n " two days f o l l o w i n g the b i r t h o f the i n f a n t showed no s t a t i s -t i c a l l y s i g n i f i c a n t d i f f e r e n c e s i n a t t i t u d e towards the baby at one month follow-up when compared to those mothers who d i d not r e c e i v e t h i s demonstration. Kang (1974) used the same demon-s t r a t i o n technique i n her study o f e l e v e n mother-infant dyads but demonstrated the "Mother B r a z e l t o n " t o both mothers and f a t h e r s i n the experimental group d u r i n g a home v i s i t when the i n f a n t s were two weeks o l d . S i g n i f i c a n t d i f f e r e n c e s were found between th e experimental and t h e c o n t r o l group mothers' p e r c e p -t i o n s o f t h e i r i n f a n t s a t one month f o l l o w - u p . On the b a s i s o f t h i s evidence Kang concluded t h a t the s h a r i n g o f i n f o r m a t i o n w i t h the p a r e n t s was worthwhile. She s t a t e d : 22 The i n f o r m a t i o n about the baby's behaviour a t the two week p e r i o d p r o v i d e s the key f o r the parents to "make sense" or " t i e i n " the i n f o r m a t i o n they have been g a t h e r i n g about t h e i r i n f a n t d u r i n g the time they have a l r e a d y been i n v o l v e d i n the acquain-tance p r o c e s s . The a b i l i t y t o p e r c e i v e the i n f a n t not as a "buzzing mass o f c o n f u s i o n " but as "orga-n i z e d w i t h unique b e h a v i o u r s " may h e l p the p a r e n t s to r e c o g n i z e t h e i r i n f a n t as a person - an i n d i v i d u a l . T h i s p e r c e p t i o n may s e t i n motion a more p o s i t i v e or r e a l i s t i c aura which may indeed i n f l u e n c e the f u t u r e q u a l i t y o f the p a r e n t a l r e l a t i o n s h i p and the c h i l d ' s subsequent growth and development. (Kang, 1974, p. 40). Both the s t u d i e s by Ryan and Kang are important e x p l o r -a t o r y s t u d i e s and o f f e r s uggestions f o r f u r t h e r i n v e s t i g a t i o n . There a r e , however, some l i m i t a t i o n s t o the g e n e r a l i z a b i l i t y o f t h e i r f i n d i n g s . The f a m i l i e s w i t h whom t h e i r n u r s i n g i n t e r -v e n t i o n was demonstrated were consumers i n a h e a l t h care system t h a t o f f e r s a v e r y s h o r t h o s p i t a l s tay f o l l o w i n g the i n f a n t ' s b i r t h . These f a m i l i e s are not f o l l o w e d r o u t i n e l y a t home by community h e a l t h nurses. Hence, they may have had v e r y few o p p o r t u n i t i e s t o l e a r n about i n f a n t behaviour. The d i f f e r e n c e s r e p o r t e d i n Kang's s t u d i e s may have been due t o the o p p o r t u n i t y o f the experimental s u b j e c t s t o r a i s e q u e s t i o n s , express con-c e r n s , and i n t e r a c t w i t h the nurse, r a t h e r than b e i n g due t o the i n f o r m a t i o n c o n t a i n e d i n the n u r s i n g i n t e r v e n t i o n . There are two d i f f e r e n c e s i n the methodology o f the Ryan and Kang s t u d i e s t h a t may have l e d to t h e i r d i f f e r e n t i a l r e s u l t s . I n the Ryan study the demonstration was o f f e r e d t o the mother i n the f i r s t two days postpartum. No s i g n i f i c a n t e f f e c t s on maternal p e r c e p t i o n were noted a t the one month r a t i n g o f the 23 i n f a n t by the mother. Kang found s i g n i f i c a n t f o l l o w - u p e f f e c t s when the demonstration was g i v e n two weeks postpartum. Optimal t i m i n g f o r the demonstration should t h e r e f o r e be i n v e s t i g a t e d . Kang d i d the b e h a v i o u r a l assessment o f the baby w i t h both p a r e n t s p r e s e n t . Ryan i n t e r v e n e d w i t h the mother o n l y . I t c o u l d be t h a t t h i s d i f f e r e n c e i n methodology produced the s i g n i f i c a n t e f f e c t s i n the study done by Kang - perhaps i n combination w i t h her t i m i n g o f the i n t e r v e n t i o n . The t e a c h i n g demonstration o f b o t h s t u d i e s was l i m i t e d t o i n f o r m a t i o n about i n f a n t r e f l e x b ehaviours and r e a c t i o n t o s t i m u l i i n a v a r i e t y o f modes. However, parents have r e p o r t e d concerns about o t h e r i n f a n t behaviours as w e l l i n the s t u d i e s conducted by Adams (1963), Carpenter (1965), and Jordan (1973). These concerns t y p i c a l l y r e f l e c t l a c k o f knowledge about i n f a n t s l e e p i n g p a t t e r n s , i n t e r p r e t a t i o n o f i n f a n t c r y i n g , and such other behaviours as h i c c u p i n g and s m i l i n g . Such i n f o r m a t i o n c o u l d e a s i l y be i n c o r p o r a t e d i n the demonstration and would o f f e r a more comprehensive method o f a s s i s t i n g mothers i n the postpartum p e r i o d . Summary The s t u d i e s and t h e o r i e s reviewed i n t h i s chapter d i s c u s s the importance o f the f i r s t month postpartum f o r the mother's adjustment t o her new maternal r o l e . The s t u d i e s g e n e r a l l y , and the Kang and Ryan s t u d i e s i n p a r t i c u l a r , suggest t h a t an important p a r t o f n u r s i n g i n t e r v e n t i o n a t t h i s time should be 24 t o a s s i s t m o t h e r s w i t h an a c c u r a t e p e r c e p t i o n o f h e r i n f a n t a n d h i s o r h e r b e h a v i o u r s . CHAPTER I I I RESEARCH DESIGN Overview The purpose o f t h i s study was t o t e s t the e f f e c t o f a n u r s i n g i n t e r v e n t i o n on the mother's postpartum adjustment and p e r c e p t i o n o f her i n f a n t . The i n t e r v e n t i o n was designed t o g i v e i n f o r m a t i o n about t y p i c a l i n f a n t behaviour p a t t e r n s ; and t o a s s i s t the mother i n i d e n t i f y i n g the b e h a v i o u r a l responses and r e f l e x behaviours c h a r a c t e r i s t i c of her i n f a n t . Because o f the nature o f the d a t a r e q u i r e d , a q u a s i - e x p e r i m e n t a l study was designed w i t h random assignment of p a r t i c i p a n t s t o e i t h e r an experimental or a c o n t r o l group f o l l o w i n g the i n f a n t s ' b i r t h s . Those s u b j e c t s assigned t o the experimental group p a r t i c i p a t e d i n the n u r s i n g i n t e r v e n t i o n on approximately the t w e l f t h postpartum day. The i n f a n t s * f a t h e r s were a l s o p r e s e n t d u r i n g the n u r s i n g i n t e r v e n t i o n . Data were obtained from the mother's h o s p i t a l r e c o r d and through the use of two q u e s t i o n -n a i r e s which a l l p a r t i c i p a n t s completed approximately one month f o l l o w i n g the i n f a n t s ' b i r t h . A l l data were subsequently analyzed a t the U n i v e r s i t y of B r i t i s h Columbia Computing Centre u s i n g the S t a t i s t i c a l Package f o r the S o c i a l S c i e n c e s (1976). Independent V a r i a b l e The independent v a r i a b l e was p a r t i c i p a t i o n i n a n u r s i n g 25 26 i n t e r v e n t i o n which used a m o d i f i c a t i o n o f the Neonatal Behav-i o u r a l Assessment S c a l e ( B r a z e l t o n , 1973). T h i s s c a l e was developed t o determine the i n d i v i d u a l c h a r a c t e r i s t i c s o f i n f a n t s , p a r t i c u l a r l y i n the ar e a o f i n t e r a c t i v e b e h aviours. I t i s a complex system of e v a l u a t i o n , intended t o scor e the i n f a n t s ' responses t o t h e i r environment and t o i n d i r e c t l y a s s e s s t h e i r e f f e c t s on t h e i r environment. T h i s s c a l e was intended f o r p r o f e s s i o n a l use. However, the p o t e n t i a l f o r adapting some o f the items f o r use i n t e a c h i n g mothers about t h e i r b a b i e s was recognized by a nurse a t the U n i v e r s i t y o f Washington. Ryan (1973) had developed the "Mother B r a z e l t o n " , which was subsequently used i n two n u r s i n g s t u d i e s a t t h a t u n i v e r s i t y . In a d d i t i o n , C l a r k (1976) has developed a t e a c h i n g t o o l based on the same s c a l e . T h i s i n v e s t i g a t o r s e l e c t e d ten o f the seventeen r e f l e x b e h a v i o u r s , f o u r o f the s i x s t a t e s , and n i n e o f the twenty-seven b e h a v i o u r a l response items from the n e u r o l o g i c a l and b e h a v i o u r a l s e c t i o n s o f the B r a z e l t o n Neonatal Assessment S c a l e . Both the behaviours and r e f l e x e s s e l e c t e d were s i m i l a r t o those adapted by Ryan (1973) and subsequently used by Kang (1974). The items i n c l u d e d weret REFLEXES I s t a r t l e ; r o o t i n g ; sucking; swallowing; gag; ste p p i n g ; b l i n k i n g ; grasp; coughing; yawning STATES * deep sleep; l i g h t s l e e p ; a l e r t s t a t e ; c r y i n g s t a t e . 27 BEHAVIOURAL RESPONSES* V i s u a l a t t e n t i o n ? l i s t e n i n g a t t e n t i o n ; muscle tone; c u d d l i n e s s ; d e f e n s i v e movements, c o n s o l a b i l i t y ; s m i l i n g ; h i c c u p i n g , t e a r i n g . During the i n t e r v e n t i o n , the i n f a n t was assessed on these items. P a r e n t s were shown these behaviours and then encouraged t o d i s c u s s the baby's responses w i t h the i n v e s t i g a t o r . In a d d i t i o n , the parents were shown how to r e c o g n i z e the baby's s t a t e ; and how t o i n t e r a c t w i t h the baby i n c e r t a i n s i t u a t i o n s , i . e . how to h e l p the baby to f o c u s on an o b j e c t . The format f o r the i n t e r v e n t i o n was i n t e r a c t i v e and thus v a r i e d somewhat from c o u p l e t o c o u p l e . During the w i n t e r of 1976, i n p r e p a r a t i o n f o r t h e p r e s e n t study, a p i l o t study was conducted w i t h f o u r f a m i l i e s . While the f o u r s e t s o f p a r e n t s were a l l pleased w i t h the i n t e r v e n t i o n , they a l l asked q u e s t i o n s concerning g e n e r a l i n f a n t behaviour p a t t e r n s . Hence, t h i s i n f o r m a t i o n was added to the i n t e r -v e n t i o n . An o u t l i n e o f the i n f o r m a t i o n g i v e n i s i n Appendix A. Dependent V a r i a b l e s There were two dependent v a r i a b l e s f o r the purpose o f t h i s study. They were p e r c e p t i o n o f the i n f a n t as measured by t h e Neonatal P e r c e p t i o n Inventory and postpartum adjustment as measured by the P o s t n a t a l Research Inventory. Both measures were administered one month f o l l o w i n g the i n f a n t ' s b i r t h . 28 Neonatal P e r c e p t i o n Inventory Broussard (1971) found t h a t maternal p e r c e p t i o n o f the i n f a n t ' s behaviour when the baby was one month o f age was a d e t e r m i n i n g f o r c e i n the e a r l y m o t h e r - c h i l d r e l a t i o n s h i p and a p r e d i c t o r o f the i n f a n t ' s subsequent growth and development. The Inventory c o n s i s t s o f twelve L i k e r t - t y p e s c a l e s - s i x f o r the mother's p e r c e p t i o n o f her own baby and the same s i x f o r her p e r c e p t i o n of the average baby (see Appendix B ) . Each o f the s i x s i n g l e - i t e m s c a l e s was assigned a v a l u e o f one to f i v e . The lower s c o r e s r e f l e c t the more d e s i r a b l e i n f a n t behaviour. Three scores are obtained from t h i s s c a l e . The "Average Baby" sc o r e sums up the mother's p e r c e p t i o n o f the average baby on the s i x s c a l e s and the "Your Baby" score sums up the mother's p e r c e p t i o n o f her own baby on the s i x s c a l e s . The d i f f e r e n c e between the s e two s c o r e s can be c a l c u l a t e d t o i n d i c a t e the mother's p e r c e p t i o n o f "her baby" i n comparison t o "the average baby." P o s t n a t a l Research Inventory T h i s Inventory was developed by Schaefer and Manheimer (1960) to a s s e s s the adjustment o f women d u r i n g the postpartum p e r i o d . The ten s c a l e s which showed the h i g h e s t i n t e r n a l con-s i s t e n c y and r e l i a b i l i t i e s were used i n the p r e s e n t study. These s c a l e s were. Fear or Concern f o r Baby; Negative Aspects o f C h i l d r e a r i n g ; I n t r a p u n i t i v e n e s s ; I g n o r i n g ; I r r i t a b i l i t y ; E x t r a p u n i t i v e n e s s ; Responsiveness t o I n f a n t ' s Needs; 29 Convalescence; Need f o r Reassurance; and D e p r e s s i o n . A separate s c o r e i s o b tained f o r each s c a l e . L i k e the Neonatal P e r c e p t i o n I n v e n t o r y , t h i s s c a l e i s simple t o a d m i n i s t e r and s c o r e (see Appendix C ) . I n t e r v e n i n g V a r i a b l e s No attempt was made t o c o n t r o l f o r maternal age or e d u c a t i o n . In a d d i t i o n , the l e n g t h o f l a b o u r , and the amount o f a n a l g e s i a and a n a e s t h e t i c d u r i n g both labo u r and t h e b i r t h were not c o n t r o l l e d . A l l mother and i n f a n t p a i r s were cared f o r i n the same postpartum u n i t ; however, the a c t u a l amount o f s e p a r a t i o n d u r i n g the f i r s t twelve hours v a r i e d f o r the p a r t i -c i p a n t s . S e t t i n g A l l the p a r t i c i p a n t s i n t h i s study d e l i v e r e d t h e i r i n f a n t s i n the same m a t e r n i t y u n i t o f an urban, u n i v e r s i t y -a f f i l i a t e d g e n e r a l h o s p i t a l . Approximately 1300 b i r t h s are r e c o r d e d each year a t t h i s h o s p i t a l . The m a t e r n i t y u n i t supports the p h i l o s o p h y o f " f a m i l y c e n t e r e d c a r e " (Ratsoy, 1974). A l l i n f a n t s whose c o n d i t i o n i s c o n s i d e r e d s t a b l e a r e cared f o r i n a c e n t r a l n u r s e r y t o which mothers have f r e e a c c e s s . * Throughout the h o s p i t a l ^ I n f a n t s whose c o n d i t i o n warrants s p e c i a l i z e d o b s e r v a t i o n are cared f o r i n the I n t e n s i v e Care Nursery o f the h o s p i t a l . T h i s n u r s e r y i s on the f l o o r below the m a t e r n i t y u n i t . I f the use o f a r e s p i r a t o r i s r e q u i r e d then the i n f a n t i s t r a n s f e r r e d t o another h o s p i t a l . 30 p e r i o d ( w i t h t h e e x c e p t i o n o f a b o u t t w e l v e h o u r s o f o b s e r v a t i o n f o r t h e i n f a n t f o l l o w i n g b i r t h ) t h e m o t h e r may h a v e t h e i n f a n t w i t h h e r i n h e r r o o m a s much o r a s l i t t l e a s s h e d e s i r e s . B a b i e s a r e f e d o n " d e m a n d " a n d f r e q u e n t b r e a s t f e e d i n g i s e n c o u r a g e d . F a t h e r s h a v e v i r t u a l l y u n l i m i t e d v i s i t i n g p r i v i -l e g e s , a r e i n v i t e d t o h a v e m e a l s a t t h e h o s p i t a l , a n d a r e w e l -come t o p a r t i c i p a t e w i t h t h e m o t h e r i n c a r i n g f o r t h e i r i n f a n t . N u r s e s o f f e r a s s i s t a n c e w i t h a n d s u p e r v i s i o n o f p h y s i c a l c a r e o f m o t h e r s and i n f a n t s . I n a d d i t i o n , a n i n d i v i d u a l i z e d p r o g r a m f o r t e a c h i n g some o f t h e s k i l l s i n v o l v e d i n c h i l d c a r e i s o f f e r e d . H e n c e , n u r s i n g a s s i g n m e n t s a r e made o n t h e b a s i s o f m o t h e r - i n f a n t p a i r s , w i t h t h e same n u r s e c a r i n g f o r t h e same f a m i l y o n c o n s e c u t i v e d a y s a s much a s p o s s i b l e . P a r t i c i p a n t s C r i t e r i a f o r S e l e c t i o n T h e s u b j e c t s i n t h i s s t u d y w e r e " h e a l t h y " women who w e r e e x p e c t i n g t h e i r f i r s t c h i l d whom t h e y p l a n n e d t o b r e a s t f e e d . T h e y had t o b e w i l l i n g a n d a b l e t o g i v e w r i t t e n c o n s e n t t o t a k e p a r t i n t h e s t u d y . T h e f a t h e r o f t h e i n f a n t had t o b e w i l l i n g t o p a r t i c i p a t e i n t h e n u r s i n g i n t e r v e n t i o n f o l l o w i n g t h e i n f a n t ' s b i r t h . S e l e c t i o n c r i t e r i a c o n c e r n i n g l a b o u r a n d b i r t h w e r e t o i n c l u d e : 1• a v a g i n a l d e l i v e r y 2 . a b s e n c e o f m a t e r n a l c o m p l i c a t i o n s s u c h a s a f o u r t h d e g r e e 31 t e a r or a postpartum hemorrhage. 3. b i r t h o f a s i n g l e i n f a n t a t term: a. whose Apgar was recorded as 7 or above a t one minute b. who d i d not have any obvious c o n g e n i t a l malformations c who d i d not r e q u i r e s p e c i a l i z e d o b s e r v a t i o n i n the I n t e n s i v e Care Nursery Recruitment I n i t i a l l y , because o f the m u l t i d i s c i p l i n a r y aspect o f the study, p r o s p e c t i v e p a r t i c i p a n t s were approached a t the p r e n a t a l t o u r o f the h o s p i t a l and i n v i t e d t o take p a r t i n the r e s e a r c h p r o j e c t . The women were t o l d b r i e f l y about the study and i n f o r m a t i o n sheets were g i v e n out (Appendix D). Telephone numbers o f women who were i n t e r e s t e d i n p a r t i c i p a t i n g i n the p r o j e c t were recorded and the women were co n t a c t e d by telephone by one of the two i n v e s t i g a t o r s a few days a f t e r the t o u r . I f bo t h p r o s p e c t i v e p a r e n t s consented t o p a r t i c i p a t e i n the study an appointment was made f o r a p r e n a t a l i n t e r v i e w . The i n t e r v i e w was t o e s t a b l i s h r a p p o r t and t o f u r t h e r e x p l a i n the c r i t e r i a t o be met f o r i n c l u s i o n i n the r e s e a r c h p r o j e c t . Questions and comments about the p r o j e c t were i n v i t e d . C o n f i d e n t i a l i t y was assured and consent was obtained (Appendix E ) . The p a r t i c i p a n t s were a l s o t o l d t h a t they would be informed o f the r e s u l t s o f the study when the i n f o r m a t i o n was a v a i l a b l e . The i n v e s t i g a t o r s v i s i t e d the postpartum u n i t on a r e g u l a r b a s i s . The h o s p i t a l r e c o r d s o f those women who had vo l u n t e e r e d t o p a r t i c i p a t e were examined, and i f the c o n d i t i o n s 32 of the b i r t h met the c r i t e r i a o u t l i n e d f o r t h i s study, the mother was assigned by the n u r s i n g i n v e s t i g a t o r t o e i t h e r the c o n t r o l or the experimental group, u t i l i z i n g a p r e v i o u s l y e s t a b l i s h e d random order o f assignment.2 Table 1 summarizes the d a t a obtained from the p a t i e n t ' s c h a r t s concerning the labour and b i r t h o f the f i r s t 32 women who v o l u n t e e r e d t o p a r t i c i p a t e i n the study. TABLE 1 BIRTH INFORMATION FOR FIRST 32 VOLUNTEERS Mother and I n f a n t P a i r s meeting C r i t e r i a 9 I n f a n t s not meeting C r i t e r i a 20 D e l i v e r e d by C a e s a r i a n S e c t i o n 9 Apgar < 7 3 Premature 1 Other c o n d i t i o n s r e q u i r i n g o b s e r v a t i o n s i n the I n t e n s i v e Care Nursery 7 Mothers w i t h postpartum c o m p l i c a t i o n s 3 Hemorrhage 2 A u s t r a l i a A n t i g e n 1 Only n i n e o f the i n i t i a l t h i r t y - t w o v o l u n t e e r s met the b i r t h c r i t e r i a f o r t h i s study. The i n v e s t i g a t o r had a n t i c i -pated t h a t approximately 50 p e r c e n t o f the v o l u n t e e r s would meet the c r i t e r i a based on the i n f o r m a t i o n a v a i l a b l e i n the c o i n was f l i p p e d t o determine i f even numbers should be assigned t o the experimental or c o n t r o l group. A t a b l e o f random numbers was then used f o r s u b j e c t assignment. 33 l i t e r a t u r e ( c f . B r a d l e y , 1976). F u r t h e r r e s e a r c h should be done to determine i f these f i n d i n g s are r e p r e s e n t a t i v e o f mothers who g i v e b i r t h t o t h e i r f i r s t i n f a n t s i n our community. S i n c e l e s s than 30 p e r c e n t o f the v o l u n t e e r s met the b i r t h c r i t e r i a , an a d d i t i o n a l method o f su b j e c t r e c r u i t m e n t was begun. A d e c i s i o n was made t o approach mothers on the postpartum u n i t who had not p r e v i o u s l y attended a p r e n a t a l t o u r . Only those women who had a l r e a d y met the b i r t h c r i t e r i a f o r the study were approached. An e x p l a n a t i o n o f the purpose o f t h e study was g i v e n t o the women a t t h i s time, consent was obtained i f the woman was w i l l i n g t o p a r t i c i p a t e , and c o n f i d e n t i a l i t y was assured. Recruitment proceeded, u s i n g v o l u n t e e r s from bbth.^the p r e n a t a l t o u r s and the postpartum u n i t u n t i l a sample o f twenty-f i v e mothers was o b t a i n e d . Subsequently, two o f these mothers (one i n each group) d i s c o n t i n u e d b r e a s t f e e d i n g d u r i n g the f i r s t postpartum month. The d e c i s i o n was made to c o n t i n u e t h e s e mothers i n the study. The f i n a l sample o f s u b j e c t s f o r t h e purposes o f t h i s study t h e r e f o r e c o n s i s t e d o f t w e n t y - f i v e s u b j e c t s . They were as s i g n e d t o one of two groups, e x p e r i -mental or c o n t r o l , w i t h o u t the p a r t i c i p a n t s * knowledge. There were twelve mothers i n the f i n a l experimental group and t h i r t e e n mothers i n the c o n t r o l group. Procedure f o r C o l l e c t i o n o f Data Regardless of the r e c r u i t m e n t r o u t e , a l l mothers were 34 seen i n the h o s p i t a l f o l l o w i n g the i n f a n t s ' b i r t h s . A t t h a t time the mothers assigned t o the experimental group were asked i f i t would be convenient f o r t h i s i n v e s t i g a t o r t o make a v i s i t t o the f a m i l y home one week f o l l o w i n g the day o f d i s c h a r g e from h o s p i t a l . I t was f u r t h e r requested t h a t b o t h p a r e n t s be p r e s e n t f o r the i n t e r v i e w and the s e l e c t e d time be such t h a t the i n f a n t had been fed about an hour p r i o r t o the appointment and would be, probably, s l e e p i n g when the i n v e s t i g a t o r a r r i v e d . A telephone c a l l on the s p e c i f i e d day confirmed t h a t i t was s t i l l con-v e n i e n t , and arranged the appointment time. The p a r e n t s i n the experimental group p a r t i c i p a t e d i n the nur s i n g i n t e r v e n t i o n d u r i n g t h i s time. The women assign e d t o the c o n t r o l group d i d not have a v i s i t on the t w e l f t h postpartum day. The f i n a l c o n t a c t w i t h a l l the p a r t i c i p a n t s was one month f o l l o w i n g the i n f a n t s ' b i r t h s . A l l p a r t i c i p a n t s were asked t o complete the two q u e s t i o n n a i r e s used i n the study (Appendices B and C ) . The completed forms were e i t h e r c o l l e c t e d by the psychology i n v e s t i g a t o r or mailed by the p a r t i c i p a n t d i r e c t l y t o the nurse i n v e s t i g a t o r . A l l p a r t i c i p a n t s were thanked f o r t h e i r c o - o p e r a t i o n and were reminded t h a t when the f i n d i n g s were com-p i l e d , they would be sent i n f o r m a t i o n about the r e s u l t s . There was no a t t r i t i o n o f s u b j e c t s i n t h i s study. A l l p a r t i c i p a n t s expressed i n t e r e s t i n the study and completed the q u e s t i o n n a i r e s as requested. However, t h e r e was some v a r i a -b i l i t y i n the l e n g t h o f time f o l l o w i n g b i r t h t h a t the q u e s t i o n -n a i r e s were completed. The forms t o be completed were mailed 35 t o the p a r t i c i p a n t s approximately three weeks a f t e r the i n f a n t ' s b i r t h t o ensure t h a t the mother would r e c e i v e the forms i n time t o complete them one month a f t e r the i n f a n t ' s b i r t h . O c c a s i o n -a l l y , these forms went through the mail v e r y q u i c k l y and the mother completed the forms immediately. In other i n s t a n c e s the mother d i d not r e c e i v e the forms u n t i l a month a f t e r the baby's b i r t h and d i d not complete them f o r s e v e r a l days. The number o f days f o l l o w i n g b i r t h t h a t the forms were completed ranged from twenty-three days t o t h i r t y - f i v e days. S t a t i s t i c a l A n a l y s i s A l l p a r t i c i p a n t s were a s s i g n e d s u b j e c t numbers t o ensure c o n f i d e n t i a l i t y . The d a t a , which comprised i n f o r m a t i o n from the h o s p i t a l r e c o r d and the s e l f - r e p o r t measures used as depen-dent v a r i a b l e s , were coded u s i n g F o r t r a n Coding Forms. They were subsequently analyzed a t the U n i v e r s i t y o f B r i t i s h Columbia Computing C e n t r e . The S t a t i s t i c a l Package f o r the S o c i a l S c i e n c e s program was used i n t h i s a n a l y s i s . D e s c r i p t i v e and i n f e r e n t i a l s t a t i s t i c s were used t o a n a l y z e and d e s c r i b e s i m i l a r i t i e s and d i f f e r e n c e s between the experimental and c o n t r o l groups. A l l s t a t i s t i c a l a n a l y s e s were t e s t e d a g a i n s t an a l p h a c r i t e r i o n o f p^.05. L i m i t a t i o n s The study was s u b j e c t t o the f o l l o w i n g l i m i t a t i o n s : 1. A l l s u b j e c t s v o l u n t e e r e d t o take p a r t i n the study. Thus they may not be r e p r e s e n t a t i v e o f the g e n e r a l p o p u l a t i o n 36 o f new mothers. The sample s i z e was s m a l l . The women were w e l l educated and were from i n t a c t - f a m i l y s i t u a t i o n s . A l l mothers experienced a "normal" l a b o u r and b i r t h o f a w e l l i n f a n t . A l l mothers b r e a s t fed t h e i r i n f a n t s i n i -t i a l l y . A l l f a t h e r s 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 be h a v i o u r a l demonstration. A l l spoke and read E n g l i s h . Hence, f i n d i n g s a re a p p l i c a b l e o n l y t o a s i m i l a r group o f pa r e n t s . Maternal adjustment and p e r c e p t i o n o f the i n f a n t d u r i n g the f i r s t month a f t e r b i r t h i s i n f l u e n c e d by more than the i n f a n t ' s b e h a v i o u r a l responses. No attempt was made t o make an assessment o f these o t h e r i n f l u e n c i n g f a c t o r s . For example, the mother-father r e l a t i o n s h i p was not assessed. The q u a l i t y o f t h i s r e l a t i o n s h i p may have a f f e c t e d the mother's postpartum adjustment and her p e r c e p t i o n o f the i n f a n t . The c r i t e r i o n v a r i a b l e s u t i l i z e d i n t h i s study were both s e l f - r e p o r t measures and hence are s u b j e c t t o the l i m i t a -t i o n s o f s e l f - r e p o r t e d d ata. I t was not p o s s i b l e t o c o n t r o l the time a t which the women completed the q u e s t i o n n a i r e s . Hence, t h e r e was some v a r i a b i l i t y i n the number o f days f o l l o w i n g the i n f a n t ' s b i r t h t h a t the q u e s t i o n n a i r e s were completed. I t was not p o s s i b l e t o o b t a i n i n f o r m a t i o n c o n c e r n i n g the amount o f s e p a r a t i o n experienced by mothers and i n f a n t s 37 d u r i n g the hours f o l l o w i n g b i r t h . K l a u s and K e n n e l l (1970, 1976) have argued t h a t the amount o f s e p a r a t i o n can a f f e c t the mother-infant r e l a t i o n s h i p . CHAPTER IV FINDINGS AND DISCUSSION R e s u l t s from the analyses are presented i n t h i s chapter i n two s e c t i o n s . A d e s c r i p t i o n o f the sample i s presented i n the f i r s t s e c t i o n . The second s e c t i o n c o n t a i n s a n a l y s e s o f the d a t a i n r e l a t i o n to the hypotheses o f the study. D e s c r i p t i o n o f the Sample The d a t a were obtained from the h o s p i t a l r e c o r d o f the t w e n t y - f i v e s u b j e c t s i n c l u d e d i n t h e sample. Range, means and standard d e v i a t i o n s were c a l c u l a t e d f o r both the experimental and c o n t r o l groups f o r age and number o f y e a r s o f educ a t i o n as shown i n Ta b l e s 2 and 3. TABLE 2 MOTHER'S AGE ( i n y e a r s ) Group Range Mean s.d. t_ p_ Experimental 18-32 23.3 2.91 0.71 n.s. C o n t r o l 18-33 23.5 3.15 Table 2 i n d i c a t e s t h a t t h e r e was no s i g n i f i c a n t d i f -f e r e n c e i n mean age f o r the two groups. The mean age o f these 38 39 women was 23.4 ye a r s . TABLE 3 MOTHER'S EDUCATION ( i n y e a r s ) Group Range Mean s. d. t p Experimental 11-16 13 . •-• 1.00 0.42 n.s. C o n t r o l 11-18 13.7 1.25 Ta b l e 3 i n d i c a t e s t h a t t h e r e was no s i g n i f i c a n t d i f f e r -ence i n the mean number o f ye a r s o f educa t i o n f o r each group. T h i s sample was a f a i r l y w e l l educated group - many o f the mothers had some u n i v e r s i t y or ot h e r post-secondary t r a i n i n g . The e t h n i c backgrounds o f the p a r t i c i p a n t s were t a b u l a t e d and are shown i n Table 4. TABLE 4 MOTHER'S ETHNIC BACKGROUND Group Caucasian O r i e n t a l Experimental 10 2 C o n t r o l 10 3 T h i s t a b u l a t i o n i n d i c a t e s t h a t t h e r e was no 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 i n terms o f e t h n i c background. 40 T h e r a t i o o f C a u c a s i a n t o O r i e n t a l e t h n i c o r i g i n i s a p p r o x i -m a t e l y w h a t o n e w o u l d e x p e c t f r o m t h e p o p u l a t i o n u s i n g t h e p a r t i c i p a t i n g h o s p i t a l . D e s c r i p t i v e d a t a o n t h e l a b o u r and b i r t h c h a r a c t e r i s t i c s w e r e t a b u l a t e d a c c o r d i n g t o l e n g t h o f l a b o u r i n h o u r s , t y p e o f a n a l g e s i a a n d a n a e s t h e s i a , a n d t h e u s e o f f o r c e p s d u r i n g t h e b i r t h p r o c e s s . T h e r e s u l t s a r e s u m m a r i z e d i n T a b l e s 5 t h r o u g h 8 . T A B L E 5 DURATION O F LABOUR ( h o u r s ) G r o u p R a n g e Mean E x p e r i m e n t a l 6 . 2 5 - 2 3 . 1 6 1 2 . 9 C o n t r o l 8 . 0 8 - 2 0 . 3 3 1 1 . 8 = 0 . 6 1 p. = n . s . T A B L E 6 A N A L G E S I A DURING LABOUR ( n u m b e r o f women r e c e i v i n g ) A n a l g e s i a E x p e r i m e n t a l C o n t r o l G r o u p G r o u p D e m e r o l 5 7 D e m e r o l a n d P h e n e r g a n 2 1 N i s e n t e l - 1 No A n a l g e s i a 5 4 "X = 0 . 8 3 p_ = n . s . 41 Table 5 i n d i c a t e s t h a t the mean l e n g t h o f labour f o r the groups was s i m i l a r . The mean l e n g t h o f labour was s h o r t e r than t h a t o f f o u r t e e n hours r e p o r t e d f o r p r i m i g r a v i d a women by Friedman (1971). Table 6 shows t h a t a f a i r l y high p r o p o r t i o n o f women .in t h e two groups r e c e i v e d no medication d u r i n g labour. Most o f the remaining women r e c e i v e d o n l y demerol i n v a r y i n g amounts. TABLE 7 ANAESTHESIA DURING DELIVERY (number of women r e c e i v i n g ) A n a e s t h e s i a Experimental C o n t r o l Group Group L o c a l I n f i l t r a t i o n 5 2 Pudendal Block 1 2 E p i d u r a l 3 5 No A n a e s t h e s i a 3 4 ~X-= 2.22 p_=n.s. The type o f a n a e s t h e s i a g i v e n t o the women d u r i n g d e l i v e r y i s t a b u l a t e d i n T a b l e 7. Three women i n the experimental group and fou r i n the c o n t r o l group were g i v e n no a n a e s t h e s i a a t a l l . Three women i n the experimental group and f i v e i n the c o n t r o l group had e p i d u r a l s ; one i n the experimental group and two i n the c o n t r o l group had pudendal b l o c k s . L o c a l i n f i l -t r a t i o n was used f o r f i v e women i n the experimental group and two i n the c o n t r o l group. Hence, the p a r t i c i p a n t s had e i t h e r 42 no a n a e s t h e s i a or had a r e g i o n a l a n a e s t h e s i a . TABLE 8 USE OF FORCEPS DURING DELIVERY Type Experimental Group  C o n t r o l Group Mid f o r c e p s 2 2 Low f o r c e p s 4 5 Spontaneous 6 6 X = 0.07 p. = n.s. The type o f d e l i v e r y f o r each p a r t i c i p a n t i s o u t l i n e d i n T a b l e 8. S i x women i n each group experienced spontaneous d e l i v e r i e s . Four women i n the experimental group and f i v e i n the c o n t r o l group had t h e i r d e l i v e r i e s a s s i s t e d by low f o r c e p s . Two women i n each group r e q u i r e d mid f o r c e p s . One o f the c r i t e r i a f o r i n c l u s i o n i n the study was the d e l i v e r y o f a hea l t h y i n f a n t . A l l i n f a n t s d e l i v e r e d t o women p a r t i c i p a t i n g i n the study were g i v e n Apgar scores o f 7 or above a t one minute. A l l i n f a n t s were cared f o r i n the "normal" newborn n u r s e r y on the postpartum f l o o r . There were s i x boys and s i x g i r l s d e l i v e r e d t o women i n the experimental group, and seven boys and s i x g i r l s d e l i v e r e d t o women i n the c o n t r o l group. Data on the Newborn 43 T h e i n f a n t s ' b i r t h w e i g h t s r a n g e d f r o m 2930 t o 3960 g r a m s ; t h e mean b i r t h w e i g h t w a s 3367 g r a m s f o r t h e e x p e r i m e n t a l g r o u p and 3250 g r a m s f o r t h e c o n t r o l g r o u p . F i n d i n g s R e l a t i n g t o H y p o t h e s i s I T h e m o t h e r s i n t h e e x p e r i m e n t a l g r o u p who r e c e i v e t h e d e m o n s t r a t i o n o f t h e i r i n f a n t ' s b e h a v i o u r a l r e s p o n s e s w i l l s c o r e s i g n i f i c a n t l y d i f f e r e n t l y o n p e r c e p t i o n o f t h e i r i n f a n t ( N e o n a t a l P e r c e p t i o n I n v e n t o r y ) t h a n w i l l t h e c o n t r o l g r o u p o f m o t h e r s who d o n o t r e c e i v e t h i s d e m o n s t r a t i o n . I n o r d e r t o d e t e r m i n e i f t h e s e d i f f e r e n c e s e x i s t e d w i t h i n t h e two g r o u p s , S t u d e n t ' s t - T e s t s f o r d e p e n d e n t s a m p l e s ( G l a s s a n d S t a n l e y , 1 9 7 0 , p . 297) w e r e d o n e o n t h e " A v e r a g e B a b y " a n d " Y o u r B a b y " s c o r e s o n t h e N e o n a t a l P e r c e p t i o n I n v e n t o r y . T a b l e 9 s u m m a r i z e s t h e r e s u l t s o f t h e s e a n a l y s e s . T A B L E 9 M E A N S , STANDARD D E V I A T I O N S AND R E S U L T S OF t - T E S T S COMPARING A V E R A G E BABY (A) AND YOUR BABY ( Y ) SCORES ON THE N E O N A T A L P E R C E P T I O N INVENTORY G r o u p mean s . d . t P. E x p e r i m e n t a l ( A ) 1 6 . 9 2 3 . 5 5 2 . 4 2 <C.05 (Y) 1 3 . 9 2 2 . 7 5 C o n t r o l ( A ) 1 7 . 0 8 2 . 1 8 1 . 1 7 n . s . (Y ) 1 6 . 0 8 3 . 5 7 T h e r e s u l t s i n d i c a t e t h a t t h e c o n t r o l g r o u p showed n o d i f f e r e n c e i n how t h e y r a t e d t h e i r b a b i e s i n c o m p a r i s o n w i t h how 44 t h e y r a t e d the average baby a t one month postpartum. The experimental group, a f t e r the n u r s i n g i n t e r v e n t i o n , d i d d i s c r i m i n a t e between t h e i r own babies and the average baby - w i t h s i g n i f i c a n t l y " b e t t e r than average" r a t i n g s o f t h e i r own b a b i e s . I t can be concluded, t h e r e f o r e , t h a t Hypo-t h e s i s I i s supported i n th a t experimental mothers p e r c e i v e d t h e i r own b a b i e s s i g n i f i c a n t l y more p o s i t i v e l y than the average baby, whereas the c o n t r o l mothers d i d not. These f i n d i n g s are c o n s i s t e n t w i t h Kang's (1974) r e s u l t s but not w i t h Ryan's (1973). Ryan suggested her l a c k o f e x p e r i -mental d i f f e r e n c e s may have been due to the small sample s i z e o f her study and the lower e d u c a t i o n a l l e v e l o f her experimental s u b j e c t s , as compared t o her c o n t r o l s u b j e c t s . The p r e s e n t r e s u l t s - and those o f Kang - would make i t appear t h a t the t i m i n g o f the i n t e r v e n t i o n (twelve days i n s t e a d o f two days postpartum) and/or the presence o f the f a t h e r may be important v a r i a b l e s i n determining whether the i n t e r v e n t i o n w i l l succeed. The p r e s e n t i n t e r v e n t i o n d i f f e r e d from t h a t o f both Kang and Ryan i n t h a t the nurse d e s c r i b e d i n d e t a i l the k i n d s o f behav i o u r s t o be expected o f the average baby so t h a t the mother c o u l d make a b e t t e r d i s c r i m i n a t i o n o f the behaviour o f her own baby. I t might be argued, t h e r e f o r e , t h a t the i n t e r v e n t i o n produced an e f f e c t by changing the experimental mothers' r a t i n g o f average b a b i e s r a t h e r than changing t h e i r p e r c e p t i o n s o f t h e i r own baby. However, t h e r e were 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 "average baby" r a t i n g s o f the 45 experimental and c o n t r o l groups. F i n d i n g s R e l a t i n g t o Hypothesis I I The mothers i n the experimental group who r e c e i v e the demonstration o f t h e i r i n f a n t ' s b e h a v i o u r a l responses w i l l score s i g n i f i c a n t l y d i f f e r e n t l y on postpartum adjustment than those who do not r e c e i v e t h i s demonstration as measured by the P o s t n a t a l Research Inventory. There are ten measures o f postpartum adjustment on the P o s t n a t a l Research Inventory (Appendix C ) . The mean scores o f the experimental mothers on each o f these measures were com-pared t o the mean sc o r e s o f the c o n t r o l mothers on the same measures i n order t o t e s t Hypothesis I I . The da t a were ana-l y z e d u s i n g Student's t - T e s t s f o r independent samples. T a b l e 10 summarizes the r e s u l t s o f these a n a l y s e s . Three o f the postpartum maternal adjustment s c a l e s on the P o s t n a t a l Research Inventory showed s t a t i s t i c a l l y s i g n i -f i c a n t d i f f e r e n c e s between the experimental and c o n t r o l groups. These s c a l e s were: Negative A s p e c t s o f C h i l d - r e a r i n g ; I r r i -t a b i l i t y ; and Dep r e s s i o n . The mothers i n the experimental group scored s i g n i f i c a n t l y lower on these measures than d i d the mothers i n the c o n t r o l group. That i s , the experimental mothers i n d i c a t e d t h a t they experienced fewer n e g a t i v e aspects o f c h i l d - r e a r i n g , l e s s i r r i t a b i l i t y , and l e s s d e p r e s s i o n than t h e c o n t r o l mothers. With d i f f e r e n c e s on th r e e out of t e n s c a l e s s i g n i f i c a n t , one must be c a u t i o u s about i n t e r p r e t i n g these r e s u l t s as 46 TABLE 10 MEANS, STANDARD DEVIATIONS, AND RESULTS OF t-TESTS BETWEEN EXPERIMENTAL (E) AND CONTROL (C) GROUPS ON POSTNATAL RESEARCH INVENTORY S c a l e Mean s .d. t 1. Fear or concern (E) 15.17 3.49 -0.75 n.s. f o r baby- (c) 16.08 2.57 2. Negative aspects (E) 14.75 2.01 -2.71 ^.05 o f c h i l d - r e a r i n g (c) 17.46 2.88 3. I n t r a p u n i t i v e (E) 15.08 2.35 0.95 n.s. (c) 14.23 2.12 4. I g n o r i n g (E) 12.50 2.78 -0.49 n.s. (C) 13.08 3.04 5. I r r i t a b i l i t y (E) 13.83 2.50 -3.04 <.05 (c) 16.77 2.30 6. E x t r a p u n i t i v e (E) 13.33 3.42 0.22 n.s. (c) 13.08 2.40 7. Responsiveness (E) 20.67 2.96 0.33 n.s. to i n f a n t ' s needs (c) 20.23 3.56 8. Convalescence (E) 13.58 2.15 0.17 n.s. (c) 13.38 3.40 9. Need f o r (E) 12.67 3.23 -1.23 n.s. reassurance (c) 14.31 3.45 10. Depression (E) 12.50 2.24 -2.37 <C.05 (c) 15.23 3.37 47 c o n f i r m i n g Hypothesis I I . C e r t a i n l y , t h e r e are some 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 t h e i r postpartum a d j u s t -ment but on s e v e r a l s c a l e s the d i f f e r e n c e s a re not s i g n i f i c a n t . N e i t h e r group o f mothers was more apt to be f e a r f u l f o r the baby or l i k e l y t o i g n o r e i t . Both groups were e q u a l l y respon-s i v e t o the i n f a n t s ' needs and showed no d i f f e r e n c e s i n t h e i r own needs f o r reassurance. The groups d i d not d i f f e r i n t h e i r l i k e l i h o o d t o blame themselves or ot h e r s f o r adjustment prob-lems ( I n t r a p u n i t i v e and E x t r a p u n i t i v e s c a l e s ) . A l s o , t h e r e were no d i f f e r e n c e s i n the r e p o r t e d p h y s i c a l recovery o f the women i n both groups from the c h i l d b i r t h e x perience. I t may be t h a t , i f most o f the women i n t h i s sample were i n t e l l i g e n t and w e l l a d j u s t e d persons t o begin w i t h , an i n t e r v e n t i o n such as the pr e s e n t one would not be expected to have a s i g n i f i c a n t e f f e c t on a l l areas o f p o s t n a t a l adjustment. F i n d i n g s R e l a t i n g t o Hypothesis I I I The mothers who have a more p o s i t i v e p e r c e p t i o n of t h e i r i n f a n t as measured by the Neonatal P e r c e p t i o n Inventory w i l l have a more p o s i t i v e postpartum adjustment as measured by the P o s t n a t a l Research Inventory. To t e s t t h i s h y p o t h e s i s , a Pearson product moment c o r r e -l a t i o n ( G l a s s and S t a n l e y , 1970, p. 113) was used t o compare the mothers' scores on the Neonatal P e r c e p t i o n Inventory and the scores on the ten s c a l e s o f the P o s t n a t a l Research Inven-t o r y . The Neonatal P e r c e p t i o n Inventory s c o r e s used were the 48 d i f f e r e n c e s between "Average Baby" and "Your Baby" s c o r e s . T a b l e 11 summarizes the r e s u l t s o f t h i s a n a l y s i s . There were s i g n i f i c a n t n e g a t i v e c o r r e l a t i o n s between the s c o r e s on the Neonatal P e r c e p t i o n Inventory and f o u r o f the s c a l e s o f the P o s t n a t a l Research Inventory. These s c a l e s werei Fear or Concern f o r the I n f a n t ; I r r i t a b i l i t y ; Need f o r Reas-surance; and D e p r e s s i o n . A h i g h s c o r e on the Neonatal Per-c e p t i o n Inventory ("Your Baby" s c o r e g r e a t e r than "Average Baby", i . e . a p o s i t i v e p e r c e p t i o n o f the i n f a n t ) was a s s o c i a t e d w i t h a low s c o r e on the four P o s t n a t a l Research Inv e n t o r y s c a l e s . I t appears t h a t t h e r e was no r e l a t i o n s h i p between p e r -c e p t i o n o f the i n f a n t and convalescence from the c h i l d b i r t h . The mother's p a t t e r n o f i g n o r i n g or responding to the i n f a n t a l s o d i d not r e l a t e t o her p e r c e p t i o n of the i n f a n t . Tendencies t o blame h e r s e l f or o t h e r s f o r p o s t n a t a l adjustment problems ( I n t r a p u n i t i v e and E x t r a p u n i t i v e s c a l e s ) or t o f i n d these problems r e s t r i c t i v e on her l i f e s t y l e (Negative Aspects) were not r e l a t e d t o her p e r c e p t i o n o f the i n f a n t . Those measures which are c o n s i s t e n t w i t h the concept o f d e p r e s s i o n or "the b l u e s " ( s c a l e s o f D e p r e s s i o n ; I r r i t a b i l i t y ; and Fear f o r the I n f a n t ) r e l a t e s i g n i f i c a n t l y t o poor p e r c e p t i o n o f the i n f a n t . S i m i l a r l y , those women who had a h i g h need f o r reassurance tended t o p e r c e i v e t h e i r i n f a n t n e g a t i v e l y . I t i s , o f course, p o s s i b l e t h a t the r e l a t i o n between maternal a d j u s t -ment and p e r c e p t i o n o f the i n f a n t works the other way. That i s , 49 T A B L E 11 C O R R E L A T I O N C O E F F I C I E N T S BETWEEN N E O N A T A L P E R C E P T I O N INVENTORY AND P O S T N A T A L R E S E A R C H INVENTORY P o s t n a t a l R e s e a r c h I n v e n t o r y S c a l e s N e o n a t a l P e r c e p t i o n I n v e n t o r y D i f f e r e n c e S c o r e s ! r D 1 . F e a r o r C o n c e r n f o r b a b y - 0 . 3 4 ^ . 0 5 2 . N e g a t i v e a s p e c t s o f c h i l d - r e a r i n g - 0 . 2 7 n . s . 3 . I n t r a p u n i t i v e - 0 . 1 5 n . s . 4 . I g n o r i n g 0 . 0 4 n . s . 5 . I r r i t a b i l i t y - 0 . 4 4 < .05 6 . E x t r a p u n i t i v e - 0 . 0 1 n . s . 7 . R e s p o n s i v e n e s s t o i n f a n t ' s n e e d s 0 . 0 2 n . s . 8 . C o n v a l e s c e n c e 0 . 0 3 n . s . 9 . N e e d f o r r e a s s u r a n c e - 0 . 3 2 < .05 1 0 . D e p r e s s i o n - 0 . 4 1 ^ . 0 5 l n Y o u r B a b y " s c o r e m i n u s " A v e r a g e B a b y " s c o r e • 50 a n e g a t i v e p e r c e p t i o n o f the i n f a n t r e s u l t s i n a depressed, i r r i t a b l e , w o r r y i n g woman who l o o k s f o r reassurance from o t h e r s . Broussard (1971) a l s o found a s t a t i s t i c a l l y s i g n i f i c a n t n e g a t i v e r e l a t i o n s h i p between maternal p e r c e p t i o n o f the i n f a n t and the De p r e s s i o n , Negative A s p e c t s , and I r r i t a b i l i t y s c a l e s i n a l a r g e sample o f primipa r o u s women from the e a s t e r n United S t a t e s . T h i s f i n d i n g was c l e a r l y r e p l i c a t e d i n the p r e s e n t study, although the p r e s e n t i n v e s t i g a t o r a l s o found Fear or Concern f o r the I n f a n t t o be s i g n i f i c a n t f o r the women i n her western Canadian sample. Summary The d e s c r i p t i o n o f the c h a r a c t e r i s t i c s o f the p a r t i -c i p a n t s i n d i c a t e s t h a t the experimental and c o n t r o l groups were v e r y s i m i l a r on the v a r i a b l e s examined. I n g e n e r a l , the s u b j e c t s i n t h i s study were young, w e l l educated women who had f a i r l y b r i e f and uncomplicated labours and gave b i r t h t o h e a l t h y i n f a n t s . The experimental r e s u l t s o f t h i s study support the c o n c l u s i o n t h a t the n u r s i n g i n t e r v e n t i o n was h e l p f u l , i n t h a t i 1. the experimental group mothers d i d d i s c r i m i n a t e between t h e i r own baby and the average baby - w i t h s i g n i f i c a n t l y " b e t t e r than average" r a t i n g s o f t h e i r own baby. 2. the experimental group mothers rep o r t e d fewer n e g a t i v e aspects o f c h i l d - r e a r i n g , l e s s i r r i t a b i l i t y , and l e s s 51 d e p r e s s i o n . 3. a p o s i t i v e p e r c e p t i o n o f t h e i n f a n t w a s a s s o c i a t e d w i t h a l o w s c o r e o n s c a l e s o f N e e d f o r R e a s s u r a n c e ; I r r i t a b i l i t y ; D e p r e s s i o n ; a n d F e a r o r C o n c e r n f o r t h e I n f a n t . B o t h m o t h e r s a n d f a t h e r s r e p o r t e d t h a t t h e y f e l t t h a t t h e i n f o r m a t i o n c o n t a i n e d i n t h e n u r s i n g i n t e r v e n t i o n was u s e f u l t o t h e m a s t h e y a d a p t e d t o t h e i r new p a r e n t a l r o l e . D e t a i l s o f t h e r e a c t i o n s o f p a r e n t s i n t h e e x p e r i m e n t a l g r o u p w i l l b e d i s c u s s e d i n t h e n e x t c h a p t e r u n d e r " I m p l i c a t i o n s f o r P r a c t i c e . " CHAPTER V IMPLICATIONS FOR NURSING PRACTICE AND RESEARCH I m p l i c a t i o n s f o r Nursing P r a c t i c e The network o f r e l a t i o n s h i p s t h a t e x i s t s between the i n f a n t and those i n h i s environment i s very important as the neonate develops i n t o a f u l l y f u n c t i o n i n g s o c i a l b e i n g. Thus, the f a m i l y , and s p e c i f i c a l l y , the r e l a t i o n s h i p s the i n f a n t has w i t h o t h e r f a m i l y members w i l l be a major i n f l u e n c e on h i s l i f e . A t the time an i n f a n t i s born the parents w i l l have had experiences t h a t w i l l be r e f l e c t e d i n the types o f p a r e n t s they become. Kennedy's 1969 study i n d i c a t e s t h a t the way i n which the mother p r o g r e s s e s through the m a t e r n i t y c y c l e can i n f l u e n c e the b e g i n n i n g m o t h e r - c h i l d r e l a t i o n s h i p . One can s p e c u l a t e from the present study t h a t the amount o f i n f o r m a t i o n mothers r e c e i v e d about i n f a n t behaviour p a t t e r n s and about the b e h a v i o u r a l responses t y p i c a l of t h e i r own i n f a n t s was a l s o a f a c t o r i n t h e i r postpartum adjustment. Perhaps the i n d i v i d u a l -i z e d assessment o f the i n f a n t (which experimental mothers r e -ceived) helped the mothers l e a r n how t o more a c c u r a t e l y p e r c e i v e the i n f a n t ' s needs and h i s or her s t y l e o f i n t e r a c t i o n . T h i s a c c u r a t e and s e n s i t i v e p e r c e p t i o n c o u l d improve t h e i r a b i l i t y to c a r e f o r the baby i n response to i t s behaviours - whatever 52 53 the infant's s t y l e of i n t e r a c t i o n . The infants, i n turn, could become more receptive to t h e i r care. The mothers' feelings of accomplishment and enjoyment i n t h e i r new r o l e s might then be enhanced. This may have been what was r e f l e c t e d i n the d i f -ferences between groups reported i n the findings of t h i s study. If the interactions between mother and c h i l d are pleasurable, mothers are l i k e l y to seek further opportunities to i n t e r a c t and hence, the q u a l i t y of the r e l a t i o n s h i p should be f a c i l i t a t e d for both mother and infant. I t has been noted that parents who exhibit maladaptive patterns and who are economically and s o c i a l l y deprived require professional assistance i n order to promote the cognitive and s o c i a l development of t h e i r children (Ainsworth, 1973). For t h i s sample of well educated, motivated, primiparous mothers, the information given i n the nursing intervention was asso-ciated with reported fewer negative aspects of c h i l d - r e a r i n g , less i r r i t a b i l i t y and depression, and a more p o s i t i v e perception of the infant over that exhibited by the same type of women not receiving the intervention. I t would appear, therefore, that t h i s kind of intervention can have measurable benefits for normal parents who are not economically or s o c i a l l y deprived. I f t h i s intervention i s included i n a postnatal nursing practice i t would seem that i t could be b e n e f i c i a l to a l l new parents and not just to selected high-risk sub-samples. This type of approach may not have been incorporated 54 i n t o our n u r s i n g p r a c t i c e i n p a r t because o f the "myth o f maternal i n s t i n c t . " Because o f t h i s myth, we have assumed t h a t when a woman becomes a mother she w i l l , l o v e the i n f a n t and hence, know how t o c a r e f o r i t ( B r a d l e y , 1976). C u r r e n t r e s e a r c h , i n c l u d i n g the present study, c l e a r l y i n d i c a t e s t h a t t h i s l o v i n g r e l a t i o n s h i p i s l e a r n e d and t h a t women can be a s s i s t e d i n e s t a b l i s h i n g t h a t r e l a t i o n s h i p by e f f e c t i v e i n t e r -v e n t i o n . T h i s study demonstrated t h a t a n u r s i n g i n t e r v e n t i o n c o u l d produce a more p o s i t i v e p e r c e p t i o n o f the newborn by the new mother, which i s a p r e r e q u i s i t e f o r a l o v i n g r e l a t i o n -s h i p . In c l i n i c a l p r a c t i c e the m a t e r n a l - c h i l d nurse should be s e n s i t i v e t o the many other f a c t o r s than can i n f l u e n c e the development o f a l o v i n g r e l a t i o n s h i p . The mothers i n the experimental group were not aware t h a t the r e s e a r c h e r was f o c u s i n g on maternal p e r c e p t i o n and adjustment. From the mother's p e r s p e c t i v e the i n v e s t i g a t o r was a r e s o u r c e to the f a m i l y to h elp them i n a d j u s t i n g t o t h e i r new i n f a n t . A l l the mothers and f a t h e r s i n the experimental group expressed i n t e r e s t i n the i n t e r v e n t i o n . T h e i r r e a c t i o n s were assessed i n s e v e r a l s u b j e c t i v e ways. F i r s t , as the assessment was implemented, p a r e n t s moved p h y s i c a l l y c l o s e r t o the i n v e s t i g a t o r and baby. O f t e n t h i s i n v o l v e d the moving o f f u r n i t u r e . Secondly, as the i n t e r v e n t i o n p r o g r e s s e d , the p a r e n t s appeared to r e l a x and they asked more frequent ques-t i o n s . F i n a l l y , the comments made at the end o f the i n t e r v i e w 55 were very p o s i t i v e . "You've answered a l l the q u e s t i o n s we had about our baby." "We d i d n ' t know how wonderful — was." "We thought the baby co u l d see but my mother s a i d he c o u l d n ' t . I t ' s g r e a t t o know how t o he l p him to f o c u s on t h i n g s and t o know what he l i k e s to lo o k a t . " They a l s o r e p o r t e d t h a t the i n f o r m a t i o n g i v e n d u r i n g the i n t e r v e n t i o n d i d not d u p l i c a t e i n f o r m a t i o n they had been g i v e n elsewhere. However, one cou p l e d i d comment t h a t they had known about some o f these behaviours but had not as y e t been ab l e t o e l i c i t t hese responses from t h e i r baby. In t h i s i n s t a n c e , p o i n t i n g out t h a t the baby could not focus on t h e i r f a c e s because they t y p i c a l l y s a t on a s o f a w i t h the i n f a n t f a c i n g a l a r g e , u s u a l l y b r i g h t , " p i c t u r e " window i n t e r f e r e d w i t h h i s a b i l i t y to see t h e i r f a c e s . Merely moving to another l o c a t i o n and h o l d i n g the baby u p r i g h t so t h a t the mother's f a c e was c l o s e t o the baby helped. The p a r e n t s were d e l i g h t e d t o then observe t h a t the baby was ab l e t o focus on and f o l l o w t h e mother's sl o w l y moving f a c e . One mother commented to the i n v e s t i g a t o r two weeks l a t e r , "Did you come t o t a l k t o us j u s t about b a b i e s ? We t a l k e d f o r hours a f t e r you l e f t about our g o a l s i n p a r e n t i n g and we wondered i f you intended us to do t h i s . " T h i s comment i s o f f e r e d as an i l l u s t r a t i o n o f the p o s s i b l e c a r r y - o v e r e f f e c t s o f the i n t e r v e n t i o n . 56 The f o c u s of the i n t e r v e n t i o n was to d e s c r i b e i n f a n t s ' behaviour p a t t e r n s and t y p i c a l b e h a v i o u r a l responses t o t h e i r p a r e n t s . As a r e s u l t , the p a r e n t s seemed t o f e e l f r e e to respond w i t h t h e i r f e e l i n g s and a t t i t u d e s towards c a r i n g f o r the baby. They made comments such as, "You mean some babies o b j e c t to b e i n g held c l o s e and p r e f e r to be held l o o s e l y . I thought I was j u s t annoying him by the way I was h o l d i n g him." Demonstrating behaviours and the r e s p o n s i v e s t y l e o f t h e i r i n f a n t s d i d appear (from the p a r e n t s ' comments) to help them a s s e s s the i n f a n t ' s i n d i v i d u a l s t y l e and t o make sense out o f t h e i r i n f a n t responses. T h i s seemed t o a l l e v i a t e p a r e n t a l a n x i e t y , as B r a z e l t o n (1961) p r e d i c t e d i t would. The chance t o ask q u e s t i o n s , v o i c e concerns, and see t h a t the i n f a n t a l r e a d y has a b e h a v i o u r a l s t y l e t h a t w i l l i n f l u e n c e the way h i s or her p a r e n t s c a r e f o r him or her d i d seem t o be important t o the p a r e n t s who took p a r t i n the i n t e r v e n t i o n . The nature o f the i n t e r v e n t i o n i s such t h a t the parents and the i n v e s t i g a t o r d i s c u s s e d the p a r e n t s ' r o l e i n r e l a t i o n t o the i n f a n t . Because o f t h i s f o c u s , one mother, f o r i n s t a n c e , r e p o r t e d t h a t she f e l t t h a t the i n v e s t i g a t o r was i n t e r e s t e d i n her and she was a b l e t o share her concerns w i t h me. She had not p r e v i o u s l y r e l a t e d these concerns t o the p u b l i c h e a l t h nurse who had come on a "baby v i s i t . " T h i s i n t e r a c t i v e focus i s important to p r o f e s s i o n a l nurses who are i n t e r e s t e d i n working w i t h f a m i l i e s as an i n t e r -a c t i v e u n i t . C l a r k (1971) has w r i t t e n t h a t the a n t i c i p a t e d 57 or a c t u a l b i r t h o f a c h i l d w i l l f o r c e the r e o r g a n i z a t i o n o f the f a m i l y as a s o c i a l system. She w r i t e s f u r t h e r t h a t the g r e a t e s t s h i f t i n r o l e s occurs when the f i r s t c h i l d i s added t o the f a m i l y . The i n t e r v e n t i o n g i v e s p a r e n t s i n f o r m a t i o n t h a t w i l l h e l p them t o behave a p p r o p r i a t e l y a c c o r d i n g t o the i n f a n t ' s cues d u r i n g the t r a n s i t i o n t o t h e i r new r o l e s . In a d d i t i o n , by l i s t e n i n g t o the p a r e n t s ' v o i c e d concerns and a t t i t u d e s towards p a r e n t i n g , the nurse i s a b l e to a s s e s s how the parents are adapting t o t h e i r new r o l e s . T h i s assessment i s , o f course, important t o f u r t h e r n u r s i n g i n t e r v e n t i o n s w i t h the f a m i l y . The f a m i l y a l s o has a chance t o see the nurse i n a d i f f e r e n t r o l e because o f the fo c u s o f t h i s i n t e r v e n t i o n . Many f a m i l i e s s t i l l t h i n k o f nurses as h e l p i n g them when they are i l l . The i n v e s t i g a t o r ' s i n t e r e s t and concern about the " t o t a l " f a m i l y was a s u r p r i s e t o some o f the p a r t i c i p a n t s i n the study. While i t was not p o s s i b l e t o do so (because o f the nature o f the r e s e a r c h ) , s e v e r a l p a r e n t s f e l t they would l i k e t o have f u r t h e r d i s c u s s i o n s about t h e i r i n f a n t w i t h the i n v e s t i g a t o r . Hence, nurses u s i n g t h i s approach c o u l d f i n d i t t o be an important v e h i c l e f o r e s t a b l i s h i n g r a p p o r t when working w i t h a f a m i l y on a c o n t i n u i n g b a s i s . D u r i n g the course o f the study t h e r e were two i n s t a n c e s i n which the i n v e s t i g a t o r f e l t t h a t mother-infant dyads were e x p e r i e n c i n g d i f f i c u l t i e s d u r i n g the acquaintance p e r i o d . In one case the community h e a l t h nurse was a l r e a d y v i s i t i n g 58 two or t h r e e times a week and was to c o n t i n u e t o do so. The second mother was r e f e r r e d by the i n v e s t i g a t o r ( w i t h the mother's consent) to the l o c a l p u b l i c h e a l t h agency f o r f u r t h e r f o l l o w - u p s . Because o f the nature o f the problems experienced by these two mothers, i t was f e l t by the i n v e s t i g a t o r t h a t the twelve-day time frame o f the i n t e r v e n t i o n used i n t h i s study was not an optimum t i m i n g f o r these mothers. The t w e l f t h day f o l l o w i n g the i n f a n t ' s b i r t h had been s e l e c t e d u s i n g Rubin's (1961) p a t t e r n s o f maternal behaviour, and because Kang (1974) had used a s i m i l a r t i m i n g f o r her s u c c e s s f u l i n t e r v e n t i o n . In c l i n i c a l p r a c t i c e however, i n d i v i d u a l assessment to determine when the mother i s i n t e r e s t e d i n o b t a i n i n g t h i s i n f o r m a t i o n would seem to be p r e f e r a b l e . T h i s study attempted t o t r a n s l a t e the e x i s t i n g t h e o r i e s about the needs o f mothers i n the postpartum p e r i o d i n t o n u r s i n g p r a c t i c e . In t h i s v e i n , the i n v e s t i g a t o r acted as a r o l e model i n a s s i s t i n g mothers to i d e n t i f y the behaviours t y p i c a l o f t h e i r i n f a n t s . At f i r s t t h i s was a d i f f i c u l t r o l e t o undertake. I t i n v o l v e d l e a r n i n g a new way o f a s s e s s i n g i n f a n t s . While a c e r t a i n number o f hours have to be spent l e a r n i n g to be sen-s i t i v e t o d i f f e r e n c e s i n i n f a n t b e h a v i o u r s , i t appears, on the b a s i s o f the f i n d i n g s o f t h i s study, t h a t i t i s a worthwhile approach f o r nurses to undertake. Advances i n n u t r i t i o n a l knowledge and the c o n t r o l o f communicable d i s e a s e s a l l o w nurses t o broaden t h e i r focus t o h e a l t h as w e l l as i l l n e s s . With t h i s focus t h e r e i s a d e s i r e 59 to help i n d i v i d u a l s and f a m i l i e s develop h e a l t h y r e l a t i o n s h i p s d u r i n g the t r a n s i t i o n to p a r e n t a l r o l e s . Nurses have the p o t e n t i a l f o r promoting and f a c i l i t a t i n g m o t h e r - i n f a n t i n t e r -a c t i o n s on the p r e v e n t a t i v e as w e l l as the remedial l e v e l ( P o r t e r , 1973). The i n v e s t i g a t o r would argue, from her ex-p e r i e n c e s w i t h t h i s study, t h a t , because o f the g e n e r a l l a c k o f support f o r p a r e n t i n g i n our s o c i e t y , nurses should a c t i v e l y i n t e r v e n e i n h e l p i n g t o e s t a b l i s h h e a l t h 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 i n the e a r l y postpartum p e r i o d . Other approaches c o u l d be i n s t i t u t e d as w e l l . Many o f these parents appeared t o enjoy t a l k i n g w i t h the i n v e s t i g a t o r about t h e i r e x p e r i e n c e s w i t h t h e i r newborn i n f a n t s . Oppor-t u n i t i e s f o r t h i s s h a r i n g o f i d e a s among pa r e n t s should be promoted. While some p a r e n t i n g c l a s s e s have a l r e a d y been e s t a b l i s h e d i n the postpartum p e r i o d , these should be i n c r e a s e d i n order to re a c h l a r g e numbers o f p a r e n t s . Although inform-a t i o n g i v i n g i s one f o c u s o f these c l a s s e s , an e q u a l l y important a s p e c t i s the sh a r i n g o f values and reinforcement o f behaviours among par e n t s . T h i s may a l s o h e l p t o form s o c i a l networks f o r young c o u p l e s who may not otherwise have t h i s o p p o r t u n i t y i n our s o c i e t y . I m p l i c a t i o n s f o r Research Based on the r e s u l t s o f the presen t study the f o l l o w i n g recommendations f o r f u r t h e r r e s e a r c h are suggested. The i n v e s t i g a t o r found t h a t l e s s than 30 p e r c e n t o f the 60 women who were approached p r e n a t a l l y met the c r i t e r i a f o r the c o n d i t i o n s o f the b i r t h t h a t are o u t l i n e d i n Chapter I I I . Over 25 p e r c e n t o f the d e l i v e r i e s were by C a e s a r i a n s e c t i o n and over 50 perc e n t o f the bab i e s d e l i v e r e d i n t h i s s m a l l sample r e q u i r e d s p e c i a l i z e d n u r s i n g care i n the I n t e n s i v e Care Nursery. Perhaps the type o f b i r t h and c o n d i t i o n o f the i n f a n t f o l l o w i n g b i r t h f o r p r i m i p a r o u s women i n our com-munity needs t o be examined f u r t h e r . I f indeed l a r g e numbers o f mother-infant p a i r s are separated because the i n f a n t ' s c o n d i t i o n warrants s p e c i a l i z e d c a r e , we need t o determine the f a c t o r s t h a t lead t o t h i s p r a c t i c e . The work o f K l a u s and K e n n e l l (1976) would i n d i c a t e t h a t these mother-infant dyads are p l a c e d i n a hig h r i s k s i t u a t i o n due t o t h i s sepa-r a t i o n f o l l o w i n g b i r t h . Research t h a t showed f a c t o r s which c o u l d be changed or procedures t h a t could be in t r o d u c e d i n ord e r -to reduce t h i s r i s k could r e p r e s e n t an important a d d i t i o n t o n u r s i n g p r a c t i c e . A r e l a t i o n s h i p t h a t i s l a r g e l y unexplored at t h i s time i s t he husband-wife r e l a t i o n s h i p f o l l o w i n g t h e b i r t h o f a c h i l d . S p e c i f i c a l l y , r e s e a r c h should be d i r e c t e d towards understanding how the mother-father r e l a t i o n s h i p a f f e c t s the r e l a t i o n s h i p between mother and c h i l d and between the f a t h e r and c h i l d . As E l f e r t (1975) has a l r e a d y suggested, nurses need t o develop r e l i a b l e and v a l i d methods f o r a s s e s s i n g maternal a d a p t i v e behaviour. The present r e s e a r c h r e p r e s e n t s a step i n t h a t d i r e c t i o n . As e a r l y as one month postpartum some 61 m o t h e r - i n f a n t p a i r s i n t h i s s t u d y g a v e i n d i c a t i o n s t h a t t h e y w e r e n o t p r o g r e s s i n g i n t h e d e v e l o p m e n t o f a p o s i t i v e r e l a -t i o n s h i p . I t a p p e a r s t h a t m a t e r n a l p e r c e p t i o n o f t h e i n f a n t w o u l d r e p r e s e n t a n i m p o r t a n t c o m p o n e n t o f a n y i n s t r u m e n t d e v e l -o p e d t o i d e n t i f y h i g h - r i s k m o t h e r - i n f a n t r e l a t i o n s h i p s . O n e a p p r o a c h t o t h e d e v e l o p m e n t o f s u c h a n a s s e s s m e n t t o o l w o u l d b e t o e x a m i n e how p r e n a t a l a t t i t u d e s a n d e x p e c t a t i o n s r e l a t e t o m o t h e r s ' p o s t n a t a l a d j u s t m e n t a n d p e r c e p t i o n o f t h e i r i n f a n t s . I f s u c h r e l a t i o n s h i p s c a n b e d e t e r m i n e d , n u r s i n g a p p r o a c h e s f o r a t t e m p t i n g t o i n f l u e n c e t h e o u t c o m e o f t h e a c -q u a i n t a n c e p e r i o d c a n b e i m p l e m e n t e d p r i o r t o o r i m m e d i a t e l y f o l l o w i n g t h e b i r t h . T h i s s t u d y l o o k e d a t m a t e r n a l p e r c e p t i o n o f t h e i n f a n t . T h i s i s o n l y o n e f a c t o r i n t h e d e v e l o p m e n t o f a p o s i t i v e m o t h e r -i n f a n t r e l a t i o n s h i p . R e s e a r c h n e e d s t o b e d o n e t o i d e n t i f y o t h e r f a c t o r s a n d d e t e r m i n e i f t h e y a r e m o r e o r l e s s i m p o r t a n t t h a n m a t e r n a l p e r c e p t i o n o f t h e i n f a n t . F o r e x a m p l e , t h e m o t h e r ' s s e l f - p e r c e p t i o n h a s b e e n s t u d i e d i n r e l a t i o n t o c h a n g e s t h a t o c c u r w i t h p r e g n a n c y . T h e c h a n g e s i n s e l f - p e r c e p t i o n t h a t o c c u r a f t e r c h i l d b i r t h s h o u l d a l s o b e e x a m i n e d t o s e e how t h e s e p e r c e p t i o n s i n f l u e n c e t h e m o t h e r ' s r e l a t i o n s h i p w i t h h e r i n f a n t . F i n a l l y , i t s h o u l d b e n o t e d t h a t r e l a t i v e l y l i t t l e r e s e a r c h h a s b e e n d o n e t o i d e n t i f y t h e n e e d s o f t h e f a m i l y a s t h e a d j u s t m e n t t o new p a r e n t a l r o l e s i s a c c o m p l i s h e d . T h i s r e s e a r c h i s r e q u i r e d i n o r d e r f o r u s t o s t u d y b e t t e r ways o f m e e t i n g t h e s e n e e d s o n c e t h e y h a v e b e e n i d e n t i f i e d . 62 Based on the r e s u l t s o f t h i s e x p l o r a t o r y study, an important n u r s i n g approach which w i l l f a c i l i t a t e the mother's adjustment f o l l o w i n g the b i r t h of her f i r s t c h i l d i s to t e a c h her about her i n f a n t ' s b e h aviours. F u r t h e r r e s e a r c h i n t o f a c t o r s t h a t may be important d u r i n g the c h i l d b e a r i n g c y c l e have been o u t l i n e d . T h i s w i l l f a c i l i t a t e nurses i n a s s i s t i n g f a m i l i e s i n the b u i l d i n g o f s a t i s f y i n g h e althy r e l a t i o n s h i p s with t h e i r i n f a n t s . 63 SELECTED BIBLIOGRAPHY Abernathy, V.D. S o c i a l network and response t o the maternal r o l e . I n t e r n a t i o n a l J o u r n a l o f S o c i o l o g y o f the Family, 1973, 1, 5, 86-92. Adams, M. E a r l y concerns o f p r i m i g r a v i d a mothers r e g a r d i n g i n f a n t c a r e a c t i v i t i e s . N u r s i n g Research, 1963, 12, 72-77. Ainsworth, M.D.S. The development o f infant-mother attachment. In B.M. C a l d w e l l and H.N. R i c c u i t i ( E d s . ) , Review of  C h i l d Development Research, Volume 3. Chicagoi U n i -v e r s i t y o f Chicago P r e s s , 1973, 1-94. Bowlby, J . The nature o f the c h i l d ' s t i e t o h i s mother. I n t e r n a t i o n a l J o u r n a l o f P s y c h o a n a l y s i s , 1958, 39, 350-373. B r a d l e y , C. The e f f e c t s o f h o s p i t a l experience on the p o s t -partum f e e l i n g s and a t t i t u d e s o f women. Unpublished Ph.D. t h e s i s , U n i v e r s i t y o f B r i t i s h Columbia, 1976. B r a z e l t o n , T.B. P s y c h o p s y c h i a t r i c r e a c t i o n i n the neonate. J o u r n a l o f P e d i a t r i c s . 1961, 58, 508-512. , . The e a r l y mother-infant adjustment, P e d i a t r i c s , 1963, 32, 931-938. . E f f e c t o f maternal e x p e c t a t i o n s on e a r l y i n f a n t behaviour, E a r l y C h i l d Development Care. 1973, 2, 259-273. . Neonatal b e h a v i o u r a l assessment s c a l e . P h i l a d e l p h i a i J.B. L i p p i n c o t t , 1973. Broussard, C. and Hartner, M. F u r t h e r c o n s i d e r a t i o n s r e g a r d i n g maternal p e r c e p t i o n o f the f i r s t born. In J . Hellmuth (Ed.), E x c e p t i o n a l i n f a n t ; s t u d i e s i n a b n o r m a l i t i e s . Volume 2. New Y o r k i Brunner Mazel, 1971, 432-444. Carpenter, H.M. The need f o r a s s i s t a n c e o f mothers w i t h f i r s t  b a b i es d u r i n g the three-month p e r i o d f o l l o w i n g the baby's b i r t h . Mimeographed d o c t o r a l d i s s e r t a t i o n , Columbia U n i v e r s i t y , 1965. C l a r k , A. The ad a p t a t i o n problem and p a t t e r n s o f an expanding f a m i l y . the ne o n a t a l p e r i o d . Nursing Forum, 1966, 5, 104. M a t u r a t i o n a l c r i s i s o f c h i l d b e a r i n g . Honolulu: U n i v e r s i t y or Hawaii, School o t Nu r s i n g and C o l l e g e of C o n t i n u i n g E d u c a t i o n and Community S e r v i c e , 1971. 64 C l a r k , A . and A f f o n s o , D . C h l l d b e a r i n g : a n u r s i n g p e r s p e c t i v e . P h i l a d e l p h i a : F . A . D a v i s C o . , 1 9 7 6 . C r o n e n w e t t , L . R . T r a n s i t i o n t o p a r e n t h o o d . I n L . K . M c N a l l a n d J . T . G a l e e n e r ( E d s . ) , C u r r e n t p r a c t i c e i n o b s t e t r i c and  g y n e c o l o g i c n u r s i n g , V o l u m e 1 . S a i n t L o u i s : C . V . M o s b y , 1 9 7 6 . E d e l s t e i n , J . M . T h e e f f e c t o f n u r s i n g i n t e r v e n t i o n w i t h t h e  B r a z e l t o n n e o n a t a l b e h a v i o u r a l a s s e s s m e n t s c a l e o n  p o s t p a r t u m ad j u s t m e n t a n d m a t e r n a l p e r c e p t i o n o f t h e  i n f a n t . U n p u b l i s h e d m a s t e r ' s t h e s i s , Y a l e U n i v e r s i t y S c h o o l o f N u r s i n g , 1 9 7 5 . E l f e r t , H . C r i t i q u e i n G . N . Z i l m , A . M . S t i n s o n , M . S t e a d and p . O v e r t o n ( E d s . ) , D e v e l o p m e n t a n d u s e o f i n d i c a t o r s  i n n u r s i n g r e s e a r c h . E d m o n t o n : U n i v e r s i t y o f A l b e r t a S c h o o l o f N u r s i n g , 1 9 7 5 . G l a s s , G . V . a n d S t a n l e y , J . C S t a t i s t i c a l m e t h o d s i n e d u c a t i o n  a n d p s y c h o l o g y . New J e r s e y : P r e n t i c e - H a l l , 1970 J o r d a n , A . D . E v a l u a t i o n o f a f a m i l y - c e n t e r e d m a t e r n i t y c a r e h o s p i t a l p r o g r a m . P a r t I : I n t r o d u c t i o n , D e s i g n , and T e s t i n g . J o u r n a l o f O b s t e t r i c . G y n e c o l o g i c , and  N e o n a t a l N u r s i n g . 1 9 7 3 , 2 , 1 , 1 3 - 3 5 . • E v a l u a t i o n o f a f a m i l y - c e n t e r e d m a t e r n i t y c a r e h o s p i t a l p r o g r a m . P a r t I I : A n c i l l a r y F i n d i n g s a n d P a r e n t s ' C o m m e n t s . J o u r n a l o f O b s t e t r i c , G y n e c o l o g i c . a n d N e o n a t a l N u r s i n g , 1 9 7 3 , 2 , 2 , 1 5 - 2 7 . K a n g , R . T h e r e l a t i o n s h i p b e t w e e n i n f o r m i n g b o t h p a r e n t s o f  t h e i r i n f a n t ' s b e h a v i o u r a l r e s p o n s e p a t t e r n s a n d t h e  m o t h e r ' s p e r c e p t i o n o f t h e i n f a n t . U n p u b l i s h e d m a s t e r ' s t h e s i s , U n i v e r s i t y o f W a s h i n g t o n , 1 9 7 4 . K e a n e , V . R . I s t h e f o c u s i n t h e f a m i l y ? A m e r i c a n N u r s e s A s s o c i a t i o n C l i n i c a l C o n f e r e n c e . 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 , 1 9 7 0 , 3 2 1 - 3 2 4 . K e n n e d y , J . T h e l i t t l e s t r a n g e r : m o t h e r - i n f a n t a c q u a i n t a n c e  p r o c e s s . U n p u b l i s h e d P h . D . t h e s i s , B o s t o n U n i v e r s i t y , 1 9 6 9 . • T h e h i g h - r i s k m a t e r n a l - i n f a n t a c q u a i n t a n c e p r o c e s s . N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 1 9 7 3 , 8 , 3 , 5 4 9 - 5 5 6 . K l a u s , M . H . a n d 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 n e w b o r n i n f a n t s . 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J o u r n a l o f Marriage and  the F a m i l y . 1968, 30, 26-39. Rubin, R. B a s i c maternal behaviour. Nursing Outlook, 1961, 9, 11, 638-686. • The f a m i l y - c h i l d r e l a t i o n s h i p and n u r s i n g c a r e . Nursing Outlook, 1964, _2, 9, 36-39. • Attainment o f the maternal r o l e : P a r t I : p r o c e s s e s . Nursing Research. 1967, _6, 237-245. Ryan, L. Mat e r n a l p e r c e p t i o n o f neon a t a l behaviour. Unpub-l i s h e d master's t h e s e s , U n i v e r s i t y o f Washington, 1973. S a r b i n , T.R. and A l l e n , V.L. Role theory. In G. L i n d z e y and E. Aronson ( E d s . ) , The Handbook o f S o c i a l Psychology. Volume 1. Massachusetts: Addison-Wesley, 1968, 488-567. Schaefer, E. and Manheimer, H. Dimensions o f p e r i n a t a l ad i u s t -ment. Paper presented a t 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 Annual Meeting. New York: A p r i l , 1960. Schwitzgebel, R.K. and K o l b , D.A. Changing human behaviour: p r i n c i p l e s o f planned i n t e r v e n t i o n . New York: McGraw-H i l l , 1974. S t a t i s t i c a l Package f o r the S o c i a l S c i e n c e s . Computer Centre: U n i v e r s i t y o f B r i t i s h Columbia, 1975. 66 Walker, L. P r o v i d i n g more r e l e v a n t m a t e r n i t y s e r v i c e s . J o u r n a l of O b s t e t r i c , Gynecologic and Neonatal N u r s i n g , 1974, 3, 35-45. W o l f f , P.H. The causes, c o n t r o l s and o r g a n i z a t i o n of behaviours i n the neonate. New Yorki I n t e r n a t i o n a l U n i v e r s i t i e s P r e s s , I n c . , 1965. 67 APPENDIX A INFORMATION INCLUDED IN THE NURSING INTERVENTION 68 INFANT SLEEPING PATTERNS Babies, l i k e a d u l t s , have two types o f sleeps deep s l e e p and l i g h t s l e e p . During deep sleep the baby l i e s very q u i e t l y , and looks very p e a c e f u l , w i t h o n l y an o c c a s i o n a l s t a r t l e . The baby's b r e a t h i n g i s deep and r e g u l a r d u r i n g t h i s t ype o f s l e e p . When the baby i s i n l i g h t s l e e p he o r she may move around and appear r e s t l e s s t o you. You w i l l n o t i c e t h a t the baby makes sucking movements a t times and t h a t t h e r e may be eye movements beneath the baby's c l o s e d e y e l i d s . Sometimes b a b i e s may appear t o h o l d t h e i r b r e a t h f o r a few seconds so t h a t t h e i r b r e a t h i n g may appear i r r e g u l a r . A l l these a c t i v i t i e s a re o f t e n seen dur i n g t h i s type o f l i g h t s l e e p . Newborns u s u a l l y spend about h a l f t h e i r s l e e p i n g time i n l i g h t s l e e p , and h a l f i n deep s l e e p . As the baby matures over the next few months you w i l l n o t i c e t h a t more time i s spent i n q u i e t , deep s l e e p and l e s s time i n l i g h t s l e e p . Newborns vary g r e a t l y i n the amount o f time they spend s l e e p i n g each day. Some seem t o spend most o f the time a s l e e p w h i l e o t h e r s remain awake f o r l o n g p e r i o d s o f time. However, most babies s l e e p between f i f t e e n t o eighteen hours a day i n the f i r s t weeks o f l i f e . As your baby matures over the next few weeks, the p a t t e r n o f your baby's sl e e p w i l l change i n two ways. The t o t a l number o f hours spent s l e e p i n g each day w i l l p r o b a b l y decrease a l i t t l e and your baby w i l l a l s o begin t o s l e e p f o r longer p e r i o d s a t one time. By the time the i n f a n t i s around s i x t e e n weeks o l d 69 y o u c a n e x p e c t p r o l o n g e d p e r i o d s o f s l e e p , w i t h m o r e s l e e p a t n i g h t t h a n i n t h e d a y t i m e . T h u s , t h e b a b y ' s p a t t e r n s o f s l e e p w i l l b e m o r e s i m i l a r t o y o u r own p a t t e r n b y t h a t t i m e . W h i l e y o u r b a b y i s a s l e e p y o u c a n s e e how he o r s h e r e a c t s t o b e i n g d i s t u r b e d b y l i g h t a n d s o u n d . B r i e f l y s h i n e a f l a s h l i g h t o v e r t h e b a b y ' s c l o s e d e y e s t o s e e i f t h e r e i s a r e s p o n s e t o t h i s t y p e o f s t i m u l a t i o n d u r i n g s l e e p . W a i t a b o u t f i f t e e n s e c o n d s a n d r e p e a t t h e s t i m u l a t i o n . Y o u c a n r e p e a t t h i s t h r e e o r f o u r t i m e s t o s e e i f t h e b a b y ' s r e s p o n s e s c h a n g e . A t a n o t h e r t i m e y o u c a n s e e how t h e b a b y r e s p o n d s t o t h e s o u n d o f a r a t t l e , a n d / o r t o t h e s o u n d o f a b e l l . A l w a y s b e s u r e t o w a i t f o r a t l e a s t f i f t e e n s e c o n d s b e t w e e n s t i m u -l a t i o n s t o g i v e t h e b a b y a c h a n c e t o r e s p o n d t o t h e d i s t u r b a n c e . B a b i e s v a r y i n h o w , o r i f , t h e y r e s p o n d t o t h i s t y p e o f s t i m u l a t i o n . Some b a b i e s r e s p o n d v e r y l i t t l e . O t h e r s may b e d i s t u r b e d a t f i r s t b u t c a n f a i r l y q u i c k l y " s h u t o u t " t h e s t i m u l u s . O t h e r b a b i e s c a n n o t s h u t o u t t h e s t i m u l a t i o n a t a l l and b e c o m e more a c t i v e e a c h t i m e t h e l i g h t i s f l a s h e d o r t h e s o u n d p r o d u c e d . What we w o u l d l i k e y o u t o s e e i s how y o u r b a b y r e a c t s t o b e i n g d i s t u r b e d d u r i n g s l e e p . W h i l e a l l t h e s e p a t t e r n s o f b e h a v i o u r a r e n o r m a l f o r t h e n e w b o r n , k n o w i n g how y o u r b a b y r e a c t s c a n a f f e c t t h e way y o u c a r e f o r t h e b a b y w h e n he o r s h e i s a s l e e p . F o r i n s t a n c e , i f t h e b a b y ' s s l e e p i s e a s i l y d i s t u r b e d b y e i t h e r l i g h t o r n o i s e , y o u may w a n t t o p r o v i d e a q u i e t , d a r k p l a c e i n w h i c h t h e b a b y w i l l s l e e p . I f , o n t h e o t h e r h a n d , y o u r i n f a n t i s n o t b o t h e r e d b y e i t h e r l i g h t 70 or n o i s e , then you w i l l not have t o he as concerned about h i s or her s l e e p i n g environment. BEHAVIOUR WHEN THE BABY IS AWAKE Your baby w i l l have a unique p a t t e r n o f wakefulness t h a t w i l l develop as he or she matures over the weeks and months ahead. Some parents are concerned because t h e i r i n f a n t i s not "tuned i n " t o day and n i g h t as a d u l t s a r e . However, j u s t as the baby w i l l e s t a b l i s h longer p e r i o d s o f s l e e p d u r i n g the f i r s t months of l i f e , he or she w i l l a l s o begin t o be awake at more reasonable times. From b i r t h , i n f a n t s can engage i n a wide v a r i e t y o f behaviours. Some behaviours w i l l be i n response t o the e n v i -ronment and w i l l become easy f o r you t o p r e d i c t . For example, you may l e a r n t h a t your baby always c r i e s when undressed f o r a bath. Others behaviours are i n response t o i n t e r n a l s t i m u l i , are unique t o your baby, and perhaps are the most f a s c i n a t i n g f o r you, as a parent t o l e a r n t o a n t i c i p a t e . As an example, by watching the baby's behaviour you w i l l l e a r n how b e s t t o h o l d and comfort your i n f a n t - b a b i e s l i k e t o be soothed i n d i f f e r e n t ways, depending on t h e i r temperaments. The behaviour your i n f a n t shows i n h i s f i r s t days and weeks w i l l depend l a r g e l y on the baby's degree o f a l e r t n e s s . You can p l a y w i t h and s t i m u l a t e your baby and he or she w i l l respond t o you when he or she i s a l e r t . However, your baby w i l l s l i p i n t o and out o f t h i s s t a t e a t f i r s t because an i n f a n t 71 d o e s n o t h a v e much a b i l i t y t o c o n t r o l h i s o r h e r s t a t e o f a t t e n t i o n . I f y o u c a n l e a r n t o r e c o g n i z e w h e n he o r s h e i s a l e r t a n d p l a y w i t h t h e b a b y d u r i n g t h i s t i m e * y o u c a n h e l p y o u r b a b y l e a r n t o b e a l e r t f o r l o n g e r p e r i o d s a t o n e t i m e . When i n f a n t s a r e a l e r t t h e i r e y e s a p p e a r t o " b r i g h t e n " a n d w i d e n . T h e b a b y u s u a l l y b e c o m e s q u i t e s t i l l a n d t h e b a b y ' s b r e a t h i n g i s s l o w e r and m o r e r e g u l a r . He o r s h e may a p p e a r t o b e l o o k i n g i n t e n t l y a t some o b j e c t t h a t i s f a i r l y c l o s e . I f y o u d o n ' t n o t i c e t h e b a b y i n t h e a l e r t s t a t e y o u m i g h t t r y h o l d i n g t h e b a b y up t o y o u r s h o u l d e r o r u p r i g h t , f a c i n g y o u , t o s e e i f t h e b a b y w i l l become a l e r t . T h e s e p o s i -t i o n s may a l s o h e l p t h e b a b y t o r e m a i n i n t h e a l e r t s t a t e f o r l o n g e r p e r i o d s a t o n e t i m e . O n c e y o u l e a r n t o t e l l when t h e b a b y i s a l e r t y o u may b e g i n t o n o t i c e t h a t t h e b a b y i s u s u a l l y a l e r t a t c e r t a i n t i m e s o f t h e d a y o r a f t e r some a c t i v i t i e s . F o r e x a m p l e , s o m e t i m e s b a b i e s a r e a l e r t i m m e d i a t e l y a f t e r b a t h i n g , o r j u s t a f t e r f e e d -i n g , o r j u s t b e f o r e g o i n g t o s l e e p . We d o know t h a t n e w b o r n s s p e n d a b o u t 10 p e r c e n t o f t h e i r w a k i n g t i m e i n t h i s a l e r t s t a t e . We h o p e y o u ' l l b e a b l e t o t e l l when t h e b a b y i s a l e r t and s h a r e some t i m e w i t h h i m o r h e r t h e n . What c a n y o u d o t o p l a y w i t h a n e w b o r n i n f a n t ? B a b i e s seem t o e n j o y l i s t e n i n g t o a v a r i e t y o f s o u n d s . A t f i r s t , b a b i e s seem t o r e s p o n d b e s t t o a s o f t , h i g h - p i t c h e d v o i c e . Y o u m i g h t t r y m o v i n g t o o n e s i d e o f t h e b a b y s o t h a t t h e b a b y c a n ' t s e e y o u a n d s o f t l y c a l l t h e b a b y ' s name s e v e r a l t i m e s . 72 N o t i c e i f the baby becomes q u i e t and appears to be l i s t e n i n g . Does he or she t u r n towards the sound? Perhaps your baby won't appear i n t e r e s t e d i n t h i s a c t i v i t y j u s t y e t . I f t h i s i s so, t r y again i n a few days. Most newborns a l s o seem to enjoy v i s u a l games. Babies seem t o l i k e to look a t b r i g h t , shiny o b j e c t s such as a red b a l l or o t h e r b r i g h t t o y . However, i n o r d e r f o r the baby t o be a b l e t o focus on the o b j e c t , i t should be i n the range o f about seven i n c h e s away from the baby's eyes. A s l o w l y moving o b j e c t seems to be be s t a t c a t c h i n g the baby's a t t e n t i o n i n the f i r s t weeks f o l l o w i n g b i r t h . Hold the baby u p r i g h t f a c i n g you and s l o w l y move your f a c e from s i d e t o s i d e or up and down i n f r o n t o f the baby. Most babies seem i n t e r -e s t e d i n watching, but remember t h a t the baby won't be able t o s t a y a l e r t f o r long. Watch f o r the baby's r e a c t i o n s and stop when he or she appears to be t i r i n g . During the next few weeks the baby's a b i l i t y t o c o n t r o l movements so t h a t he or she can look a t what i s o f i n t e r e s t i n c r e a s e s r a p i d l y . Soon the baby w i l l be a b l e t o t u r n h i s or her head i n order t o see a moving o b j e c t . L a t e r , o f course, the baby w i l l be able t o c o n t r o l and c o o r d i n a t e a l l movements. But t h i s c o n t r o l u s u a l l y begins w i t h d e l i b e r a t e head movements so t h a t the baby can see what i s o f i n t e r e s t . You can help the baby i n t h i s development by n o t i c i n g when the baby i s a l e r t and by p l a c i n g o b j e c t s so t h a t the baby can see them. Another a c t i v i t y your baby may enjoy i s s i t t i n g up. P l a c e the baby on your l a p w i t h h i s or her head near your knees. Take the baby g e n t l y , but f i r m l y , by the hands and s l o w l y help 73 h i m o f h e r u p t o a s i t t i n g p o s i t i o n . D o y o u f e e l r e s i s t a n c e a s y o u p u l l u p ? D o e s t h e b a b y a t t e m p t t o p l a c e h i s o r h e r h e a d u p r i g h t i n t h e m i d l i n e ? Some b a b i e s r e a l l y seem t o e n j o y t h i s a c t i v i t y w h i l e o t h e r s a r e n o t r e a d y f o r i t a s y e t . T h e a c t i v i t y o f s i t t i n g u p d e p e n d s l a r g e l y o n t h e b a b y ' s m u s c l e t o n e . A n o t h e r way t o a s s e s s t h e b a b y ' s m u s c l e t o n e i s t o p l a c e t h e b a b y o n h i s o r h e r s t o m a c h . D o e s t h e b a b y l i f t h i s o r h e r h e a d a n d t u r n i t t o t h e s i d e ? M o s t b a b i e s h a v e t h i s a b i l i t y t o move t h e i r h e a d s t o m a i n t a i n a c l e a r a i r w a y . V e r y l i t t l e i s k n o w n a b o u t t h e r e a s o n s f o r t h e t e n t a t i v e s m i l e s y o u w i l l s e e i n y o u r n e w b o r n . B u t e v e n t h e y o u n g e s t i n f a n t s s m i l e . A t f i r s t , y o u w i l l h a v e d i f f i c u l t y g e t t i n g t h e b a b y t o s m i l e . S h o r t l y , h o w e v e r , t h e b a b y w i l l s m i l e i n r e s p o n s e t o y o u . T h e m o r e y o u h e l p t h e b a b y t o r e s p o n d t o y o u b y p l a y i n g d u r i n g t h e a l e r t t i m e , t h e s o o n e r y o u w i l l b e g i n t o s e e r e s p o n s i v e s m i l e s . C R Y I N G Many n e w b o r n s seem t o c r y m o r e t h a n t h e i r p a r e n t s e x p e c t a n d t h i s i s o f c o n c e r n t o a l o t o f new p a r e n t s . B a b i e s c r y f o r many r e a s o n s , some o f w h i c h a r e r e a d i l y a p p a r e n t , w h i l e o t h e r s a r e n o t . A s y o u a r e g e t t i n g " a c q u a i n t e d " w i t h y o u r b a b y l i s t e n f o r t h e r h y t h m o f t h e b a b y ' s c r y i n g . T h i s may h e l p y o u t o d i s t i n g u i s h a h u n g r y c r y f r o m a c r y t h a t r e s u l t s f r o m b e i n g t i r e d , o r c r a n k y . C r y i n g c a n a l s o r e s u l t f r o m b e i n g t o o w a r m , o r n o t warm e n o u g h ; f r o m t o o much s t i m u l a t i o n ( n o i s e , e x c e s s i v e 74 h a n d l i n g ) o r f r o m l a c k o f s t i m u l a t i o n ( b o r e d o m ) . I n f a n t s may a l s o c r y when t h e y a r e u n d r e s s e d , d u r i n g b a t h i n g , o r j u s t b e f o r e h a v i n g a b o w e l m o v e m e n t . I t w i l l t a k e t i m e f o r y o u t o l e a r n w h a t t y p e o f s i t u a t i o n s a r e l i k e l y t o make y o u r i n f a n t c r y a n d t o l e a r n t o t e l l t h e v a r i o u s t y p e s o f c r i e s f r o m o n e a n o t h e r I A s w e l l a s l e a r n i n g t o t e l l why y o u r b a b y i s c r y i n g , y o u w i l l want t o w o r k o u t m e t h o d s o f s o o t h i n g o r c o n s o l i n g y o u r b a b y d u r i n g t h o s e t i m e s when t h e b a b y i s c r y i n g a n d n o t h i n g a p p a r e n t i s t h e p r o b l e m . J u s t p l a c i n g y o u r f a c e w h e r e t h e b a b y c a n s e e i t w o r k s w i t h some b a b i e s . O t h e r i n f a n t s q u i e t t o t h e s o u n d o f a v o i c e o r t o t h e s o u n d o f m u s i c . P l a c i n g y o u r h a n d f a i r l y f i r m l y o n t h e b a b y ' s abdomen a n d / o r h o l d i n g t h e b a b y ' s a r m s w i l l h e l p o t h e r b a b i e s t o q u i e t ( t h i s p r e v e n t s t h e s t a r t l e r e f l e x f r o m o c c u r r i n g ; s o m e t i m e s t h i s r e f l e x seems t o f r i g h t e n t h e n e w b o r n a n d c a u s e f u r t h e r c r y i n g ) . Some b a b i e s p u t t h e i r t h u m b o r f i n g e r s i n t h e i r m o u t h s t o s u c k a n d q u i e t t h e m s e l v e s . ( T h i s i s n o t n e c e s s a r i l y a s i g n o f h u n g e r s i n c e a l l b a b i e s s u c k a t t i m e s o t h e r t h a n when t h e y a r e h u n g r y . ) T h i s t y p e o f s u c k i n g i s i m p o r t a n t b e c a u s e i t i s a w a y t h e b a b y c a n c o m f o r t h i m s e l f . T h i s t y p e o f s u c k i n g w i l l n o t a f f e c t t h e b a b y ' s t e e t h u n l e s s i t c o n t i n u e s p a s t t h e f o u r t h b i r t h d a y . I t may b e t h a t y o u r b a b y i s s o o t h e d b e s t b y t h e u s e o f a p a c i f i e r . O f c o u r s e , t h e m o s t common way t o q u i e t a b a b y i s t o h o l d t h e b a b y a n d / o r w a l k o r r o c k h i m o r h e r . H o w e v e r , y o u w i l l h a v e t o d i s c o v e r t h e b e s t w a y s o f c o n s o l i n g f o r y o u and y o u r b a b y . I n c l u d e d i n t h i s l e a r n i n g i s w a t c h i n g t h e b a b y t o s e e how t h e b a b y l i k e s t o b e h e l d . Some b a b i e s s n u g g l e and m o l d t o y o u r b o d y w h i l e o t h e r s 75 s e e m t o s t i f f e n a n d f e e l u n c o m f o r t a b l e b e i n g h e l d i n t h i s w a y . Some b a b i e s a r e m o s t r e l a x e d when y o u h o l d t h e m c l o s e . O t h e r s p r e f e r b e i n g o n y o u r l a p s o t h a t t h e y c a n l o o k a r o u n d . T h i s i s a n i n d i c a t i o n o f y o u r b a b y ' s i n d i v i d u a l i t y . L o o k a t t h e w a y y o u r b a b y r e a c t s t o b e i n g h e l d and t h e n d e c i d e w h a t m e t h o d o f h o l d i n g a n d c o m f o r t i n g i s b e s t f o r t h e b a b y a n d f o r y o u . W h a t e v e r m e t h o d o f h o l d i n g a n d c o n s o l i n g y o u r b a b y i s b e s t f o r y o u , p l e a s e remember o n e p o i n t . T h e b a b y may s t o p c r y i n g b e f o r e he o r she i s f u l l y r e l a x e d . Y o u s h o u l d c o n t i n u e w h a t e v e r c o m f o r t m e a s u r e y o u u s e u n t i l t h e b a b y s t o p s c r y i n g a n d y o u f e e l h i s o r h e r b o d y r e l a x . W h a t e v e r t h e r e a s o n f o r c r y i n g , t h e b a b y i s u s i n g o n e o f h i s f e w m e t h o d s o f c o m m u n i c a t i o n a t t h i s t i m e . Y o u c a n n o t " s p o i l " a n e w b o r n b a b y b y r e s p o n d i n g t o h i s c r y i n g d u r i n g t h e f i r s t few m o n t h s o f h i s l i f e . S o m e t i m e s p a r e n t s n o t i c e t h a t when t h e b a b y c r i e s t h e r e a r e n o t e a r s . T h i s o c c u r s b e c a u s e t e a r d u c t s i n b a b i e s a r e n o t f u l l y d e v e l o p e d u n t i l t h e b a b y i s a b o u t t h r e e m o n t h s o l d , s o t e a r i n g i s d e l a y e d u n t i l t h e n f o r some b a b i e s . B a b i e s d o c r y a n d many new p a r e n t s a r e s u r p r i s e d b y how much c r y i n g t h e r e i s . P e r h a p s i t w i l l h e l p y o u t o know t h a t m o s t b a b i e s c r y m u c h l e s s a f t e r t h e y a r e a b o u t s i x w e e k s o l d . OTHER BEHAVIOURS A s y o u k n o w , t h e n e r v o u s s y s t e m o f y o u r b a b y i s n o t y e t f u l l y d e v e l o p e d . T h i s i s why y o u may o b s e r v e some 76 t r e m b l i n g i n y o u r b a b y n o w , p a r t i c u l a r l y a f t e r t h e b a b y h a s b e e n c r y i n g o r i s c o l d . T h i s i m m a t u r i t y i s a l s o why b a b i e s h i c c u p s o m u c h . P e r h a p s y o u h a v e a l r e a d y o b s e r v e d t h i s i n y o u r b a b y . A s y o u r b a b y m a t u r e s y o u w i l l o b s e r v e l e s s o f t h i s b e h a v i o u r . Y o u c a n t r y t o b u r p t h e b a b y o r y o u c a n t r y g i v i n g t h e b a b y a l i t t l e more f e e d i n g t o s e e i f t h i s w i l l h e l p . W h a t e v e r t h e c a u s e , h i c c u p i n g u s u a l l y s t o p s i n a b o u t t e n m i n u t e s . I n s p i t e o f t h i s i m m a t u r i t y o f t h e n e r v o u s s y s t e m t h e n e w b o r n h a s s e v e r a l i n b o r n p r o t e c t i v e m e c h a n i s m s . T h e a b i l i t y t o c r y a n d t h u s c o m m u n i c a t e w i t h h i s p a r e n t s i s o n e o f t h e b e s t m e t h o d s o f p r o t e c t i o n . O t h e r m e t h o d s i n c l u d e b l i n k i n g i f a n o b j e c t a p p r o a c h e s t h e e y e s , c o u g h i n g o r s n e e z i n g t o c l e a r t h e a i r w a y , a n d y a w n i n g t o g e t more o x y g e n . I n a d d i t i o n , i f y o u p l a c e y o u r b a b y o n h i s s t o m a c h w i t h h i s f a c e p l a c e d a g a i n s t t h e s u r f a c e o n w h i c h h e i s l y i n g , y o u w i l l n o t e t h a t h e l i f t s h i s h e a d a n d t u r n s i t t o one s i d e . T h i s a b i l i t y t o move t h e h e a d i s a n o t h e r i m p o r t a n t method o f p r o t e c t i o n ( o f c o u r s e , t h e b a b y m u s t b e p l a c e d o n a f i r m s u r f a c e t h a t d o e s n o t h a v e l o o s e o b j e c t s w h i c h may become t a n g l e d u p w i t h h i s o r h e r h e a d ) . We a r e f a s c i n a t e d b y t h e d i f f e r e n t w a y s i n w h i c h n e w b o r n s b e h a v e i n t h e i r f i r s t w e e k s o f l i f e . B e c a u s e e a c h i n f a n t i s so u n i q u e i t may t a k e some t i m e f o r y o u , a s a p a r e n t , t o f e e l c o n f i d e n t i n i n t e r p r e t i n g y o u r b a b y ' s b e h a v i o u r . We h o p e t h a t t h e i n f o r m a t i o n we h a v e i n c l u d e d h e r e w i l l a s s i s t y o u i n y o u r new p a r e n t a l r o l e . 77 APPENDIX B BROUSSARD NEONATAL PERCEPTION INVENTORY 78 A V E R A G E BABY A l t h o u g h t h i s i s y o u r f i r s t b a b y , y o u p r o b a b l y h a v e some i d e a s o f w h a t m o s t l i t t l e b a b i e s a r e l i k e . P l e a s e c h e c k t h e b l a n k y o u t h i n k b e s t d e s c r i b e s t h e A V E R A G E B A B Y . 1 . How much c r y i n g d o y o u t h i n k t h e a v e r a g e b a b y d o e s ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 2 . How much t r o u b l e d o y o u t h i n k t h e a v e r a g e b a b y h a s i n f e e d i n g ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 3. How much s p i t t i n g u p o r v o m i t i n g d o y o u t h i n k t h e a v e r a g e b a b y d o e s ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 4 . How much d i f f i c u l t y d o y o u t h i n k t h e a v e r a g e b a b y h a s i n s l e e p i n g ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 5 . How much d i f f i c u l t y d o e s t h e a v e r a g e b a b y h a v e w i t h b o w e l m o v e m e n t s ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 6 . How much t r o u b l e d o y o u t h i n k t h e a v e r a g e b a b y h a s i n s e t t l i n g down t o a p r e d i c t a b l e p a t t e r n o f e a t i n g a n d s l e e p i n g ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 79 YOUR BABY Y o u h a v e h a d a c h a n c e t o l i v e w i t h y o u r b a b y f o r a b o u t a m o n t h n o w . P l e a s e c h e c k t h e b l a n k y o u t h i n k b e s t d e s c r i b e s y o u r b a b y . 1 . How much c r y i n g h a s y o u r b a b y d o n e ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 2 . How much t r o u b l e h a s y o u r b a b y h a d w i t h f e e d i n g s ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 3. How much s p i t t i n g u p o r v o m i t i n g h a s y o u r b a b y d o n e ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 4 . How much d i f f i c u l t y h a s y o u r b a b y h a d i n s l e e p i n g ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 5 . How much d i f f i c u l t y h a s y o u r b a b y had w i t h b o w e l m o v e m e n t s ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 6 . How much t r o u b l e h a s y o u r b a b y h a d i n s e t t l i n g down t o a p r e d i c t a b l e p a t t e r n o f e a t i n g a n d s l e e p i n g ? a g r e a t d e a l a g o o d b i t m o d e r a t e a m o u n t v e r y l i t t l e n o n e 80 A P P E N D I X C S C H A E F E R AND M A N H E I M E R ' S P O S T N A T A L R E S E A R C H INVENTORY AND SCORE S H E E T 81 1. I w o r r y a b o u t w h e t h e r my b a b y i s g e t t i n g t h e r i g h t amount o r r i g h t k i n d o f f o o d . O f t e n ; S o m e t i m e s j R a r e l y ; N e v e r . 2 . I m i s s my f r e e d o m s i n c e h a v i n g a b a b y . O f t e n j S o m e t i m e s ; R a r e l y ; N e v e r . 3 . When t h e b a b y c r i e s a l o t , I w o r r y a b o u t w h a t I ' m d o i n g w r o n g . O f t e n ; S o m e t i m e s ; R a r e l y j N e v e r . 4 . I t h i n k t h a t a y o u n g b a b y s h o u l d b e h a n d l e d o n l y a s much a s i s n e c e s s a r y t o c a r e f o r h i m o r h e r . S t r o n g l y a g r e e ; M i l d l y a g r e e ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 5 . I ' m a f r a i d I ' l l l o s e my t e m p e r w i t h t h e b a b y . O f t e n j S o m e t i m e s ; R a r e l y } N e v e r . 6 . I t w o u l d h a v e b e e n e a s i e r f o r me t o t a k e c a r e o f t h e b a b y i f I d i d n ' t h a v e t o l e a v e t h e h o s p i t a l s o s o o n . S t r o n g l y a g r e e j M i l d l y a g r e e } M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 7 . W h e n e v e r t h e b a b y h a s a b o w e l movement I c h a n g e t h e d i a p e r : I m m e d i a t e l y ; W i t h i n a f e w m i n u t e s ; W i t h i n f i f t e e n m i n u t e s ; W i t h i n t h e h o u r ; I n a n h o u r o r s o . 8 . A f t e r h a v i n g my b a b y , I f e l t l i k e d o i n g a s much w o r k a s I d i d b e f o r e p r e g n a n c y : I n l e s s t h a n a week j I n l e s s t h a n two w e e k s ; I n l e s s t h a n t h r e e o r f o u r w e e k s ; N o t y e t . 9 . I ' v e w i s h e d t h a t I c o u l d h a v e someone t o t e l l me i f I am d o i n g a g o o d j o b i n c a r i n g f o r my b a b y . O f t e n 5 S o m e t i m e s ; R a r e l y ; N e v e r . 10. I h a v e o f t e n f e l t u n h a p p y a n d i n l o w s p i r i t s s i n c e h a v i n g t h e b a b y . O f t e n ; S o m e t i m e s j R a r e l y } N e v e r . 11. I w o r r y a b o u t how much c l o t h i n g o r how many b l a n k e t s t h e b a b y s h o u l d h a v e . O f t e n ; S o m e t i m e s ; R a r e l y ; N e v e r . 12. I h a v e n ' t had t h e t i m e t o r e s t o r r e l a x s i n c e I came home. S t r o n g l y a g r e e ' M i l d l y a g r e e ', M i l d l y d i s a g r e e j S t r o n g l y d i s a g r e e • 82 13. I f I c o u l d o n l y be more sure o f myself i n c a r i n g f o r the baby, I t h i n k the baby would be more r e l a x e d . S t r o n g l y agree } M i l d l y agree ; M i l d l y d i s a g r e e j S t r o n g l y d i s a g r e e . 14. There's no use i n t a l k i n g t o a baby u n t i l he g e t s a l i t t l e o l d e r . S t r o n g l y agree j M i l d l y agree ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 15. Taking c a r e o f the baby l e a v e s me on edge and t e n s e . Often ; Sometimes } R a r e l y ; Never . 16. I t h i n k t h a t my f a m i l y and f r i e n d s c o u l d have been more h e l p f u l t o me when I came home from t h e h o s p i t a l . S t r o n g l y agree j M i l d l y agree } M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 17. When my baby wets h i s d i a p e r I change him: Immediately ; W i t h i n a few minutes ; W i t h i n a h a l f hour ; W i t h i n an hour ; Whenever I get around to i t . 18. I could climb s t a i r s e a s i l y a f t e r having my baby w i t h i n : Three days ; A week ; Two weeks ; More than two weeks . 19. I'd f e e l encouraged i f people would t e l l me my baby looks strong and h e a l t h y . S t r o n g l y agree ; M i l d l y agree ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 20. Since having the baby, I've had c r y i n g s p e l l s . Often ; Sometimes ; R a r e l y ; Never . 21. I worry t h a t something might happen t o the baby when I bathe him. S t r o n g l y agree ; M i l d l y agree 5 M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 22. We can't manage t o go out s i n c e having the baby. S t r o n g l y agree j M i l d l y agree ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 23. I f I had p a i d more a t t e n t i o n t o what I was t o l d by d o c t o r s and n u r s e s , I wouldn't have as many problems i n c a r i n g f o r my baby as I do. S t r o n g l y agree ; M i l d l y agree ; M i l d l y d i s a g r e e $ S t r o n g l y d i s a g r e e • 83 2 4 . T h e b e s t way t o b r i n g u p a b a b y i s t o p u t h i m o n a r e g u l a r f e e d i n g s c h e d u l e f r o m t h e b e g i n n i n g . S t r o n g l y a g r e e ; M i l d l y a g r e e ; M i l d l y d i s a g r e e j S t r o n g l y d i s a g r e e • 2 5 . A b a b y ' s c r y i n g g e t s o n y o u r n e r v e s a f t e r a w h i l e . S t r o n g l y a g r e e ; M i l d l y a g r e e j M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 2 6 . I w i s h my h u s b a n d w o u l d g i v e me m o r e h e l p w i t h t h e b a b y t h a n he d o e s . S t r o n g l y a g r e e ; M i l d l y a g r e e ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 2 7 . I f my b a b y c r i e s f o r s o m e t h i n g t o e a t , I f e e d h i m : I m m e d i a t e l y ; W i t h i n f i v e m i n u t e s ; W i t h i n f i f t e e n m i n u t e s ; O n l y i f i t ' s t i m e f o r a f e e d i n g . 2 8 . A f t e r h a v i n g t h e b a b y I f e l t l i k e g o i n g o u t f o r a n e v e n i n g a g a i n w i t h i n J A week j Two w e e k s ; T h r e e o r f o u r w e e k s ; N o t y e t . 2 9 . I ' v e w i s h e d a d o c t o r w o u l d s e e my b a b y s o he c o u l d t e l l me i f h e o r s h e w e r e a l r i g h t . O f t e n j S o m e t i m e s j R a r e l y ; N e v e r . 3 0 . I ' v e b e e n d i s c o u r a g e d a b o u t n o t b e i n g a b l e t o c a r e f o r t h e b a b y . O f t e n ; S o m e t i m e s ; R a r e l y ; N e v e r . 3 1 . I am c o n c e r n e d w h e t h e r t h e b a b y i s g r o w i n g a s h e s h o u l d . S t r o n g l y a g r e e j M i l d l y a g r e e ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 3 2 . I n e v e r g e t c a u g h t u p w i t h my w o r k s i n c e h a v i n g t h e b a b y . S t r o n g l y a g r e e } M i l d l y a g r e e ; M i l d l y d i s a g r e e j S t r o n g l y d i s a g r e e . 3 3 . I b l a m e m y s e l f f o r p r o b l e m s t h e b a b y h a s . O f t e n ; S o m e t i m e s ; R a r e l y j N e v e r . 3 4 . A v e r y y o u n g b a b y i s n o t s o c i a l e n o u g h t o be f u n . S t r o n g l y a g r e e j M i l d l y a g r e e j M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 3 5 . C l e a n i n g , d i a p e r i n g and c a r i n g f o r a b a b y c a n g e t a woman d o w n . S t r o n g l y a g r e e ; M i l d l y a g r e e $ M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 84 3 6 . T h e s t a f f a t t h e h o s p i t a l d i d n ' t t a k e e n o u g h t i m e t o e x p l a i n t h i n g s t o me o r h e l p me. S t r o n g l y a g r e e ; M i l d l y a g r e e } M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 3 7 . When t h e b a b y c r i e s a t n i g h t , I g e t u p t o s e e w h a t m i g h t be c a u s i n g i t : I m m e d i a t e l y ; W i t h i n a f e w m i n u t e s j W i t h i n t e n m i n u t e s ; N o t a t a l l . 3 8 . A f t e r c h i l d b i r t h I f e l t l i k e my o l d s e l f a g a i n . W i t h i n a week ; W i t h i n two w e e k s ; W i t h i n t h r e e o r f o u r w e e k s 5 N o t y e t . 3 9 . I ' v e f e l t t h a t i t w o u l d h e l p i f a n e x p e r i e n c e d woman w o u l d t e l l me i f my b a b y was a l l r i g h t . O f t e n ; S o m e t i m e s ; R a r e l y ; N e v e r . 4 0 . I had t h e " b a b y b l u e s " (was d e p r e s s e d a n d d i s c o u r a g e d ) : F o r m o r e t h a n a week ; F o r s e v e r a l d a y s ; F o r o n e o r two d a y s ; F o r l e s s t h a n a d a y ; N o t a t a l l . 4 1 . I ' v e w o r r i e d t h a t s o m e t h i n g was w r o n g w i t h my b a b y . O f t e n ; S o m e t i m e s ; R a r e l y 5 N e v e r . 4 2 . T a k i n g c a r e o f a y o u n g b a b y k e e p s me f r o m d o i n g o t h e r t h i n g s I w o u l d l i k e t o d o . O f t e n j S o m e t i m e s j R a r e l y ; N e v e r . 4 3 . I f I t r i e d t o l e a r n more a b o u t c a r i n g f o r my b a b y , I w o u l d n ' t h a v e a s many p r o b l e m s w i t h h i m . S t r o n g l y a g r e e j M i l d l y a g r e e ; M i l d l y d i s a g r e e j S t r o n g l y d i s a g r e e . 4 4 . A b a b y g e t s s p o i l e d i f y o u p i c k h i m u p when h e c r i e s . S t r o n g l y a g r e e j M i l d l y a g r e e ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 4 5 . I ' v e b e e n n e r v o u s a n d jumpy s i n c e h a v i n g t h e b a b y . O f t e n ; S o m e t i m e s ; R a r e l y ; N e v e r . 4 6 . I ' v e n e e d e d m o r e h e l p t h a n I ' v e g o t t e n i n c a r i n g f o r t h e b a b y a n d d o i n g my h o u s e w o r k . S t r o n g l y a g r e e j M i l d l y a g r e e ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 4 7 . I f e e l t h e m o t h e r s h o u l d a l w a y s b e c l o s e e n o u g h t o h e r b a b y t o h e a r h i m i f he c r i e s . S t r o n g l y a g r e e ; M i l d l y a g r e e ; M i l d l y d i s a g r e e ; S t r o n g l y d i s a g r e e . 85 4 8 . I ' m u n h a p p y and d i s c o u r a g e d a b o u t t h e t h i n g s I c a n ' t d o s i n c e I h a v e h a d a b a b y . O f t e n ; S o m e t i m e s ; R a r e l y } N e v e r . 86 SCORE SHEET S c a l e s Q u e s t i o n s 1 1 . F e a r o r C o n c e r n f o r b a b y 1 11 21 31 41 2 . N e g a t i v e a s p e c t s o f c h i l d - r e a r i n g 2 12 22 32 42 3 . I n t r a p u n i t i v e 3 13 23 33 43 4 . I g n o r i n g 4 14 24 34 44 5 . I r r i t a b i l i t y 5 15 25 35 45 6 . E x t r a p u n i t i v e 6 16 26 36 46 7 . R e s p o n s i v e n e s s t o i n f a n t ' s n e e d s 7 17 27 37 47 8 . C o n v a l e s c e n c e 8 18 28 38 9 . N e e d f o r r e a s s u r a n c e 9 19 29 39 1 0 . D e p r e s s i o n 10 20 30 40 48 R e s p o n s e s f o r t h e d i f f e r e n t c a t e g o r i e s a r e w e i g h t e d 5 , 4 , 3 , 2 , o r 1 . H i g h w e i g h t s a r e g i v e n t o a g r e e m e n t o r h f r e q u e n c y . 87 A P P E N D I X D INFORMATION SHE 88 P A R E N T - I N F A N T PROGRAM A p r o g r a m d e s i g n e d t o l e a r n more a b o u t t h e f e e l i n g s a n d e x p e r i e n c e s o f p a r e n t s who a r e h a v i n g t h e i r f i r s t c h i l d i s now b e i n g o f f e r e d t o c o u p l e s who p l a n t o g i v e b i r t h a t S t . P a u l ' s H o s p i t a l . I n f o r m a t i o n g a i n e d t h r o u g h t h i s p r o g r a m w i l l e n a b l e p r o f e s s i o n a l s t o p l a n more c o m p r e h e n s i v e c a r e f o r e x p e c t a n t c o u p l e s and new p a r e n t s . P a r t i c i p a t i o n i n t h e p r o g r a m w i l l i n v o l v e s h a r i n g y o u r f e e l i n g s a b o u t y o u r p r e g n a n c y , t h e b a b y ' s b i r t h , a n d t h e f i r s t f e w w e e k s o f new p a r e n t h o o d . One o f t h e p r o g r a m s t a f f w i l l v i s i t y o u b e f o r e t h e b a b y ' s b i r t h t o t a l k a b o u t y o u r p r e g n a n c y e x p e r i e n c e a n d y o u r e x p e c t a t i o n s f o r c h i l d b i r t h . A f t e r t h e b a b y ' s a r r i v a l t h e r e w i l l b e o n e o r two m o r e v i s i t s t o d i s c u s s y o u r b i r t h e x p e r i e n c e and y o u r new r o l e a s p a r e n t s . I n f o r m -a t i o n w i l l a l s o b e g a t h e r e d f r o m y o u r h o s p i t a l r e c o r d s and f r o m o b s e r v a t i o n s o f y o u r new b a b y i n y o u r home e n v i r o n m e n t . P r e v i o u s p a r t i c i p a n t s i n t h i s p r o g r a m h a v e f o u n d t h a t t a l k i n g w i t h a p r o f e s s i o n a l whom t h e y know d u r i n g t h e f i r s t w e e k s o f p a r e n t h o o d h e l p s w i t h t h e a d j u s t m e n t p e r i o d a f t e r t h e b a b y ' s b i r t h . We i n v i t e y o u t o j o i n o u r p r o g r a m and s h a r e y o u r e x p e r i e n c e s w i t h u s . O n e o f o u r s t a f f w i l l b e i n t o u c h w i t h y o u i n t h e n e x t week t o a n s w e r a n y q u e s t i o n s y o u may h a v e a b o u t t h i s p r o g r a m . I f y o u w i s h t o c a l l f o r m o r e i n f o r m a t i o n , o u r p h o n e n u m b e r s a r e l i s t e d b e l o w . S u s a n L e e P a i n t e r , D e p a r t m e n t o f P s y c h o l o g y , U . B . C 2 2 8 - 6 4 8 7 S h e e n a D a v i d s o n , S c h o o l o f N u r s i n g , U . B . C . 2 2 4 - 4 2 7 6 89 A P P E N D I X E INFORMED CONSENT FORM 90 INFORMED CONSENT FORM We u n d e r s t a n d how t h i s s t u d y w i l l i n v o l v e u s a n d o u r b a b y and t h a t t h e r e s u l t s o f t h i s s t u d y w i l l b e w r i t t e n i n s u c h a m a n n e r t h a t o u r i d e n t i t i e s w i l l r e m a i n a n o n y m o u s . We a l s o u n d e r s t a n d t h a t t h e r e p o r t o f t h i s r e s e a r c h w i l l b e a v a i l a b l e f o r s t u d e n t s and p r o f e s s i o n a l s i n t e r e s t e d i n c h i l d c a r e . We u n d e r s t a n d t h a t t h e m i n i m a l d i s c o m f o r t we may e x p e r i e n c e i n v o l v e s t h e e x p o s u r e t o t h e i n t e r v i e w s , q u e s -t i o n n a i r e s , o b s e r v a t i o n s d u r i n g f e e d i n g a n d t h e e v a l u a t i o n s o f o u r i n f a n t . We u n d e r s t a n d t h a t we may c h o o s e n o t t o p a r t i c i p a t e o r t o w i t h d r a w f r o m t h i s s t u d y a t a n y t i m e . We a l s o u n d e r s t a n d t h a t we a r e f r e e t o a s k q u e s t i o n s a t a n y t i m e t h r o u g h o u t t h e s t u d y and t h a t we w i l l b e g i v e n a c o p y o f t h i s c o n s e n t f o r m f o r o u r own i n f o r m a t i o n . M o t h e r 1 s s i g n a t u r e F a t h e r 1 s s i g n a t u r e I n v e s t i g a t o r 

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