LESSON 2 - THEORIES RELATED TO

MATERNAL AND CHILD HEALTH

NURSING
INTRODUCTION
Nursing models and theories are as old as the nursing profession itself. Nursing
was designed to meet the needs of various groups and developmental stages. Nursing
model give direction to nurses working in a particular area and it helps predict expected
outcomes of nursing actions. Models provide for the identification and labeling of
concepts which allow for recognition and communication with others (Fitzpatrick, 2005).
A theory is a set of propositions about defined and related constructs that describe the
relationships among the variables in order to systematically describe the phenomena of
interest (Kerlinger, 1986). Theory involves concepts closely tied to individuals, groups,
situations or events and tries relationships between them (Fawcett, 1993). When ideas
are less concrete, the ways, phenomena are viewed and organized is sometimes
referred to as a conceptual model. Conceptual models have some of the same
components as theories, but are more loosely generally lack the propositions that
identify the existence of relationships between concepts.

The Maternal and Child nursing (MCH) is a subspecialty of nursing that deals
with needs of mothers and children. Theories and models in MCH provide guidelines for
decision-making the clients. Each model reveals and orders reality from a particular
perspective. According to Ellis (2003), nursing models articulate the essence of nursing
across time. Despite the acclaimed popularity of models and the suggestion that the use
of models is one of the hallmarks of success in of success in nursing practice (Fawcett
and Carino, 1989), for many nurses, models and are viewed as distant and elitist are
not always `valued by practitioners or managers' (Bellman, 1996). Theories and models
are very relevant in Maternal and Child Health nursing practice. Nursing Students need
to understand various models and theories are applicable in MCH but this chapter will
focus more on models and theories specific to MCH nursing specialty.

LEARNING OBJECTIVES
After reading this chapter, learners should be able to.
1) Identify theories and models applicable to maternal and child health nursing
practices.
2) Describe the relevance of bonding and attachment theories in the care of mother
and child.
3) Discuss maternal role attainment theory as a framework for care.
4) Describe the use of The Mother and Child Integrative Developmental Care Model
in nursing care.
5) Explain concepts used in Barnard's parent-child interaction model.
LEARNING CONTENT

Let’s start…

Bonding and Attachment Theory

The term bonding is used most often to refer to a rapid process, occurring
immediately after birth that reflects mother-to-infant attachment (not the infant's
attachment to the mother). This process of establishing a bond between mother and
newborn is seen as being facilitated by physical and skin-to-skin contact between
mother and newborn. Infant suckling, visual contact between mother and infant and the
mother's fondling of the infant are involved. Similar behaviours on the part of the father
and infant are said to result in a bond as well (Sherwen, Scoloveno and Weingerten,
1995).

Attachment theory was developed jointly by John Bowlby and Mary Ainsworth
(Ainsworth and Bowlby, 1991). It was originally developed by John Bowlby (1907 -
1990), a British psychoanalyst who tried to explain the intense distress experienced by
infants who had been separated from their parent. It was then further developed by
Mary Ainsworth. The theory describes the dynamics of long-term relationships between
humans especially in families a, long friends.
Drawing on concepts from ethology, cybernetics,
information processing, developmental
psychology, object relations theory and
psychoanalysts, John Bowlby formulated the
basic tenets of the theory (Bretherton, 1992).
 It proposes that the affectional tie between mother, father, and infant develops
out of response patterns that ensure that infants will be cared for during their years of
dependency (Sherwen, 1995). Although Bowlby and Ainsworth worked independently of
each other during their early careers, both were influenced by Freud and other
psychoanalytic thinkers-directly in Bowlby's case, indirectly in Ainsworth's. He thereby
revolutionized our thinking about a child’s tie to the mother and its disruption through
separation, and bereavement. Mary Ainsworth's innovative methodology not only made
it possible to test some of Bowlby's ideas empirically but also helped expand the theory
itself and is responsible for some of the new directions it is now taking. Ainsworth
contributed the of the attachment figure as a secure base from which an infant can
explore the world (Bretherton, 1992). This attachment between mother and infant at one
year relates to later social and cognitive development of the child.
Early attachment behaviours coming from the infant are specific to humans and
are elicited by the human adult. As the infant grows and develops, the responses
become increasingly complex and directed to particular others in the infant's
environment. The nature of the relation is mutual- affection which grows in both the
mother/ father and the infant, over time. Secure attachment between mother and infant
is the basis for trust, which the infant uses to function eventually as an independent
individual apart from his/her parents. Attachment theory explains how the parents'
relationship with the influences development. Infants become attached to individuals,
who are sensitive and responsive in social interactions with them and who remain as
consistent caregivers for some months during the id from about six months to two years
of age; this is known as sensitive responsiveness. When the infant begins to crawl and
walks, they begin to use attachment figures (familiar people) as a secure base to
explore from and return to Caregivers' responses lead to the development of patterns of
attachment. These, in turn, lead to internal working models which will guide the
individual's perceptions, emotions, thoughts and expectations in later relationships
(Bretherton and Munholland, 1999).
If early maternal-infant contact increases maternal feelings or affection sensitivity
to the infant's individual response style, this should reflect in the patterns of care giving
that influences the quality of attachment at one year. In other words, bonding may set
the stage, in a positive direction, for the developing patterns of interactions between
mother and infant during the first year and help ensure the attainment of secure
attachment between both mother and infant at one year and after. Separation during
this time, however, does not prevent subsequent positive patterns of interaction
between mother and infant and the development of affectional ties over the first year of
the infant's life. Because separation is a clear-cut and undeniable event, its effects on
the child and the parent-child relationship were easier to document than more subtle
influences of parental and familial interaction Research by developmental psychologist
Mary Ainsworth in the 1960s and 70s reinforced the basic concepts, introduced the
concept of the “secure base” and developed a theory of a number of attachment
patterns in infants: secure attachment, avoidant attachment was identified later. In
addition, she formulated the concept of maternal sensitivity to infant signals and its role
in the development of infant-mother attachment patterns.
One of the major tenets of security theory is that infants and young children need
to develop a secure dependence on parents before launching out into unfamiliar
situations.
Infants form attachments to any consistent caregiver who is sensitive and
responsive in social interactions with them. The quality of the social engagement is
more influential than the amount of time spent. Although the biological mother is usually
the principal attachment figure, the role can be taken by anyone who consistently
behaves in a “mothering" or care giving way over a period of time.

Major Concepts
 Attachment: An enduring emotional tie to a special person characterized by a
tendency to seek and maintain closeness especially during times of stress.
 Attachment in the context of children: The enduring deep emotional bond
between a child and a specific caregiver
 Separation produces extreme distress in children.
 There are significant long-term adverse effects on the children as a result of even
relatively brief separations.
  Theory emphasizes the role of mother in child's development where father plays
the second fiddle to mothering.

Stages
Phase of limited discrimination (birth-2 months)
 Baby's innate signals attract caregiver.
 Caregivers remain close by when the baby responds positively:
Phase of limited preference (2-7 months)
 Develops a sense of trust that caregiver will respond when signaled.
 Infants respond more positively to familiar caregivers.
 Babies don't protest when separated from parent
Phase of focused attachment and secure base (7-24 months)
 Babies display separation anxiety.
 Babies protest when parent leaves.
Phase of goal-corrected partnership (24–36 months)
 Children increase their understanding of symbols and language improves.
 Children understand that parents will return.

Maternal Role Attainment Theory

The Maternal Role Attainment Theory was developed to serve as a framework
for nurses to provide appropriate health care interventions for non-traditional mothers in
order for them to develop a strong maternal identity. As a head nurse in paediatrics and
staff nurse in intrapartum, postpartum, and newborn nursery units, Ramona Mercer had
a great deal of experience in nursing care for mothers and infants. This gave her a
strong foundation for creating her maternal pole attainment theory for nursing.

This mid-range theory can be

used throughout pregnancy and
postnataI care, but is also beneficial for
adoptive or foster mothers, or others who
find themselves in the maternal role
unexpectedly. The process used in this nursing model helps the mother develop an
attachment to the infant, which in turn helps the infant form a bond with the mother. This
helps develop the mother-child relationship as the infant grows. The primary concept of
this theory is the developmental and interactional process, which occurs over a period
of time. In the process, the mother bonds with the infant, acquires competence in
general caretaking tasks, and then comes to express joy and pleasure in her role as a
mother.

The nursing process in the maternal role attainment theory follows four stages of
acquisition. They are: anticipatory, formal, informal, and personal. The anticipatory
stage is the social and psychological adaptation to the maternal role. This includes
learning expectations and can involve fantasizing about the role. The formal stage is the
assumption of the maternal role at birth. In this stage, behaviours are guided by others
in the mother's social system or network, and relying on the advice of others in making
decisions. The informal stage is when the mother develops hero mothering which are
not conveyed by a social system. She finds what works for her and the child. The
personal stage is the joy of motherhood. In this stage, the mother finds harmony and
competence in the maternal role. In some cases, he may find herself ready for or
looking forward to another child. (www.nursing-theorist.org, 2008.)

Maternal role attainment is a process that followed the four stages in the
acquisition roles (adapted from Thorn and Nardi, 1975).
(i.) Anticipatory: starts with the social and psychological penialaian on the role by
studying the experiences of the role. Mothers fantasize about the role, dealing
with the fetus in the womb and begin to play a role.
(ii.) Formal: starts by assuming the role at the time of delivery; behaviour is
guided by a formal role, consensual expectations on others in the social
system of the mother.
(iii.) Informal: starts as the mother develop a unique way of relating to the role
which is not believed by the social system
 (iv.) Personal: experience the mother will be harmony, confidence and
competence in the way he did the role, the role of motherhood is achieved.
The main focus of the theory of maternal role attainment which is becoming a
mother is a picture of maternal role attainment process and the process of becoming a
mother with a variety of underlying assumptions. These models also served as
guidelines for nurses in assessing the infant and its environment, is used to identify the
purpose of the baby, providing assistance to infants with education and support,
providing services to infants who are unable to perform self-care and able to interact
with the baby and the environment.
The main assumptions of assumptions of Mercer in maternal role attainment are as
follows:
1. A “core self/herself relatively stable” is required through a long socialization life,
determining how a mother explains in the events, perceptions on the response of
the baby and the other role of motherhood which she did along with her life
situation and the reality of the world which she must respond.
2. On the other hand, on the socialization of capital, level of development and
innate personal characteristics will also affect behavioural responses.
3. The role of partner's mother, her baby will reflect the competencies of mother in
the role of motherhood through growth and development.
4. Infants considered to be an active partner in the process of making the role of the
mothers they will influence and be influenced by the role.
5. The identity of the mother developing in line with others maternal love and
depend on others.

Mercer theoretical concept can be applied in the care of newborns, especially in

the psychosocial and emotional condition of the newbom which is still often overlooked.
Mercer conceptual model considers that the nature of the infant affect the identity of the
mothering. Response to the development of newborns who interact with the
development of maternal role identity can be observed from the pattern of infant
behaviour. Differences with Rubin who do the writing achievement of the role of the
points on the acceptance of pregnancy on postpartum months 1 (first); Mercer saw
beyond that which the period to 12 post partum. Mercer presents a model of four stages
that occur in the process of maternal role attainment during the first year of motherhood.
The four stages are labeled as follows:
a. Physical healing phase, occurs in the first month of birth dairy
b. Phase attainment of the month to 2 to 4 or 5
c. Phase interference occurs from 8 months
d. Stage after the introduction of eight months and year in the future
The Mother and Child Integrative Developmental Care Model
The Mother and Child Integrative Developmental Care Model is a newly created
model that has simplified aspects from the Universe of Developmental Care Model.
Through valuable caregiver feedback, the Integrative Developmental Care Model has
incorporated a user- friendly interface with the universe of developmental cares com
measures to guide practice. These core measures/developmental principles are
depicted on petals of a lotus as family involvement, positioning and nesting, protecting
skin, minimizing stress and pain, optimizing nutrition, and safeguarding sleep. The
overlapping petals model demonstrate the integrative nature of developmental care
(Altimierz, 2011). The infant's sensory experience in the NICU environment, with its
exposure to bright lights and high sound levels, and frequent stressful interventions
exert harmful effects on the immature brain that alters its subsequent development.
(Als, Duffy, McAnulty, 2004; Limperopoulos, Gauvreau and O'Leary, 2008).
A developmental care approach advocates a broad range of interventions
designed to minimize the negative impact of such an environment, thereby improving
neurodevelopmental outcomes (McAnulty, Butler, Bernstein, Als, Duffy and Zurakowski,
2010). This includes controlling external stimuli such as sound, light, and activity,
encouraging family involvement; and considering appropriate comforting measures
(BLISS, 2005). It also advocates an individual approach to care that is dictated by cues
from the infant (Als, 2008).
A 2005 Cochrane review concluded that developmental care interventions
demonstrate some specific benefit for preterm infants including improved short term
growth and feeding outcomes, decreased respiratory support, decreased length and
cost of hospital stay, and improved neurodevelopment outcomes to 24 months
corrected gestational age. (Symington and Pinelli, 2005)
Barnard's Parent-Child Interaction Model
Kathryn E. Barnard was born 1938 in Omaha Nebraska. She was a graduate
with Bachelor of Science in Nursing in June 1960, M.Sc. in Nursing 1962 and PhD in
the Ecology of early childhood development from the University of Washington. Barnard
stated that the parent-infant system was influenced by individual characteristics of each
member and that the individual characteristics were also modified to meet the needs of
the system. She defines modification as adaptive behaviour.
A major focus of Barnard's work was the development of assessment tools to
evaluate child health, growth and development while viewing the parent and child as an
interactive system. In 1977, Barmand began researching methods for disseminating
information about newborns and young children to parents.
The following concepts are used to explain Barnard's model:
 Infant’s Clarity of Cues: Participating in a synchronous, relationship, the infant
must send cues to his/her caregiver.
 The skills and clarity with which these cues are sent will make it either easy or
difficult for the parent to “read” the cues and make the appropriate modification of
his/her own behavior. Some of the cues are: sleeplessness, fussiness, alertness,
hunger and satiation, changes in body activity, confusing cues sent by an infant
can interrupt a caregiver's abilities e.g. crying
 Infants Responsiveness to the Caregiver: As infant must “send” cues for parents
to modify his/her behaviour, infant must also “read" cues so that he/she can
modify his/her behaviour in return. Obviously if the infant is unresponsive to the
behavioural cues of his/her caregivers, adaptation is not possible.
 Parent's Sensitivity to the Child's Cues: Parents must be able to accurately “read”
the cues given by the infant if they are to appropriately modify their behaviour.
There are also other influences on the parent's sensitivity. Parents who are
greatly concemed about other aspects of their lives, e.g occupational, financial
problems etc. may be unable to be as sensitive as they would be otherwise, only
 the stresses are reduced. Some parents are able to “read” the cues of their
young children.
 Parents' Ability to Alleviate the Infant Distress: Some cues sent by the infant
signal that assistance from the parent is needed. The effectiveness of parents in
alleviating the distress of their infants depends upon several factors.
 Recognize the distress is occurring.
 Know the appropriate action which will alleviate distress.
 They must be available to put this knowledge of work.
 Parents Social and Emotional Growth Activities: The ability to initiate social and
emotional growth-fostering activities depends upon more global parent
adaptation. The parent need to be able to play affectionately with the child,
engage in social interactions e.g. as those associated with eating and in provide
appropriate social reinforcement of desirable behaviours. Parents must be aware
of the child's level of development and be able to adjust his/her behaviour
accordingly. This depends on the parent's available energy as his/her knowledge
and skill.
 Parent's Cognitive Growth fostering activities: The parent must have a good
grasp of the child's present level of understanding and the parents also have the
energy available to use these skills. The three major concepts of this theory are:
a. Child – baby
b. Mother – caregiver
c. Environment – physical environment of the family, father
CONCLUSION
Theories germane to MCH nursing continue to be developed and evolve. Many
theories presented in earlier times have served nursing well as the discipline has
its scope of practice. When care was mainly centered in the patient-nurse
relationship, many theories were especially pertinent and as holistic views of
patient-environment became greater concerns, then systems thinking was an
asset for conceptualizing practice. Theories used in the past continue to have
meaning, but nurses need models that reflect the discipline's ethos and provide a
framework to consider the vocation and goals of nursing.