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Assessment of maternal concerns, beliefs and infant

attachment behaviour of mothers of pre term infants.
Authors: Anupama Purathayil and Deepa Premala
Date: July-Dec 2019
From: Indian Journal of Continuing Nursing Education(Vol. 20, Issue 2)
Publisher: Medknow Publications and Media Pvt. Ltd.
Document Type: Article
Length: 3,905 words
Lexile Measure: 1650L

Full Text:
Byline: Anupama. Purathayil, Deepa. Premala

One of the major causes of neonatal mortality in India is prematurity. Although prematurity in itself poses multiple challenges for the
neonate in the immediate newborn period, sustaining survival in the later period, after discharge from a newborn intensive care
facility, remains a greater challenge for parents in low- and middle-income countries. The present study assessed the maternal
concerns, beliefs and infant attachment behaviour of mothers of pre-term infants admitted in newborn nurseries. A quantitative
approach with a descriptive cross-sectional design was used. The investigator used consecutive sampling to select 95 mothers of
pre-term infants. The interview schedule was used to assess maternal concerns, neonatal intensive care unit (NICU) parental belief
scale was used to assess maternal beliefs and the Index of parental behaviour in NICU was used to assess infant attachment
behaviour. The findings revealed that 63.2% of mothers of pre-term infants belonged to the moderately concerned group, 62.1% of
mothers of pre-term infants had strong parental belief and 94.74% of mothers of pre-term infants had appropriate infant attachment
behaviour. The study found that there was no significant correlation between maternal concerns and infant attachment behaviour.
There was a significant positive correlation (r = 0.23) between beliefs and infant attachment behaviour. Maternal concerns were
associated with monthly family income and the number of children, beliefs and the infant attachment behaviour were associated with
duration of hospital stay.

Introduction

Pre-term birth (premature birth) is a significant public health problem worldwide because it is associated with immediate or late
morbidity and mortality along with disabilities in children.[1] Pre-term is defined as babies born alive before 37 completed weeks of
gestation or fewer than 259 days of gestation since the 1st day of a woman's last menstrual period. According to the WHO, every
year about 15 million babies are born prematurely around the world and that is more than one in 10 of all babies born globally. Almost
1 million children die each year due to complications of pre-term birth. Across 184 countries, the rate of pre-term birth ranges from
5% to 18% of babies born. In India, out of 27 million babies born every year, 3.5 million babies born are premature.[1] The
advancement of medical science, especially in the field of reproductive induction methods and its laboratory procedures in one hand
and abnormal growth in caesarean deliveries, on the other hand, have increased premature birth. Therefore, the number of mothers
associated with this experience has also increased.[2]

Premature birth can cause different emotional reactions in mothers. The lost dream of having a normal and healthy baby may affect
not only the mother's physical and mental capacity but also the stability and function of the family. In addition, the lack of attention to
mothers and their emotional and psychological concerns in the long term can affect their health and lead to the loss of ability to make
decisions and communicate with others.[3]

A study on maternal concepts and expectations regarding a pre-term infant showed that comparison with full-term mothers, pre-term
mothers verbally expressed more feelings and reactions predominantly negative or conflicting in relation to infant birth. Higher levels
of maternal anxiety and depression in the pre-term group correlated with more verbal expressions about negative or conflicting
emotions. In addition, lower birth weight, higher neonatal risk and longer length of stay in intensive care nursery of the infants were
related with more negative or conflicting concepts by the mothers.[4]

Assessment of parental concerns about their premature infant's health after discharge from the neonatal intensive care unit (NICU)
revealed that the most common parental concerns were developmental delay, poor growth, poor feeding and nutritional problems.
Parental concerns about developmental delay, growth failure related to body weight and length, and overweight were high in
specificity but very low in sensitivity. After discharge from the NICU, 30% of premature infants experienced infectious diseases before
18 months of corrected age, the most common of which were respiratory tract infection.[5]
A study was conducted to compare the beliefs of mothers of term infants with the beliefs of mothers of pre-term infants in regard to
their locus of control, mainly influencing their personal health and well-being. Between the group of mothers of term infants and the
group of mothers of pre-term infants, there was a significant difference in the level of fatalistic external control of health and disease
they experienced. The mother's beliefs regarding internal and social external control did not differ between the two groups.[6] Self-
blame, stigmatization, reluctance to express negatives, delayed joy in mothering were some of the themes that emerged from a
Korean study on emotional adjustment and concerns of mothers of pre-term baby.[7] Maternal concerns, their attitude and beliefs and
the infant attachment issues are under-examined or under-reported in the Indian literature. Therefore, this study was undertaken to
look at maternal concerns, beliefs and infant attachment behaviour in mothers of pre-term babies admitted in the neonatal intensive
care units(NICU) of a Government Medical College hospital in South India.

In this study, maternal concern referred to the worries of the mother related to the growth and development of the pre-term infant,
prognosis, treatment, financial resources and parental role. This included the mothers' concerns regarding their pre-term infants.
Beliefs denoted the trust, faith or confidence experienced by mothers of pre-term infants admitted in NICU in terms of parental role
confidence, parent-baby interaction and knowledge of the NICU. The infant attachment behaviour refers to the behaviour of mothers
displaying attachment to the pre-term infants that can be observed and assessed in terms of the feeling of love, warmth, affection and
communication.

Objectives

*To assess maternal concerns of mothers of pre-term infants admitted in NICU *To assess the beliefs of mothers of pre-term infants
admitted in NICU *To assess the infant attachment behaviour of mothers of pre-term infants admitted in NICU *To determine the
correlation between maternal concerns and infant attachment behaviour of mothers of pre-term infants *To determine the correlation
between beliefs and infant attachment behaviour of mothers of pre-term infants *To determine the association between maternal
concerns, beliefs and infant attachment behaviour of mothers of pre-term infants with selected socio-personal and clinical variables.

Methods

Design and sampling

A quantitative approach with cross-sectional survey design was undertaken and the study was conducted in a Government Medical
College Hospital in South India, for 8 weeks. Sample size was estimated as 95. Mothers of pre-term infants admitted in NICU who
had a minimum 3 days interaction with the infant were included in the study by consecutive sampling method. Mothers of critically ill
pre-term infants were excluded from the study.

Instruments

Tool 1: Sociodemographic and clinical data sheet of mother and pre-term infant

The sociodemographic data sheet had ten questions regarding the socio-personal data of mother, which includes age, education,
occupation, age and education of husband, monthly family income, history of infertility, complications during pregnancy, number of
children and history of pre-term birth. The clinical variables of pre-term infants had 12 questions which include gestational age at
birth, age and gender, duration of hospital stay, mode of delivery, birth weight, and classification according to size, classification
based on weight for gestational age, clinical diagnosis and complications during intranatal and postnatal periods. The socio-personal
data were collected by interviewing the mother and clinical variables were obtained by record review.

Tool 2: Interview schedule to assess maternal concerns of mothers of pre-term infants

Interview schedule was prepared by the researcher. It included 24 statements relating concerns about the baby (4), breastfeeding (4),
herself (6), husband (2), family (2), community (3) and admission in NICU (3). The items were scored as extremely concerned (2),
concerned to some extent (1) and not at all concerned (0) with a total score ranging from 0 to 48 and was interpreted as 0-16 - less
concerned, 17-33 - moderately concerned and 34-48 - extremely concerned. It was given to 10 experts in the field of paediatrics,
psychiatry, neonatology, community medicine, child health nursing and mental health nursing. The relevance of each item was
sought and the content validity indices (CVI) were calculated. The CVI was 0.67.

Tool 3: Neonatal intensive care unit parental belief scale

NICU parental belief scale is a standardized tool to assess the mothers' beliefs about their pre-term infant and their role and it was
developed by Melnyk et al .[8] in 1997. NICU parental belief scale had 18 statements. Test-retest correlations for parental belief scale
ranged from 0.84 to 0.92. Each item was scored on a scale of 1 (strongly disagree) to 5 (strongly agree) with a total score range of
18-90 and was interpreted as 18-42 - weak belief, 43-67 - neutral belief and 68-90 - strong belief. Higher scores indicate more
positive belief. The level of maternal concerns is outlined in [Table 1]{Table 1}

Tool 4: Index of parental behaviour in neonatal intensive care unit

Index of parental behaviour in NICU is a standardised tool to assess the infant attachment behaviour of mothers of pre-term infants
admitted in newborn nurseries. It was developed by Melnyk et al . in 1997[8] and it contains fifteen positive statements and two
negative statements. Internal consistency of Index of parental behaviour in NICU was checked by Cronbach's alpha and it was found
to be 0.85. Scoring in positive statements was no (0) yes (1) no opportunity (2) and scoring in negative statements was no (1) yes (0)
no opportunity (2) with a total score range of 0-34 and was interpreted as 0-11 least appropriate, 12-22 - appropriate and 23-34 -
most appropriate.
Data collection and analysis

After obtaining permission from Scientific Review Committee and Institutional Human Ethics Committee of Government College of
Nursing, Hospital authorities and Head of the Department of Pediatric Medicine, the study was conducted in the NICUs of the
hospital. One to two mothers were interviewed per day.

The investigator explained the purpose of the study and established rapport with participants. A written informed consent was
obtained from mothers. The clinical variables were obtained by record review. The infant attachment behaviour of mothers of pre-
term infants was observed by the researcher for 30 min in the morning hours during 8 am to 11am. It was observed only once for
each mother infant duo. The socio-personal data and maternal concerns were collected by interviewing the mothers. It took about 20
min. The maternal beliefs were collected by self-report and it took 15 min for the mothers to complete it.

The data were entered into the Excel and analysed by SPSS Version 23 (IBM: New york, USA). Descriptive statistics were used to
analyse socio-personal data and clinical variables, maternal concerns, beliefs and infant attachment behaviour. The relationship
between maternal concerns and infant attachment behaviour, beliefs and infant attachment behaviour were analysed by computing
Karl Pearson's correlation coefficient. Chi-square test was computed to determine association between maternal concerns, beliefs
and infant attachment behaviour with socio-personal and clinical variables.

Results and Discussion

Among the 95 mothers of pre-term infants, 36.8% were aged between 20 and 24 years. Forty percentages of the mothers were
educated up to degree/postgraduate level. Majority (64.2%) of the mothers were homemakers. It was seen that 31.6% of mothers of
pre-term infants had no history of complications during pregnancy and 25.5% of mothers had gestational diabetes.

[Figure 1] depicts that 26.3% of pre-term infants had a birth weight of 1-1.5 kg, about 26.3% of pre-term infants had a birth weight of
2-2.5 kg. It was seen that a total of 51.6% of pre-term infants had low birth weight. Sixty percentage of pre-term infants were
appropriate for gestational age and 34.7% were small for gestational age. The results showed that 46.3% of pre-term infants had no
complications during the intranatal period and 45.2% of pre-term infants had respiratory distress. It was seen that 43.2% of pre-term
infants had no complications during postnatal period, while 26.3% of pre-term infants developed neonatal jaundice.{Figure 1}

Any woman who has delivered a newborn will have specific concerns related to her ability to care for the baby or related to the baby's
growth and development. When pre-term delivery occurs these concerns may be heightened as the neonate is generally kept in
newborn care units for various length of times. In the present study, majority (63.2%) of mothers had moderate concerns and the rest
had less concerns about (36.8%) factors related to their baby, themselves or their family [Table 1]. None had extreme concern. Some
of the major concerns were related to physical appearance of the baby (48.4%), maintaining safety (48.4%), breast feeding (47.4%),
adequacy of breast milk needed for the baby (44.2%), burping after breastfeeding (44.2%) and intellectual development of the baby
(42.1%). Most of the concerns were related to baby's appearance and behaviour and very few mothers were concerned about
themselves or others in the family. The study findings were similar to a study conducted in the USA by Alkozei et al .[9] which found
that 52% of mothers of pre-term infants experienced increased stress. However in Alkozei et al .'s [9] study, alteration in the parenting
role was the major source of stress followed by behaviour and appearance of the baby. It is also to be noted that different scale was
used to measure stress in the USA study. Another study conducted by Bolívar Montes and Montalvo Prieto [10] revealed that there
was a high level of uncertainty among 49.3% of the mothers and the infant-related factors were low birth weight and mechanical
ventilation. Emotional concern such as self-blame and stigma which was found in the qualitative study from Korea was not elicited in
this study probably due to the type of scale that was used.[5]

Parents beliefs about their role and the beliefs about their pre-term infant's behaviour, characteristics and safety influence the
parents' experience of stress and anxiety in NICU and after.[11] In this study, 62.1% of mothers of pre-term infants showed strong
beliefs [Table 2]. The mean score of beliefs of mothers of pre-term infants was 69.43 with a standard deviation 6.33 showing a
positive belief about their roles and the pre-term infants. Similar finding was found in a study conducted in USA by Melnyk et al .[12]
which revealed that mean score of beliefs of mothers of pre-term infants was 64.31 with a standard deviation 11.57. Melnyk et al .[12]
found that mothers of pre-term infants had stronger beliefs about their parental role and what behaviours and characteristics to
expect of their infants during hospitalisation.{Table 2}

It is evident from [Table 3] that 97% of mothers agreed that they had strong beliefs in being confident in asking the doctors and
nurses questions about their baby's medical condition and 96% of mothers strongly believed in telling nurses and doctors about what
will best help their baby. A qualitative study done to assess mothers' strategies in handling pre-term babies brought themes such as
relying on beliefs, seeking information from the treating team, and participating in infant care which were similar to what the mothers
in this study believed that they could or would do.[3] The mothers' beliefs in their ability to participate in deciding what is best for their
baby reveals a positive trend in self-efficacy in Indian mothers.{Table 3}

Maternal attachment to their newborn is defined as the bond which is developed with the infant both at emotional and behavioural
levels.[13] This study observed only the attachment cues provided by the mother's behaviour and found that most (94.74%) of the
mothers had appropriate infant attachment behaviour [Table 4]. The finding is congruent with a meta-analysis on mother-preterm
interaction which revealed that the results from 18 studies showed an equal or higher level of infant-mother attachment behaviours in
groups of pre-term when compared to normal newborn.[14] In the present study, the mean score of infant attachment behaviour of
mothers of pre-term infants was 15.52 with a standard deviation of 2.1 which shows that majority had higher level of attachment
behaviours. The mothers in this study exhibited behaviours such as gentle handling, cuddling or rocking when baby was distressed
and looked for information when they needed to know how they can handle their baby. Their comments about baby revealed a
positive outlook and an acceptance of their baby which were fundamental in establishing attachment [Table 5]. This finding is
encouraging as evidence show that good mother-infant attachment has a positive long term effect on a child's cognitive, emotional
and social development.[15] In contrast to these findings a study conducted by Melnyk (2018) revealed a lower mean score of 8.82
with a standard deviation of 3.71 for mother infant attachment behaviour. Another study conducted in South Africa by Ncube et al
.[16] showed that mothers were shocked by the sudden birth of a pre-term infant and found the neonatal environment intimidating.
This increased their fear and anxiety and delayed development of a relationship with their infants. Maternal infant attachment,
therefore, can be influenced by both internal and external factors.{Table 4}{Table 5}

The study also looked at the relationship between maternal concerns, beliefs and the mother-infant attachment. It was seen that
maternal concerns of mothers of pre-term infants were negatively correlated to infant attachment behaviour of mothers with r = -0.1.
Although majority (63.2%) of mothers in this study were moderately concerned and many of them about aspects such as appearance,
safety, feeding and intellectual development, the negative correlation was not statistically significant. A study conducted in France by
Petit et al .[17] [Table 6] showed that post traumatic reaction to pre-term birth negatively correlated with the quality of mother-infant
interaction. In the present study, beliefs of mothers of pre-term infants had a significant weak positive correlation ( r = +0.23) with
infant attachment behaviour. Evidence shows that any condition that causes psychological tension or alters the ability to perform their
role as parent decreases secure attachment.[17] The findings are consistent with the study conducted by Melnyk (2018) which found
that creating opportunities for parent empowerment program indirectly acted on maternal beliefs and had a positive impact on
mother-infant interaction.{Table 6}

There was a significant association between maternal concerns and monthly family income and number of children. Maternal anxiety
was not associated with any maternal demographic factors in Alkozei's [13] study. It was seen that the mothers of pre-term infants
who belonged to high income families had less concerns. This difference was found to be statistically significant at P < 0.01 level. It
was also found that mothers who had only one child expressed moderate concerns (77.8%) than mothers with more than one child
(50%). There were 45 (47.4%) primi mothers and 50 (52.6%) multipara mothers. There was a significant association between
maternal concerns and their parity. However, there was no association between beliefs of mothers and parity and also between infant
attachment behaviours of mothers and their parity.

In this study, beliefs of mothers of pre-term infants were associated with duration of hospital stay. However, there was no association
with other socio-personal and clinical variables. The study findings were consistent with the study conducted by Allen et al .,[18]
which found that parental perceptions were not associated with maternal age, education, marital status, income, child gender,
gestational age and birth weight.

In the present study, infant attachment behaviour of mothers of pre-term infants was not associated with socio-personal and clinical
variables. However, a study conducted by Gerstein et al .[19] found that maternal positive affective involvement in the NICU were
associated with socio-economic status.

Conclusion

This study has given important insight into mothers' concerns and beliefs related to their pre-term infant admitted in the NICU. It also
reveals that mothers expressed moderate concerns and exhibited good maternal-infant attachment behaviour which was mediated by
the general positive beliefs that mothers had regarding their pre-term infants and their maternal role in the NICU. Multiple internal and
environmental factors beyond the socio-demographic factors could have influenced the finding which was beyond the scope of this
study. Further studies with robust instrument especially for measuring maternal concern are needed to generalize the findings.
Moreover, the concerns, beliefs and maternal-infant attachment may vary in mothers with critically ill pre-term infants who were not
part of the study. However, it may be concluded that nurses can play a vital role in enhancing these positive attributes in mothers of
pre-term infants admitted in the NICU.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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Source Citation (MLA 9th Edition)
Purathayil, Anupama, and Deepa Premala. "Assessment of maternal concerns, beliefs and infant attachment behaviour of mothers of
pre term infants." Indian Journal of Continuing Nursing Education, vol. 20, no. 2, July-Dec. 2019, p. 111. Gale Academic OneFile,
link.gale.com/apps/doc/A629351157/AONE?u=finger_main&sid=bookmark-AONE&xid=804fb51a. Accessed 26 Feb. 2024.
Gale Document Number: GALE|A629351157