Jeanne L. Alhusen

A Literature Update on Maternal-Fetal Attachment

OBJECTIVEnTo critically review and synthesize original research published since 2000 designed to measure factors that influence maternal-fetal attachment.nnnDATA SOURCESnEBSCOhost Research Databases that included PubMed, CINAHL Plus, PsycINFO, and SCOPUS were searched for journal articles published in the past 7 years (2000-2007) that examined variables thought to increase, decrease, or cause no change in level of maternal-fetal attachment. Keyword searches included maternal-fetal attachment, parental attachment, and prenatal attachment.nnnSTUDY SELECTIONnTwenty-two studies were selected that met the inclusion criteria of original research, clear delineation of the measurement of maternal-fetal attachment, measurement of maternal-fetal attachment during pregnancy, and inclusion of women or couples, or both.nnnDATA EXTRACTIONnStudies measuring maternal-fetal attachment included a broad range of variables as potential risk or protective factors, or both. Factors associated with higher levels of maternal-fetal attachment included family support, greater psychological well-being, and having an ultrasound performed. Factors such as depression, substance abuse, and higher anxiety levels were associated with lower levels of maternal-fetal attachment.nnnDATA SYNTHESISnThe large majority of studies reviewed were limited by small, homogenous samples deemed insufficient to detect significant differences, inconsistent measurement of maternal-fetal attachment during gestational periods, and cross-sectional designs.nnnCONCLUSIONSnFurther research is essential to identify factors influencing maternal-fetal attachment. Specifically, research needs to be conducted on larger sample sizes of greater racial and ethnic diversity.

A longitudinal study of maternal attachment and infant developmental outcomes

Extant research has demonstrated that compared to adults with insecure attachment styles, more securely attached parents tend to be more responsive, sensitive, and involved parents, resulting in improved outcomes for their children. Less studied is the influence of a mothers attachment style on her attachment to her unborn child during pregnancy and the consequent developmental outcomes of the child during early childhood. Thus, the aim of this prospective longitudinal study was to examine the relationship between maternal–fetal attachment (MFA) during pregnancy and infant and toddler outcomes and the role of mothers attachment style on early childhood developmental outcomes in an economically disadvantaged sample of women and their children. Gamma regression modeling demonstrated that an avoidant maternal attachment style (bu2009=u2009.98, 95xa0% CI [.97, .98], pu2009<u20090.001) and post-partum depressive symptomatology (bu2009=u2009.97, 95xa0% CI [.96–.99], pu2009=u20090.03) were significant predictors of early childhood development. Women demonstrating higher avoidant attachment styles and greater depressive symptomatology were more likely to have children demonstrating early childhood developmental delays than those women with less avoidant attachment styles and less depressive symptomatology. Furthermore, women reporting higher MFA during pregnancy had more secure attachment styles, and their children had more optimal early childhood development than those women reporting lower MFA and less secure attachment styles. Findings have implications for enhancing early intervention programs aimed at improving maternal and childhood outcomes. An earlier identification of disruptions in attachment may be beneficial in tailoring interventions focused on the mother–child dyad.

Intimate Partner Violence During Pregnancy: Maternal and Neonatal Outcomes

The effects of intimate partner violence (IPV) on maternal and neonatal outcomes are multifaceted and largely preventable. During pregnancy, there are many opportunities within the current health care system for screening and early intervention during routine prenatal care or during episodic care in a hospital setting. This article describes the effects of IPV on maternal health (e.g., insufficient or inconsistent prenatal care, poor nutrition, inadequate weight gain, substance use, increased prevalence of depression), as well as adverse neonatal outcomes (e.g., low birth weight [LBW]), preterm birth [PTB], and small for gestational age [SGA]) and maternal and neonatal death. Discussion of the mechanisms of action are explored and include: maternal engagement in health behaviors that are considered risky, including smoking and alcohol and substance use, and new evidence regarding the alteration of the hypothalamic-pituitary-adrenal axis and resulting changes in hormones that may affect LBW and SGA infants and PTB. Clinical recommendations include a commitment for routine screening of IPV in all pregnant women who present for care using validated screening instruments. In addition, the provision of readily accessible prenatal care and the development of a trusting patient-provider relationship are first steps in addressing the problem of IPV in pregnancy. Early trials of targeted interventions such as a nurse-led home visitation program and the Domestic Violence Enhanced Home Visitation Program show promising results. Brief psychobehavioral interventions are also being explored. The approach of universal screening, patient engagement in prenatal care, and targeted individualized interventions has the ability to reduce the adverse effects of IPV and highlight the importance of this complex social disorder as a top priority in maternal and neonatal health.

Estimating the Effect of Intimate Partner Violence on Women’s Use of Contraception: A Systematic Review and Meta-Analysis

Background Intimate partner violence (IPV) is an important global public health problem. While there is a growing literature on the association between IPV and women’s reproductive health (RH) outcomes, most studies are cross-sectional—which weakens inference about the causal effect of IPV on women’s RH. This systematic review synthesizes existing evidence from the strongest study designs to estimate the impact of IPV on women’s use of contraception. Methods We searched 11 electronic databases from January of 1980 to 3 December 2013 and reviewed reference lists from systematic reviews for studies examining IPV and contraceptive use. To be able to infer causality, we limited our review to studies that had longitudinal measures of either IPV or women’s use of contraception. Results Of the 1,574 articles identified by the search, we included 179 articles in the full text review and extracted data from 12 studies that met our inclusion criteria. We limited the meta-analysis to seven studies that could be classified as subject to low or moderate levels of bias. Women’s experience of IPV was associated with a significant reduction in the odds of using contraception (n = 14,866; OR: 0.47; 95% CI: 0.25, 0.85; I2 = 92%; 95% CII2: 87%, 96%). Restricting to studies that measured the effect of IPV on women’s use of partner dependent contraceptive methods was associated with a reduction in the heterogeneity of the overall estimate. In the three studies that examined women’s likelihood of using male condoms with their partners, experience of IPV was associated with a significant decrease in condom use (OR: 0.48; 95% CIOR: 0.32, 0.72; I2 = 51%; 95% CII2: 0%, 86%). Conclusions IPV is associated with a reduction in women’s use of contraception; women who experience IPV are less likely to report using condoms with their male partners. Family planning and HIV prevention programs should consider women’s experiences of IPV.

The Role of Mental Health on Maternal‐Fetal Attachment in Low‐Income Women

OBJECTIVEnTo examine and describe the influence of maternal depressive symptoms on maternal-fetal attachment (MFA) in predominantly low-income women.nnnDESIGNnMixed method.nnnSETTINGnThree urban obstetric/gynecologic (OB/GYN) clinics serving predominantly low-income women.nnnPARTICIPANTSnA convenience sample of 166 women participated in the quantitative component and a purposeful subsample of 12 women participated in the qualitative component; all women were between 24 and 28 weeks gestation at the time of data collection.nnnMETHODSnLinear regression models were used to examine the influence of depressive symptoms and social support on MFA. Individual in-depth interviews were conducted among a subsample of women to explore the influence of maternal depressive symptoms on MFA.nnnRESULTSnFifty-nine percent (nxa0=xa098) of participants had scores that were clinically significant for depressive symptoms. In the final model of social support and depressive symptoms regressed on MFA, social support (bxa0=xa0.23, 95% CI [0.09, .37], pxa0=xa0.002) and depressive symptoms (bxa0=xa0-1.02, 95% CI [-1.32, -.73], pxa0<xa00.001) were significant predictors. This multivariate linear regression model with two variables accounted for 65.2% of the total variance in overall MFA. Qualitative participants discussed the importance of social support in contributing to their mood state and MFA.nnnCONCLUSIONSnFindings from this study highlight the importance of assessing for depressive symptoms during pregnancy given its influence on MFA. By understanding how important it was for these women to have a supportive person to experience their pregnancies with, nurses can improve the pregnancy experience for vulnerable populations.

The influence of maternal–fetal attachment and health practices on neonatal outcomes in low‐income, urban women

Maternal-fetal attachment (MFA) has been associated with health practices during pregnancy, but less is known about this relationship in low-income women, and no identified studies have examined this relationship to neonatal outcomes. This longitudinal descriptive study was conducted to examine the relationships among MFA, health practices during pregnancy, and neonatal outcomes in a sample of low-income, predominantly African-American women and their neonates. MFA was associated with health practices during pregnancy and adverse neonatal outcomes. Health practices during pregnancy mediated the relationships of MFA and adverse neonatal outcomes. The results support the importance of examining MFA in our efforts to better understand the etiology of health disparities in neonatal outcomes.

Intimate partner violence, substance use, and adverse neonatal outcomes among urban women.

OBJECTIVEnTo assess the prevalence of intimate partner violence, substance use, and their co-occurrence during pregnancy and to examine their associations with adverse neonatal outcomes.nnnSTUDY DESIGNnBetween February 2009-February 2010, pregnant women receiving obstetrical care at 3 urban clinics were screened for intimate partner violence and substance use between 24-28 weeks gestation. A chart review was conducted upon delivery to assess for adverse neonatal outcomes of low birth weight, preterm birth, and small for gestational age (SGA).nnnRESULTSnMaternal and neonatal data were collected on 166 mothers and their neonates. Overall, 19% of the sample reported intimate partner violence during their pregnancies. Of the studys neonates, 41% had at least 1 adverse neonatal outcome. Nearly one-half of the mothers reported using at least 1 substance during pregnancy. Women experiencing intimate partner violence had a higher prevalence of marijuana use than their nonabused counterparts (P < .01). Experiencing intimate partner violence was associated with a 4-fold increase in having a SGA neonate (aOR = 4.00; 95% CI 1.58-9.97). Women who reported marijuana use had 5 times the odds of having a neonate classified as SGA (aOR = 5.16, 95% CI 2.24-11.89) or low birth weight (aOR 5.00; 95% CI 1.98-12.65).nnnCONCLUSIONSnThe prevalence of intimate partner violence during pregnancy and substance use is high in urban mothers, the risks of which extend to their neonates. Pediatric providers are urged to routinely screen for both issues and recognize the impact of co-occurrence of these risk factors on poor neonatal and childhood outcomes.

Intimate partner violence and suicidal ideation in pregnant women

Intimate partner violence (IPV) during pregnancy is a major public health issue with significant implications for maternal mental health. Less studied is the association between IPV during pregnancy and suicidal ideation. This study reports the prevalence and correlates of suicidal ideation among low-income pregnant women receiving prenatal care at a university obstetrical clinic from February 2009 to March 2010. We performed a cross-sectional analysis of 166 women surveyed between 24 and 28xa0weeks of gestation using the Edinburgh Postnatal Depression Scale (EPDS) and the Abuse Assessment Screen (AAS). Multiple logistic regression identified factors associated with antenatal suicidal ideation. The prevalence of suicidal ideation was 22.89xa0%. In the fully adjusted model, antenatal depressive symptomatology (ORu2009=u200917.04; 95xa0% CI 2.10–38.27) and experiencing IPV (ORu2009=u20099.37; 95xa0% CI 3.41–25.75) were significantly associated with an increased risk of antenatal suicidal ideation. The prevalence of antenatal suicidal ideation in the current study was higher than other population-based samples though this sample was predominantly single, low-income, and 19xa0% experienced IPV during pregnancy. Given the strong association of antenatal suicidal ideation, depressive symptomatology, and IPV, health care providers are urged to identify those women at risk so that antenatal care can be tailored to best support optimal maternal and neonatal outcomes.

Intimate partner violence during pregnancy and adverse neonatal outcomes in low-income women

BACKGROUNDnIntimate partner violence (IPV) affects an estimated 1.5 million U.S. women annually. IPV impacts maternal and neonatal health with higher rates of depression and low birth weight (LBW). Less studied is experiencing IPV and delivering a small for gestational age (SGA) baby. SGA neonates are at increased risk of developmental and behavioral problems. The negative sequelae persist into adulthood with increased rates of diabetes mellitus and coronary heart disease.nnnMETHODSnIn a sample of 239 pregnant women experiencing IPV, in urban and rural settings, we examined cross-sectional associations of severity of IPV and neonatal outcomes (i.e., birth weight and gestational age). Severity of IPV was measured by the Conflict Tactics Scale 2 and neonatal outcomes were collected at the time of delivery.nnnRESULTSnOutcomes were collected on 194 neonates; 14.9% (n=29) were classified as LBW, 19.1% (n=37) classified as SGA, and 9.8% (n=19) as LBW and SGA. Women reporting higher severity of IPV during pregnancy had a greater likelihood of delivering an SGA neonate (odds ratio [OR] 4.81; 95% confidence interval [95% CI] 1.86-12.47), and LBW neonate (OR 4.20; 95% CI 1.46-12.10).nnnCONCLUSIONSnIn a sample of pregnant women experiencing perinatal IPV, women experiencing greater severities of IPV were more likely to deliver a neonate with an adverse outcome. Early recognition and intervention of IPV is essential to reduce disparities in birth outcomes and long-term health outcomes for these neonates.

Engaging and retaining abused women in perinatal home visitation programs.

OBJECTIVES: Intimate partner violence (IPV) during pregnancy affects 0.9% to 17% of women and affects maternal health significantly. The impact of IPV extends to the health of children, including an increased risk of complications during pregnancy and the neonatal period, mental health problems, and cognitive delays. Despite substantial sequelae, there is limited research substantiating best practices for engaging and retaining high-risk families in perinatal home visiting (HV) programs, which have been shown to improve infant development and reduce maltreatment. METHODS: The Domestic Violence Enhanced Home Visitation Program (DOVE) is a multistate longitudinal study testing the effectiveness of a structured IPV intervention integrated into health department perinatal HV programs. The DOVE intervention, based on an empowerment model, combined 2 evidence-based interventions: a 10-minute brochure-based IPV intervention and nurse home visitation. RESULTS: Across all sites, 689 referrals were received from participating health departments. A total of 339 abused pregnant women were eligible for randomization; 42 women refused, and 239 women were randomly assigned (124 DOVE; 115 usual care), resulting in a 71% recruitment rate. Retention rates from baseline included 93% at delivery, 80% at 3 months, 76% at 6 months, and 72% at 12 months. CONCLUSIONS: Challenges for HV programs include identifying and retaining abused pregnant women in their programs. DOVE strategies for engaging and retaining abused pregnant women should be integrated into HV programs’ federal government mandates for the appropriate identification and intervention of women and children exposed to IPV.