Prenatal attachment: using measurement invariance to test the validity of comparisons across eight culturally diverse countries

It takes a village: Caregiver diversity and language contingency in the UK and rural Gambia

INTRODUCTION

There is substantial diversity within and between contexts globally in caregiving practices and family composition, which may have implications for the early interaction's infants engage in. We draw on data from the Brain Imaging for Global Health (BRIGHT, www.globalfnirs.org/the-bright-project) project, which longitudinally examined infants in the UK and in rural Gambia, West Africa. In The Gambia, households are commonly characterized by multigenerational, frequently polygamous family structures, which, in part, is reflected in the diversity of caregivers a child spends time with. In this paper, we aim to 1) evaluate and validate the Language Environment Analysis (LENA) for use in the Mandinka speaking families in The Gambia, 2) examine the nature (i.e., prevalence of turn taking) and amount (i.e., adult and child vocalizations) of conversation that infants are exposed to from 12 to 24 months of age and 3) investigate the link between caregiver diversity and child language outcomes, examining the mediating role of contingent turn taking.

METHOD

We obtained naturalistic seven-hour-long LENA recordings at 12, 18 and 24 months of age from a cohort of N = 204 infants from Mandinka speaking households in The Gambia and N = 61 infants in the UK. We examined developmental changes and site differences in LENA counts of adult word counts (AWC), contingent turn taking (CTT) and child vocalizations (CVC). In the larger and more heterogenous Gambian sample, we also investigated caregiver predictors of turn taking frequency. We hereby examined the number of caregivers present over the recording day and the consistency of caregivers across two subsequent days per age point. We controlled for children's cognitive development via the Mullen Scales of Early Learning (MSEL).

RESULTS

Our LENA validation showed high internal consistency between the human coders and automated LENA outputs (Cronbach's alpha's all >.8). All LENA counts were higher in the UK compared to the Gambian cohort. In The Gambia, controlling for overall neurodevelopment via the MSEL, CTT at 12 and 18 months predicted CVC at 18 and 24 months. Caregiver consistency was associated with CTT counts at 18 and 24 months. The number of caregivers and CTT counts showed an inverted u-shape relationship at 18 and 24 months, with an intermediate number of caregivers being associated with the highest CTT frequencies. Mediation analyses showed a partial mediation by number of caregivers and CTT and 24-month CVC.

DISCUSSION

The LENA provided reliable estimates for the Mandinka language in the home recording context. We showed that turn taking is associated with subsequent child vocalizations and explored contextual caregiving factors contributing to turn taking in the Gambian cohort.

The Role of Maternal Depression Symptoms and Maternal Attachment in Predicting Exclusive Breastfeeding: A Multisite Prospective Study

Background: Previous research shows that 61% of children younger than 6 months in low- and middle-income countries (LMICs) are not exclusively breastfed. Although data on the role of pre- and postnatal depression on breastfeeding exclusivity is mixed, fetomaternal attachment might foster breastfeeding exclusivity. Thus, we tested the potential mediating role of fetomaternal attachment and postnatal depression in the relationship between maternal prenatal depression and exclusive breastfeeding. Materials and Methods: Data were collected as part of a prospective, cross-cultural project, Evidence for Better Lives Study, which enrolled 1208 expectant mothers, in their third trimester of pregnancy across eight sites, from LMICs. Of the whole sample, 1185 women (mean age = 28.32, standard deviation [SD] = 5.77) completed Computer-Aided Personal Interviews on prenatal depressive symptoms, fetomaternal attachment, and socioeconomic status. A total of 1054 women provided follow-up data at 3-6 months after birth, about postnatal depressive symptoms, exclusive breastfeeding, and infant health indicators. Path analysis was used to assess parallel mediation. Results: In the whole sample, the effect of prenatal depression on breastfeeding exclusivity was completely mediated by postnatal depression, whereas fetomaternal attachment did not mediate the relationship. The full mediation effect was replicated individually in Pakistan and Sri Lanka. Conclusions: The study results indicate that prenatal depression symptoms contributed to the development of depressive symptoms after birth, negatively affecting the probability of exclusive breastfeeding. Future research should explore this in early prevention interventions, increasing the chances of healthy child development in LMICs. Considering the mixed results around the sites, it is important to better understand the relationship between maternal depression, fetomaternal attachment and breastfeeding behavior in each site's socio-cultural context.

The Protective Role of Maternal-Fetal Bonding for Postpartum Bonding Following a NICU Admission

INTRODUCTION

Admission of a newborn to a neonatal intensive care unit (NICU) can be a highly stressful event that affects maternal psychological well-being and disrupts the early maternal-infant bonding relationship. Determining factors that promote maternal-infant bonding among those with a NICU admission is essential for the development of effective interventions.

METHODS

Using a longitudinal clinic-based sample of diverse and low-income pregnant women, we examined whether maternal-fetal bonding measured during the second trimester moderated the association between NICU admission and postpartum bonding measured at six months post birth, controlling for demographic characteristics.

RESULTS

Approximately 18% of the sample experienced a NICU admission at birth. NICU admission was associated with lower postpartum bonding (b = -8.74; p < .001, Model 1), whereas maternal-fetal bonding was associated with higher bonding reported at six months postpartum (b = 3.74, p < .001, Model 2). Results of the interaction revealed that women who reported higher maternal-fetal bonding reported higher postnatal bonding regardless of NICU admission status.

DISCUSSION

Because maternal-fetal bonding can be enhanced through intervention, it is a promising target for reducing the risks of NICU admission for the early maternal-infant relationship.

Quality of prenatal care and maternal fetal attachment among primigravid mothers in the Philippines: A cross sectional study

BACKGROUND

The prenatal period is a proper chance for evaluating maternal-fetal attachment.

AIM

To determine the relationship between quality of prenatal care and maternal-fetal attachment among primigravida mothers during late pregnancy period.

METHODS

The study conducted a survey using a 46-item Quality of Prenatal Care Questionnaire and 24-item Maternal-Fetal Attachment Scale among 343 primigravida mothers in village health stations. Pearson correlation was used to correlate maternal-fetal attachment scores and quality of prenatal scores. Linear regression was used to determine relationships between variables.

RESULTS

Maternal-fetal attachment scores is correlated with: age ≤19 years (4.10 [95 % CI 1.81-6.39]), companion during visits (2.76 [95 % CI 0.34-5.18]), education (3.45 [95 % CI 0.93-5.97]). On multivariate analysis, the following were significantly associated with maternal-fetal attachment scores: information sharing (8.67 [95 % CI 4.74 - 12.60]), sufficient time (-2.34 [95 % CI -3.45 - -1.24]), support and respect (8.49 [95 % CI 4.54 - 12.45]), maternal age < 19 years (-3.78 [-5.81 to -1.75]), and unmarried (2.55 [95 % CI 0.70 - 4.41]).

CONCLUSION

The quality of prenatal care is correlated significantly with maternal-fetal attachment. Women valued the care given when it was individualized and the health workers were approachable in their ways and addressed their own particular needs. Combination of prenatal education and counselling tailored to address own particular emotional and social concerns of pregnant mothers are interventions that should be integrated in maternal care services.

Anxiety and Depression Symptoms in At-Risk Pregnancy: Influence on Maternal-Fetal Attachment in Tunisia

OBJECTIVES

To investigate maternal prenatal anxiety and depression in high-risk pregnancies and examine their influence on maternal-fetal attachment.

METHODS

We included 95 hospitalized high-risk pregnant women. The Hospital Anxiety and Depression Scale (HADS) and the Prenatal Attachment Inventory (PAI) were used to assess the primary objective. Internal consistency and construct validity of the PAI were investigated.

RESULTS

The average age was 31 years and gestational age ranged from 26 to 41 weeks. Prevalence of depressive symptoms was 20% and anxiety symptoms 39%. Cronbach alpha coefficient of the PAI Tunisian version was 0.8 and the construct validity in favour of one factor model. PAI scores correlated negatively and significatively with the HADS total score (r = - 0.218, p = 0.034) and was attributed to the depression dimension only (r = - 0.205, p = 0.046).

CONCLUSIONS FOR PRACTICE

Emotional wellbeing of pregnant women especially in high-risk pregnancies should be explored in order to prevent consequences on women, their growing fetus, and prenatal attachment.

The precursors's adaptation to pregnancy, prenatal attachment and maternal self-confidence

We investigated the precursors for prenatal attachment (PA), adaptation to pregnancy and maternal self-confidence, and the relationship of these variables with each other. This cross-sectional study was conducted between July and December 2020. Data were obtained using an online survey from social media groups. The mean Prenatal Self Evaluation Questionnaire scores of women had a negative and moderate correlation with mean Pharis Self-Confidence Scale (r=-0.287, p=.000) and negative and weak correlation with mean Prenatal Attachment Inventory scores (r=-0.317, p=.000). Women who conceived following assisted reproductive techniques had a higher level of readiness to give birth (17.62 ± 5.22) than women who conceived spontaneously (29.57 ± 6.15) (β=-0.285, t=-3.547, p=.002). We concluded that when women's adaptation to pregnancy increased in the prenatal period, their PA level and self-confidence towards baby care increased. The results of this study may guide healthcare professionals in terms of improving care for women who have attachment and adaptation problems during pregnancy. Women who conceived following assisted reproductive techniques can be reassured that infertility does not have a negative impact on their readiness for birth. Healthcare professionals could ensure adaptation in women who have problems with adaptation during pregnancy by initiating interventions that support PA and increase the maternal self-confidence levels of women.Impact StatementWhat is already known on this subject? There were few studies examining the relationship between women's conception style with prenatal attachment (PA), adaptation to pregnancy, and maternal self-efficacy.What do the results of this study add? In this study, it was determined that women who conceived following assisted reproductive techniques have higher levels of being ready to give birth than women who conceived spontaneously without medical assistance. Additionally, it was found that as women evaluate themselves positively in the prenatal period, their PA and maternal self-confidence level regarding baby care increased.What are the implications of these findings for clinical practice and/or further research? Since this study examines the precursors of maternal self-confidence, PA and adaptation to pregnancy in Turkish pregnant women, it was shown that studies in different cultures are needed in terms of generalisability of the results. In addition, there is a need to identify risky women who have low self-confidence in baby care during pregnancy and have attachment and adjustment problems, and to culture-specific intervention programs need to be developed and tested.

Antenatal depression: Efficacy of a pre-post therapy study and repercussions in motor development of children during the first 18 months postpartum. Study: "Pregnancy care, healthy baby"

AIMS

To evaluate the efficacy of brief psychotherapeutic interventions of cognitive behavioral therapy to treat antenatal depression and verify the association between interventions and motor development of infants at 3 and 18 months of age.

METHODS

Pre-post-intervention study nested a randomized clinical trial, both of which are extracts from a population-based cohort study of a southern Brazilian city. The major depressive episode was measured through Mini Plus, the severity of depressive symptoms by BDI-II and motor development using Bayley-III and AIMS. The follow-ups occurred during the gestational period (T2) and at 3 (T3) and 18 months (T4) after delivery.

RESULTS

Data were analyzed from 336 women in the control group (not intervened) and 108 from the group of depressed women who received intervention for antenatal depression. The effectiveness of the interventions for a major depressive episode was around 80% for both models in the two follow-up stages (3 and 18 months postpartum). In addition, the children whose mothers received intervention presented 3.7 (95% CI 0.7-6.6) points higher in Bayley-III at 3 months old when compared to the children in the control group (p = 0.01). There was no difference between the two psychotherapy models tested, both being equally effective (p > 0.05).

CONCLUSIONS

We found that the brief psychotherapeutic interventions of cognitive behavioral therapy for gestational depression were effective in causing remission of the condition both in the short and long term, besides indirectly causing benefits also to the children, with regard to their motor development.

Perceived stress during the prenatal period: assessing measurement invariance of the Perceived Stress Scale (PSS-10) across cultures and birth parity

Maternal prenatal stress places a substantial burden on mother's mental health. Expectant mothers in low- and middle-income countries (LMICs) have thus far received less attention than mothers in high-income settings. This is particularly problematic, as a range of triggers, such as exposure to traumatic events (e.g. natural disasters, previous pregnancy losses) and adverse life circumstances (e.g. poverty, community violence), put mothers at increased risk of experiencing prenatal stress. The ten-item Perceived Stress Scale (PSS-10) is a widely recognised index of subjective experience of stress that is increasingly used in LMICs. However, evidence for its measurement equivalence across settings is lacking. This study aims to assess measurement invariance of the PSS-10 across eight LMICs and across birth parity. This research was carried out as part of the Evidence for Better Lives Study (EBLS, vrc.crim.cam.ac.uk/vrcresearch/EBLS). The PSS-10 was administered to N = 1,208 expectant mothers from Ghana, Jamaica, Pakistan, the Philippines, Romania, South Africa, Sri Lanka and Vietnam during the third trimester of pregnancy. Confirmatory factor analysis suggested a good model fit of a two-factor model across all sites, with items on experiences of stress loading onto a negative factor and items on perceived coping onto a positive factor. Configural and metric, but not full or partial scalar invariance, were established across all sites. Configural, metric and full scalar invariance could be established across birth parity. On average, first-time mothers reported less stress than mothers who already had children. Our findings indicate that the PSS-10 holds utility in assessing stress across a broad range of culturally diverse settings; however, caution should be taken when comparing mean stress levels across sites.

It takes two: An antenatal to postnatal RDoC framework for investigating the origins of maternal attachment and mother–infant social communication

Transformation of the maternal–fetal relationship into the mother–infant relationship remains an enigmatic process. This progression is considered using a Research Domain Criteria (RDoC) informed approach centered on domains of Arousal/Regulation, Positive/Negative Valence, and Social Processes. One hundred and fifty-eight maternal–fetal dyads began participation during pregnancy, maternal–infant dyads were followed at 6 months postpartum. Women exhibited stability in feelings of attachment to the fetus and infant, and in positive/negative appraisal of pregnancy and motherhood. Elicited maternal physiological arousal to emotionally evocative videos generated fetal heart rate variability and motor activity responses. Parasympathetic (i.e., heart rate variability) suppression in the fetus was associated with more positive and regulated infant social communication in the Face-to-Face Still Face protocol; suppression of maternal respiratory sinus arrhythmia was related to infant affect but in the opposite direction. Maternal ratings of infant temperament aligned with maternal antenatal affective valence. Attachment trajectories characterized by stability from antenatal to postnatal periods were most associated with maternal affective appraisal of pregnancy; shifts were influenced by infant characteristics and maternal sympathetic responsivity. Results illustrate how variation in arousal and regulatory systems of the pregnant woman and fetus operate within the context of maternal positive and negative valence systems to separately and jointly shape affiliation and temperament in early infancy.

The impact of maternal adverse childhood experiences and prenatal depressive symptoms on foetal attachment: Preliminary evidence from expectant mothers across eight middle-income countries

BACKGROUND

Mothers from middle-income countries (MIC) are estimated to have higher rates of adverse childhood experiences (ACEs) and depression during pregnancy compared to mothers from high income countries. Prenatal depression can adversely impact on a mother's feelings towards her foetus and thus may be partially responsible for intergenerational transmission of risk associated with maternal ACEs. However, the extent to which prenatal depressive symptoms mediate the association between maternal ACEs and foetal attachment is unknown.

METHODS

Data on foetal attachment, ACEs, and prenatal depression came from mothers in their third trimester of pregnancy (n = 1,185) located across eight MICs, participating in the prospective birth cohort Evidence for Better Lives Study - Foundational Research (EBLS-FR). Data were from the baseline measurement.

RESULTS

Full-sample path mediation analyses, adjusting for relevant covariates, suggested a full mediating effect of prenatal depression. However, at the individual-country level, both positive and negative effects of ACEs on foetal attachment were observed after the inclusion of depressive symptoms as a mediator, suggesting cultural and geographical factors may influence a mother's empathic development after ACE exposure.

LIMITATIONS

As no follow-up measurements of depressive symptoms or postnatal attachment were included in the analyses, the findings cannot be extrapolated to the postnatal period and beyond. Further, causality cannot be inferred as the study was observational.

CONCLUSIONS

The findings reinforce the importance of screening for prenatal depression during antenatal care in MICs. Addressing prenatal depression within maternal health care may support foetal attachment and contribute to reducing the intergenerational transmission of disadvantage.