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Major influences on maternal responsiveness to infants
Major Influences on Maternal R e s p o n s i v e n e s s to Infants Deidre M. Blank, Mary Ann Schroeder, and Johanna Flynn
Thirty healthy, middle-class mothers were interviewed during their postpartum hospital stay to identify major influences on mothers' responses to their infants. Sullivan's theorem of tenderness served as a guide for exploring maternal responsiveness. Three major categories, infant tenderness needs, maternal perception, and maternal needs, and their related properties, were described. Support persons were viewed as very important. Mothers also believed that some infant needs were more important than others. Finally, mothers felt that they were constantly faced with priorities, and that the emotional state of the mother and infant often influenced their interaction. Copyright © 1995 by W.B. Saunders Company
NFANTS LEARN what to expect from the world through experiences with their primary caretaker, most often a mother (Crockenberg, 1981). A mother must respond appropriately to her infant if the infant is to learn functionally effective behavior (Watson, 1966). Nurses are in an ideal position to assess the factors contributing to a nurturing environment, as well as those factors that impair mother-infant interaction. This study was designed to examine the interpersonal factors, as identified by healthy, middleclass mothers, that were viewed as important in deciding responsiveness to infants. This approach was used because mothers do not always interact with their infants based on an objective assessment but on complex, subtle, and often subjective factors (Johnson, Emde, Pannabecker, Stenberg, & Davis, 1982; Nover, Shore, Timberlake, & Greenspan, 1984). Other researchers have shown that parent reports can capture both the objective
I
From the College of Nursing, Rutgers University, Newark, N J, Administrative Research, Harris Methodist Forth Worth, TX, and School of Nursing, Emory University, Atlanta, GA. Deidre M. Blank, DSN, RN, FAAN:Assistant Professor and Henry E. Rutgers Fellow, Rutgers University, College of Nursing, Newark, NJ; Mary Ann Schroeder, PhD, RN, FAAN: Director, Administrative Research, Harris Methodist Forth Worth, Fort Worth, TX; and Johanna Flynn, MA, RN: Associate Professor (Retired), Emory University, School of Nursing, Atlanta, GA. Funded in part by the Division of Nursing, Health Resources and Services Administration. Address reprint requests to Deidre M. Blank, DSN, RN, FAAN, 815 Dawes Dr, Yardley, PA 19067. Copyright © 1995 by W.B. Saunders Company 0897-1897/95/0801-000755.00/0 34
characteristics of the child and the subjective characteristics of the parent (Bates & Bayles, 1984). Sullivan's (Perry and Gawel, 1953) tendemess theorem served as the basis for exploring maternal responsiveness. This theorem offers an interpersonal description of the early reciprocal interaction of mothers and infants. From this perspective, infants must be able to express their needs to an appropriate individual to help ensure that their needs will be resolved. Beginning with the infant's first activities, certain behaviors become associated withthe diminution of selected tenderness needs. Sullivan uses the term tenderness to emphasize two types of infants needs, physiological and contact. Examples of physiological needs include oxygen, water, food, adequate body temperature, and elimination of bodily wastes. Contact needs include physical closeness and touch. Although the infant is almost totally dependent on the intervention of others for survival, both physiologically and interpersonally, the pattern of complexity of those needs changes because o f the maturing biological capability of the infant. Nonetheless, ongoing fulfillment of these needs is believed to be necessary for infant survival. In tum, the mother has a complementary need to manifest the appropriate behavior necessary to satisfy her infant. To accomplish this task, the mother must accurately perceive what it is that the infant requires. The cooperative interaction between infant and mother is thought to promote mutual satisfaction. That is, the infant gains by having the need met and by having experienced selected maternal behavior, for example, gentle touch and soothing words. The mother, in turn, feels a sense of fulfillment in meeting her infant's need. Although infant appearance and behavior play a Applied Nursing Research, VoI. 8, No. I (February), 1995: pp. 34-38
MATERNAL RESPONSIVENESS TO INFANTS
key role in eliciting ongoing maternal responses (Broussard, 1979; Kronstadt, Oberkiaid, Ferb, & Swartz, 1979), previous work (Gottlieb, 1978) suggests that a mother's ability to recognize and interpret infant characteristics is also essential. Other researchers (Nover et al., 1984) have found that mothers exhibiting distorted perceptions of infant behavior interact less and display less affection with their infants than mothers who perceive their infant's behavior accurately. Various factors influence perception, including previous experience with infants, feelings of confidence, temperament, availability of support systems (Kronstadt et al., 1979), preconceptions of the perfect infant (Broussard, 1979), and level of anxiety (Blumberg, 1980). Thus, mother-infant interaction does not occur in a vacuum. It is part of a complex system (Pederson et al., 1990). Family and friends make up an important part of a new mother's system. Researchers (Aaronson, 1989; Brown, 1986; Mercer, Ferketich, DeJoseph, May, & Sollid, 1988) have shown that social support plays an important role in health and behavior. Further, social support was shown to be the best predictor of attachment (Crockenberg, 1981). Although additional studies (Jacobson & Frye, 1991; Pianta, Stroufe, & Egeland, 1989; Zarling, Hirsch, & Landry, 1988) have shown the importance of social support in enhancing attachment, many have also been limited to high-risk, low-income motherinfant pairs. Thus, there is a need for additional research studying more stable working- and middle-class families and documenting the impact of social support in these groups. Furthermore, a lack of maternal support influences affective development during early infancy (Jacobson & Frye, 1991). Research that encompasses what mothers believe is important in their responses to infants should provide a better understanding of why mothers respond the way they do to their infants. Finally, a review (Pianta et al., 1989) of previous literature presents a contradictory view about whether maternal sensitivity is static or dynamic. However, researchers (Pianta et al., 1989) found that stress, whether from the infant or environment, resulted in less maternal sensitivity over time. Also, it has been suggested that the presence of stress may magnify the need for support (Jacobson & Frye, 1991). There are some researchers (Pederson et al., 1990) who suggest, because of the high correlation between maternal sensitivity
35
and attachment, that stress is needed to be able to detect individual differences in maternal sensitivity. Mercer et al. (1988) showed that perceived social support accounted for more variances in family functioning for high-risk than low-risk pregnant women. Asking mothers what they think, in the present study, will help clarify what the role of stress is in mother-infant interaction for healthy, middle-class mothers. METHODS
The study used an exploratory qualitative approach to collect healthy mothers' descriptions of what was important in deciding responsiveness to their infants. Mothers were conveniently recruited from one large, Southern metropolitan hospital. The hospital typically averaged 200 deliveries a month, with approximately 85% being normal, low-risk deliveries for a predominantly middleclass group of mothers. Criteria for sample selection included healthy post-partum mothers over 18 years of age. Healthy mothers referred to those without any major physical or psychological complications, specifically any condition that might not be suitable to a lengthy interview. Mothers were recruited for the study during their first postpartum day in the hospital. All subjects gave written informed consent to participate in the study. Each mother was interviewed, for approximately 1 to 11/2hours. The instruments for the study consisted of a demographic sheet and a semistructured interview guide. The Sullivan (Perry & Gawel, 1953) tenderness theorem was used as a guide for generating the interview questions. The questions were designed for women who had previous experience with infants. The goals of the interview were to (a) identify the perceived needs of infants and characteristics associated with expression of these infant needs, and (b) describe the perceived maternal factors thought to influence maternal responsiveness. The guide dealt with three broad areas. The first section of the interview contained general questions about infant needs. Questions addressed areas such as the kinds of needs infants had and how they demonstrated their needs. The second section included questions related to the mothers' role in addressing infant needs, and included questions about how a mother distinguished between infants needs. The last section contained general questions
BLANK, SCHROEDER,AND FLYNN
36
designed to elicit information about what could be done to enhance mother-infant interaction. Questions addressed how a mother felt when she is able, and unable, to meet her infant's needs and what could be done to help meet these needs. All interviews were tape-recorded. The interviews were transcribed and checked for accuracy. The data were analyzed to find which clusters or groups of properties emerged from the raw data. Major categories were then generated from the data, using Sullivan's tenderness theorem as a guide in the naming process. Sample
The resulting convenient sample consisted of 30 healthy mothers who had prior experience with infants, including 29 multiparas, ranging in age from 27 to 41 (M = 33.0; SD = 3.2) years. Twentyfour mothers were white, five were black, and one was Hispanic. Maternal gestation ranged from 34 to 41 (M = 38.9; SD = 1.5) weeks. Only 4 of the 30 maternal gestations were between 34 and 37 weeks. Education ranged from 12 to 18 (M = 15.4; SD = 1.7) years of school, and gross family income varied from $26,000 to $90,000 (M = $54,000; SD = $13,700). These were all middleclass mothers, according to Green's (1970) socioeconomic index, which takes into consideration educational level, income, and ethnicity. Twentyone mothers had a support person present at the time of delivery, with the husband being named the support figure for 20 mothers and the mother's father for one mother. Although the mothers completed the study during the first post partum day, 26 mothers planned to breast-feed, while four planned to bottle-feed, their infants. FINDINGS
Three categories were determined: infant tenderness needs, maternal perception, and maternal needs. The categories and their related properties are illustrated in Tables 1-3. A description of each category, based on Sullivan (Perry & Gawel, 1953), is offered: Infant tenderness needs are those infant requirements that are essential. That is, they rely almost exclusively on the intervention of others. The manner in which these early needs are addressed not only satisfies a biologic disequilibrium, but also addresses the very early interpersonal needs of the infant. Maternal perception refers to the capacity to recognize and interpret the critical elements necessary to be able to act out or relieve the infant's disequilibrium. Maternal needs
Table 1. Infant Needs and Related Properties Category: Infant tenderness needs Related properties • Time is a factor, progressing from simple to complex with age, e.g., "the most immediate needs of infants are eating, sleeping", "their needs change a little as they get o l d e r . . , may take more time to figure out" • Expression of need depends not only on the particular behavior, but also on the variation in the behavior, e.g., "certain cries mean certain things" • Nature of needs varies, e.g., "food", "warmth", "comfort", "love", "attachment", "stimulation" • Meeting need helps an infant adapt to the outside world, "you know that their need for food is essential" • An infant is active in expressing need, e.g., "they will let you know by crying or touching" • Immediate gratification usually expected, e.g., "my first child could not wait to have her needs met" • The pattern of interaction often decides if and how needs are met, e.g., "the persistant cry told me he really need to be picked up"
refer to the mother's requirement to be able to manifest the appropriate activity. That is, she has a need to behave tenderly toward her infant, thus leaving her with a sense of fulfillment. In addition, several other findings were identified. Healthy, well-educated, middle-class, mothers who had given birth recently believed that they needed support from other persons. For example, 20 of the mothers showed a need for moral support, understanding, and a feeling of confidence about what they were doing as a mother. Also, 21 Table 2. Maternal Perception and Related Properties Category: Maternal perception Related properties • Influenced by total situation, including physiologic status of the mother, e.g., amoung of sleep and energy affects you" • Previous time and experience with an infant are important, e.g., " . . . at the beginning with my first child, it took a little time to figure out what she w a s trying to tell me" • Infant age gives a clue, e.g., "Older infants have more expressions" • Infant size, e.g., "premature infants require more attention" • Infant sex, e.g., "different for the physical aspects" • Knowledge base about infants and awareness of what books say infants should be doing, e.g., "babies have more than just food or diaper change needs" • Use of the various senses has an impact, e.g., "'a cry says it is more urgent than a smile" • Individual temperaments have impact, e.g., " m y other two weren't really that way"
MATERNAL RESPONSIVENESS TO INFANTS
Table 3. Maternal Needs and Related Properties Category: Maternal needs Related properties • Moral support, e.g., "moral support is needed if you have a problem" • Ability to nurture or care for someone else, e.g., "you are able to help your child grow up" • Ability to set priorities, e.g., "it's tiring and you can't do everything" • Sense of feeling or trust from the infant, e.g., "a nice f e e l i n g . . , having your baby trust that you're going to be there for them'" • Feeling of mutual satisfaction and confidence, e.g., "I've done a good job"
of the 30 mothers had a support person available at the delivery. Mothers reported that some infant needs were more urgent than others. That is, 16 of the mothers clearly reported that they could distinguish how urgent the need was, frequently by the quality of the cry, for example, a "shrill, loud" cry. Some mothers described the cry as "frantic", suggesting to them that their infants were in a state of panic. Most mothers were constantly faced with setting priorities for both themselves and their infants. For example, at least 12 expressly said that it was difficult to balance all the activities that needed to get done and how they often felt left with so many responsibilities. Finally, mothers frequently felt that the emotional state of the mother and the infant influence one another in the interaction. For example, 10 of the mothers reported that when they were "upset" the infant became "upset." Some said that when they were "nervous" the infant would cry. Others said that their being "uptight" may have been the reason the infant became "colicky." DISCUSSION
The three empirically generated categories, infant tenderness needs, maternal perception, and maternal needs, offer initial support for using Sullivan's (Perry & Gawel, 1953) theorem of tenderness in assessing maternal responsiveness to infants. In addition, a rich source of information was derived from the identification of many properties associated with each category. For example, mothers recognized that there are a variety of needs, such as the need for food, warmth, security, close-
37
ness, stroking, and love. They also suggested that some of these needs are more basic than others. These findings are consistent with Sullivan's partitioning of tenderness needs into both physiological and contact needs. They are also consistent with previous research (Blank, 1985) where mothers illustrated differences between physiological and contact needs. An important question arises from this research. How does tenderness relate, if at all, to the idea of attachment? Although purely speculative at this point, the tenderness process may serve as a more objective indicator of the bond that is developing between infant and mother. That is, the process not only examines the physiological needs, but also considers the interpersonal or emotional behavior used to fulfill the needs. Examining this process therefore may provide clues in terms of impaired mother-infant interaction. Expanded research in this area will help to verify this speculation. Further, consistent with previous literature (Blumberg, 1980; Broussard, 1979; Broussard & Hartner, 1970, 1971; Day, 1982; Gottlieb, 1978), it seems that infant appearance and behavior and a mother's ability to discriminate among various infant characteristics and behaviors are important qualities in deciding a mother's response to her infant. Experiences with an infant, preconceptions of the perfect infant, recognition of the impact of individual temperaments, and availability of support systems, as reported in previous literature (Blumberg, 1980; Kronstadt et al., 1979; Nover et al., 1984), also influenced maternal responsiveness in this study. The mothers' indications that infants play an active role and that mothers need mutual satisfaction in the interaction is consistent with Sullivan's portrayal of the tenderness process as reciprocal. In addition, the current study extended previous literature by suggesting that maternal needs represent major interpersonal components that must be present in middle-class families, if the infant's tenderness needs are to be satisfied. Finally, mothers were cognizant that being "upset" can influence the infant, and that a mother should avoid making the infant "nervous" because the infant needs to feel secure. These beliefs are consistent with Sullivan's (Perry & Gawel, 1953) theorem of anxiety, which suggests that high levels of maternal anxiety can diminish maternal perception and create a feeling of insecurity in an infant.
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BLANK, SCHROEDER,AND FLYNN
CLINICAL IMPLICATIONS
It is important that nurses recognize individual differences and explain to parents that such differences in infant behavior and appearance, are normal. Nurses should consider assessing the infant when the parents are present, pointing out the normal characteristics of infants and encouraging the parents to interact with their infant. Also, nurses are~ in a unique position to help mothers in identifying initial support systems, and provide opportunities for them to verbalize their feelings. Both nurses and support groups may be particularly valuable for parents without access to extended family systems, especially if they are to develop the necessary knowledge and awareness needed for effective parenting. Nurses need to be alert to maternal concerns about feelings of satisfaction and confidence, and to show acceptance of these feelings to ease re-
sponsive mothering. When working with parents, nurses need to recognize that parenting is a learned behavior, and that nurses are in an enviable position of being able to provide the necessary knowledge that parents need to guide them in the care of their infants. Also, nurses should assess mothers for fatigue, and provide opportunities for flexible rooming-in. Finally, nurses need to be attuned to the many stressors which can affect a mother and her family surrounding the birth of an infant and need to provide assurance that a solution can be found. CONCLUSION
The data suggest that there are some readily identifiable influences that affect how a mother responds to her infant. Recognition of these major influences will help nurses in their ability to diagnose mothers who are at risk for unresponsive mothering and help them to intervene when appropriate.
REFERENCES
Aaronson, L.S. (1989). Perceived and received support: Effects on health behaviorduring pregnancy.Nursing Research, 38, 4-9. Bates, J.E., & Bayles, K. (1984). Objectiveand subjective components in mothers' perceptionsof their childrenfrom age 6 months to 3 years. Merrill-Palmer Quarterly, 30, 111-130. Blank, D.M. (1985). Developmentof the Infant Tenderness Scale. Nursing Research, 34(2), 211-216. Blumberg, N.L. (1980). Effects of neonatal risk, maternal attitude, and cognitive style on early postpartum adjustment. Journal of Abnormal Psychology, 89, 139-150. Broussard, E.R. (1979). Assessmentof the adaptive potential of the mother-infantsystem: The Neonatal Perception Inventories. Seminars in Perinatology, 3, 91-100. Broussard, E.R., & Hartner, M.S.S. (1970). Maternal perception of the neonate as related to development. Child Psychiatry and Human Development, 1, 16-25. Broussard, E.R., & Hartner, M.S.S. (1971). Furtherconsiderations regarding maternal perception of the first born. In J. Hellmuth (Ed.), Exceptional infant: Vol. 2. Studies in abnormalities (pp. 432-449). New York: Brunner/Mazel. Brown, M.A. (1986). Social support, stress, and health: A comparison of expectant mothers and fathers. Nursing Research, 35(2), 72-76. Crockenberg, S.B. (1981). Infant irritability,motherresponsiveness, and social supportinfluenceson the securityof infantmother attachment. Child Development, 52, 857-865. Day, S. (1982). Mother-infantactivitiesas providers of sensory stimulation.The American Journal of Occupational Therapy, 36, 579-585. Gottlieb, L. (1978). Maternal attachment in primiparas. JOGN Nursing, 7(1), 39-44. Green, L. (1970). Manual for scoring socioeconomicstatus for research on health behavior. Public Health Reports, 85(9), 815-827.
Jacobson, S.W., & Frye, K.F. (1991). Effect of maternal social support on attachment: Experimental evidence. Child Development, 62, 572-582. Johnson, W.F., Emde, R.N., Pannabecker,B.J., Stenberg, C.R., & Davis, M.H. (1982). Matemal perception of infant emotion from birth through 18 months. Infant Behavior and Development, 5, 313-322. Kronstadt, D., Oberklaid, F., Ferb, T.E., & Swartz, J.P. (1979). Infantbehaviorand maternaladaptationsin the first six months of life. American Journal of Orthopsychiatry, 49(3), 454-464. Mercer, R.T., Ferketich, S.L., DeJoseph, J., May, K.A., & Sollid, D. (1988). Effect of stress on familyfunctioningduring pregnancy. Nursing Research, 37(5), 268-275. Nover, A., Shore, M.F., Timberlake,E.M., & Greenspan, S.I. (1984). The relationshipof maternal perception and maternal behavior: A study of normal mothers and their infants. American Journal of Orthopsychiatry, 54(2), 210-223. Pederson, D.R., Moran, G., Sitko, C., Campbell, K., Ghesquire, K., & Acton, H. (1990). Maternal sensitivityand the securityof infant-motherattachment:A Q-sort Study. Child Development, 61, 1974-1983. Perry, H.S., & Gawel, M.L. (Eds.) (1953). The interpersonal theory of psychiatry. New York: W.W. Norton. Pianta, R.C., Stroufe, L.A., & Egeland, B. (1989). Continuity and discontinuityin maternalsensitivityat 6, 24, and 42 months in a high-risk sample. Child Development, 60, 481487. Watson, J. (1966). The developmentand generalizationof "contingency awareness" in early infancy: Some hypotheses. Merrill-Palmer Quarterly, 12, 123-135. Zarling, C.L., Hirsch, B.J., Landry, S. (1988). Maternal social networks and mother-infantinteractionsin full-termand very low birthweight, preterm infants. Child Development, 59, 178-185.
Thirty healthy, middle-class mothers were interviewed during their postpartum hospital stay to identify major influences on mothers' responses to their infants. Sullivan's theorem of tenderness served as a guide for exploring maternal responsiveness. Three major categories, infant tenderness needs, maternal perception, and maternal needs, and their related properties, were described. Support persons were viewed as very important. Mothers also believed that some infant needs were more important than others. Finally, mothers felt that they were constantly faced with priorities, and that the emotional state of the mother and infant often influenced their interaction. Copyright © 1995 by W.B. Saunders Company
NFANTS LEARN what to expect from the world through experiences with their primary caretaker, most often a mother (Crockenberg, 1981). A mother must respond appropriately to her infant if the infant is to learn functionally effective behavior (Watson, 1966). Nurses are in an ideal position to assess the factors contributing to a nurturing environment, as well as those factors that impair mother-infant interaction. This study was designed to examine the interpersonal factors, as identified by healthy, middleclass mothers, that were viewed as important in deciding responsiveness to infants. This approach was used because mothers do not always interact with their infants based on an objective assessment but on complex, subtle, and often subjective factors (Johnson, Emde, Pannabecker, Stenberg, & Davis, 1982; Nover, Shore, Timberlake, & Greenspan, 1984). Other researchers have shown that parent reports can capture both the objective
I
From the College of Nursing, Rutgers University, Newark, N J, Administrative Research, Harris Methodist Forth Worth, TX, and School of Nursing, Emory University, Atlanta, GA. Deidre M. Blank, DSN, RN, FAAN:Assistant Professor and Henry E. Rutgers Fellow, Rutgers University, College of Nursing, Newark, NJ; Mary Ann Schroeder, PhD, RN, FAAN: Director, Administrative Research, Harris Methodist Forth Worth, Fort Worth, TX; and Johanna Flynn, MA, RN: Associate Professor (Retired), Emory University, School of Nursing, Atlanta, GA. Funded in part by the Division of Nursing, Health Resources and Services Administration. Address reprint requests to Deidre M. Blank, DSN, RN, FAAN, 815 Dawes Dr, Yardley, PA 19067. Copyright © 1995 by W.B. Saunders Company 0897-1897/95/0801-000755.00/0 34
characteristics of the child and the subjective characteristics of the parent (Bates & Bayles, 1984). Sullivan's (Perry and Gawel, 1953) tendemess theorem served as the basis for exploring maternal responsiveness. This theorem offers an interpersonal description of the early reciprocal interaction of mothers and infants. From this perspective, infants must be able to express their needs to an appropriate individual to help ensure that their needs will be resolved. Beginning with the infant's first activities, certain behaviors become associated withthe diminution of selected tenderness needs. Sullivan uses the term tenderness to emphasize two types of infants needs, physiological and contact. Examples of physiological needs include oxygen, water, food, adequate body temperature, and elimination of bodily wastes. Contact needs include physical closeness and touch. Although the infant is almost totally dependent on the intervention of others for survival, both physiologically and interpersonally, the pattern of complexity of those needs changes because o f the maturing biological capability of the infant. Nonetheless, ongoing fulfillment of these needs is believed to be necessary for infant survival. In tum, the mother has a complementary need to manifest the appropriate behavior necessary to satisfy her infant. To accomplish this task, the mother must accurately perceive what it is that the infant requires. The cooperative interaction between infant and mother is thought to promote mutual satisfaction. That is, the infant gains by having the need met and by having experienced selected maternal behavior, for example, gentle touch and soothing words. The mother, in turn, feels a sense of fulfillment in meeting her infant's need. Although infant appearance and behavior play a Applied Nursing Research, VoI. 8, No. I (February), 1995: pp. 34-38
MATERNAL RESPONSIVENESS TO INFANTS
key role in eliciting ongoing maternal responses (Broussard, 1979; Kronstadt, Oberkiaid, Ferb, & Swartz, 1979), previous work (Gottlieb, 1978) suggests that a mother's ability to recognize and interpret infant characteristics is also essential. Other researchers (Nover et al., 1984) have found that mothers exhibiting distorted perceptions of infant behavior interact less and display less affection with their infants than mothers who perceive their infant's behavior accurately. Various factors influence perception, including previous experience with infants, feelings of confidence, temperament, availability of support systems (Kronstadt et al., 1979), preconceptions of the perfect infant (Broussard, 1979), and level of anxiety (Blumberg, 1980). Thus, mother-infant interaction does not occur in a vacuum. It is part of a complex system (Pederson et al., 1990). Family and friends make up an important part of a new mother's system. Researchers (Aaronson, 1989; Brown, 1986; Mercer, Ferketich, DeJoseph, May, & Sollid, 1988) have shown that social support plays an important role in health and behavior. Further, social support was shown to be the best predictor of attachment (Crockenberg, 1981). Although additional studies (Jacobson & Frye, 1991; Pianta, Stroufe, & Egeland, 1989; Zarling, Hirsch, & Landry, 1988) have shown the importance of social support in enhancing attachment, many have also been limited to high-risk, low-income motherinfant pairs. Thus, there is a need for additional research studying more stable working- and middle-class families and documenting the impact of social support in these groups. Furthermore, a lack of maternal support influences affective development during early infancy (Jacobson & Frye, 1991). Research that encompasses what mothers believe is important in their responses to infants should provide a better understanding of why mothers respond the way they do to their infants. Finally, a review (Pianta et al., 1989) of previous literature presents a contradictory view about whether maternal sensitivity is static or dynamic. However, researchers (Pianta et al., 1989) found that stress, whether from the infant or environment, resulted in less maternal sensitivity over time. Also, it has been suggested that the presence of stress may magnify the need for support (Jacobson & Frye, 1991). There are some researchers (Pederson et al., 1990) who suggest, because of the high correlation between maternal sensitivity
35
and attachment, that stress is needed to be able to detect individual differences in maternal sensitivity. Mercer et al. (1988) showed that perceived social support accounted for more variances in family functioning for high-risk than low-risk pregnant women. Asking mothers what they think, in the present study, will help clarify what the role of stress is in mother-infant interaction for healthy, middle-class mothers. METHODS
The study used an exploratory qualitative approach to collect healthy mothers' descriptions of what was important in deciding responsiveness to their infants. Mothers were conveniently recruited from one large, Southern metropolitan hospital. The hospital typically averaged 200 deliveries a month, with approximately 85% being normal, low-risk deliveries for a predominantly middleclass group of mothers. Criteria for sample selection included healthy post-partum mothers over 18 years of age. Healthy mothers referred to those without any major physical or psychological complications, specifically any condition that might not be suitable to a lengthy interview. Mothers were recruited for the study during their first postpartum day in the hospital. All subjects gave written informed consent to participate in the study. Each mother was interviewed, for approximately 1 to 11/2hours. The instruments for the study consisted of a demographic sheet and a semistructured interview guide. The Sullivan (Perry & Gawel, 1953) tenderness theorem was used as a guide for generating the interview questions. The questions were designed for women who had previous experience with infants. The goals of the interview were to (a) identify the perceived needs of infants and characteristics associated with expression of these infant needs, and (b) describe the perceived maternal factors thought to influence maternal responsiveness. The guide dealt with three broad areas. The first section of the interview contained general questions about infant needs. Questions addressed areas such as the kinds of needs infants had and how they demonstrated their needs. The second section included questions related to the mothers' role in addressing infant needs, and included questions about how a mother distinguished between infants needs. The last section contained general questions
BLANK, SCHROEDER,AND FLYNN
36
designed to elicit information about what could be done to enhance mother-infant interaction. Questions addressed how a mother felt when she is able, and unable, to meet her infant's needs and what could be done to help meet these needs. All interviews were tape-recorded. The interviews were transcribed and checked for accuracy. The data were analyzed to find which clusters or groups of properties emerged from the raw data. Major categories were then generated from the data, using Sullivan's tenderness theorem as a guide in the naming process. Sample
The resulting convenient sample consisted of 30 healthy mothers who had prior experience with infants, including 29 multiparas, ranging in age from 27 to 41 (M = 33.0; SD = 3.2) years. Twentyfour mothers were white, five were black, and one was Hispanic. Maternal gestation ranged from 34 to 41 (M = 38.9; SD = 1.5) weeks. Only 4 of the 30 maternal gestations were between 34 and 37 weeks. Education ranged from 12 to 18 (M = 15.4; SD = 1.7) years of school, and gross family income varied from $26,000 to $90,000 (M = $54,000; SD = $13,700). These were all middleclass mothers, according to Green's (1970) socioeconomic index, which takes into consideration educational level, income, and ethnicity. Twentyone mothers had a support person present at the time of delivery, with the husband being named the support figure for 20 mothers and the mother's father for one mother. Although the mothers completed the study during the first post partum day, 26 mothers planned to breast-feed, while four planned to bottle-feed, their infants. FINDINGS
Three categories were determined: infant tenderness needs, maternal perception, and maternal needs. The categories and their related properties are illustrated in Tables 1-3. A description of each category, based on Sullivan (Perry & Gawel, 1953), is offered: Infant tenderness needs are those infant requirements that are essential. That is, they rely almost exclusively on the intervention of others. The manner in which these early needs are addressed not only satisfies a biologic disequilibrium, but also addresses the very early interpersonal needs of the infant. Maternal perception refers to the capacity to recognize and interpret the critical elements necessary to be able to act out or relieve the infant's disequilibrium. Maternal needs
Table 1. Infant Needs and Related Properties Category: Infant tenderness needs Related properties • Time is a factor, progressing from simple to complex with age, e.g., "the most immediate needs of infants are eating, sleeping", "their needs change a little as they get o l d e r . . , may take more time to figure out" • Expression of need depends not only on the particular behavior, but also on the variation in the behavior, e.g., "certain cries mean certain things" • Nature of needs varies, e.g., "food", "warmth", "comfort", "love", "attachment", "stimulation" • Meeting need helps an infant adapt to the outside world, "you know that their need for food is essential" • An infant is active in expressing need, e.g., "they will let you know by crying or touching" • Immediate gratification usually expected, e.g., "my first child could not wait to have her needs met" • The pattern of interaction often decides if and how needs are met, e.g., "the persistant cry told me he really need to be picked up"
refer to the mother's requirement to be able to manifest the appropriate activity. That is, she has a need to behave tenderly toward her infant, thus leaving her with a sense of fulfillment. In addition, several other findings were identified. Healthy, well-educated, middle-class, mothers who had given birth recently believed that they needed support from other persons. For example, 20 of the mothers showed a need for moral support, understanding, and a feeling of confidence about what they were doing as a mother. Also, 21 Table 2. Maternal Perception and Related Properties Category: Maternal perception Related properties • Influenced by total situation, including physiologic status of the mother, e.g., amoung of sleep and energy affects you" • Previous time and experience with an infant are important, e.g., " . . . at the beginning with my first child, it took a little time to figure out what she w a s trying to tell me" • Infant age gives a clue, e.g., "Older infants have more expressions" • Infant size, e.g., "premature infants require more attention" • Infant sex, e.g., "different for the physical aspects" • Knowledge base about infants and awareness of what books say infants should be doing, e.g., "babies have more than just food or diaper change needs" • Use of the various senses has an impact, e.g., "'a cry says it is more urgent than a smile" • Individual temperaments have impact, e.g., " m y other two weren't really that way"
MATERNAL RESPONSIVENESS TO INFANTS
Table 3. Maternal Needs and Related Properties Category: Maternal needs Related properties • Moral support, e.g., "moral support is needed if you have a problem" • Ability to nurture or care for someone else, e.g., "you are able to help your child grow up" • Ability to set priorities, e.g., "it's tiring and you can't do everything" • Sense of feeling or trust from the infant, e.g., "a nice f e e l i n g . . , having your baby trust that you're going to be there for them'" • Feeling of mutual satisfaction and confidence, e.g., "I've done a good job"
of the 30 mothers had a support person available at the delivery. Mothers reported that some infant needs were more urgent than others. That is, 16 of the mothers clearly reported that they could distinguish how urgent the need was, frequently by the quality of the cry, for example, a "shrill, loud" cry. Some mothers described the cry as "frantic", suggesting to them that their infants were in a state of panic. Most mothers were constantly faced with setting priorities for both themselves and their infants. For example, at least 12 expressly said that it was difficult to balance all the activities that needed to get done and how they often felt left with so many responsibilities. Finally, mothers frequently felt that the emotional state of the mother and the infant influence one another in the interaction. For example, 10 of the mothers reported that when they were "upset" the infant became "upset." Some said that when they were "nervous" the infant would cry. Others said that their being "uptight" may have been the reason the infant became "colicky." DISCUSSION
The three empirically generated categories, infant tenderness needs, maternal perception, and maternal needs, offer initial support for using Sullivan's (Perry & Gawel, 1953) theorem of tenderness in assessing maternal responsiveness to infants. In addition, a rich source of information was derived from the identification of many properties associated with each category. For example, mothers recognized that there are a variety of needs, such as the need for food, warmth, security, close-
37
ness, stroking, and love. They also suggested that some of these needs are more basic than others. These findings are consistent with Sullivan's partitioning of tenderness needs into both physiological and contact needs. They are also consistent with previous research (Blank, 1985) where mothers illustrated differences between physiological and contact needs. An important question arises from this research. How does tenderness relate, if at all, to the idea of attachment? Although purely speculative at this point, the tenderness process may serve as a more objective indicator of the bond that is developing between infant and mother. That is, the process not only examines the physiological needs, but also considers the interpersonal or emotional behavior used to fulfill the needs. Examining this process therefore may provide clues in terms of impaired mother-infant interaction. Expanded research in this area will help to verify this speculation. Further, consistent with previous literature (Blumberg, 1980; Broussard, 1979; Broussard & Hartner, 1970, 1971; Day, 1982; Gottlieb, 1978), it seems that infant appearance and behavior and a mother's ability to discriminate among various infant characteristics and behaviors are important qualities in deciding a mother's response to her infant. Experiences with an infant, preconceptions of the perfect infant, recognition of the impact of individual temperaments, and availability of support systems, as reported in previous literature (Blumberg, 1980; Kronstadt et al., 1979; Nover et al., 1984), also influenced maternal responsiveness in this study. The mothers' indications that infants play an active role and that mothers need mutual satisfaction in the interaction is consistent with Sullivan's portrayal of the tenderness process as reciprocal. In addition, the current study extended previous literature by suggesting that maternal needs represent major interpersonal components that must be present in middle-class families, if the infant's tenderness needs are to be satisfied. Finally, mothers were cognizant that being "upset" can influence the infant, and that a mother should avoid making the infant "nervous" because the infant needs to feel secure. These beliefs are consistent with Sullivan's (Perry & Gawel, 1953) theorem of anxiety, which suggests that high levels of maternal anxiety can diminish maternal perception and create a feeling of insecurity in an infant.
38
BLANK, SCHROEDER,AND FLYNN
CLINICAL IMPLICATIONS
It is important that nurses recognize individual differences and explain to parents that such differences in infant behavior and appearance, are normal. Nurses should consider assessing the infant when the parents are present, pointing out the normal characteristics of infants and encouraging the parents to interact with their infant. Also, nurses are~ in a unique position to help mothers in identifying initial support systems, and provide opportunities for them to verbalize their feelings. Both nurses and support groups may be particularly valuable for parents without access to extended family systems, especially if they are to develop the necessary knowledge and awareness needed for effective parenting. Nurses need to be alert to maternal concerns about feelings of satisfaction and confidence, and to show acceptance of these feelings to ease re-
sponsive mothering. When working with parents, nurses need to recognize that parenting is a learned behavior, and that nurses are in an enviable position of being able to provide the necessary knowledge that parents need to guide them in the care of their infants. Also, nurses should assess mothers for fatigue, and provide opportunities for flexible rooming-in. Finally, nurses need to be attuned to the many stressors which can affect a mother and her family surrounding the birth of an infant and need to provide assurance that a solution can be found. CONCLUSION
The data suggest that there are some readily identifiable influences that affect how a mother responds to her infant. Recognition of these major influences will help nurses in their ability to diagnose mothers who are at risk for unresponsive mothering and help them to intervene when appropriate.
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