- Email: [email protected]
The relationship between infant feeding method and maternal role adjustment
THERELATIONSHIPBETWEENINFANTFEEDINGMETHODAND MATERNALROLEADJUSTMENT
Susan Flagler Virden,
RN, DNS
ABSTRACT The benefits of breastfeeding
for the infant are well known.
Much less is known,
how-
choice of feeding method is related to her maternal role adjustment during the initial weeks postpartum. Mother-infant mutuality and maternal anxiety scores of 60 first time mothers were examined using analysis of variance techniques. Method of infant feeding (breast, bottle, or combination) was found to be responsible for a significant amount of the variance in both scores. At one month postpartum, women who breastfed their infants had scores indicating less anxiety and more mutuality than the women bottle feeding their infants. An interpretation of the results using role theoy concepts provides a possible explanation of the relationships found. Differences in the character of interactions involved with breast and bottle feeding may influence other aspects of maternal role transitions. ever, about how the woman’s
The advantages of breastfeeding for the infant’s health and mother’s emotional bond to the infant are widely accepted by perinatal health professionals. Yet for social, cultural, and personal reasons, some women will elect to bottlefeed their neonates. While a large body of knowledge exists on the nutritional and immunological benefits of breastfeeding for the infant,’ much less is known about how the woman’s choice of feeding method influences her initial weeks as a mother. Feeding represents a substantial part of the infant care responsibilities a new mother must assume. Especially for primiparas, the mother’s
Address correspondence to: Susan F. Virden, Research Fellow, Clinical Nurse Scholars Program, School of Nursing, Helen Wood Hall, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642. This project was funded in part by the University of California San Francisco Graduate Division and the Alpha Eta Chapter of Sigma Theta Tau.
Journal of Nurse-Midwifery
??Vol.
perception of success with infant feeding is taken as an assessment of her ability to mother. How is the method selected for the frequent and essential activity of feeding related to the new mother’s initial adjustment? The purpose of this investigation was to explore the relationship between method of infant feeding-breast, bottle, or combination of breast and bottle-and the degree of maternal anxiety and mother-infant mutuality evident at one month postpartum. Infant care is an area of concern expressed by new mothers.*9 Many first time mothers have feelings of inadequacy associated with their lack of knowledge about infant care. Using a combination of interviews and quantitative measures, Leifefi conducted a longitudinal study of the psychological changes of 19 primiparas from the first trimester of pregnancy through the seventh month postpartum. Most of the women experienced anxiety during the postpartum period about their ability to
33, No. 1, January/February
Copyright 0 1988 by the American College of Nurse-Midwives
1988
provide adequate care for the baby. In another longitudinal study of 57 first time parents, Shereshefsky, Liebenberg, and Lockman found that most women experienced some uncertainty and anxiety about understanding their infant’s behavior and a sense of inadequacy about meeting the infant’s needs. In a study involving 64 couples with their first child, Robert@ examined the impact of infant behavior that necessitated action by the parent (obligatory infant behavior) on the ease of role transition and parental perception of the role competence. The amount of obligatory infant behavior was negatively correlated with ease of transition into parenthood (r = - .32) and parental perceptions of role competence (r = -.27). The greater amount of infant behavior that required action on the parent’s part the lower was the parent’s perception of adequacy in the role. Feeding is frequently a particular area of concern for new mothers. In 31 0091-2182188/$03.50
their analysis of telephone calls made by new parents to a health care facility, Sumner and Fritsch7 found that the majority of calls (62%) were made by primiparas and that nearly one-third of all questions were about feeding. In an earlier study, Adams2 interviewed 40 primiparas to determine their concerns about infant care. Feeding was found to be one of the major areas of concern throughout the first month. In studying the interactional behavior of 58 mother-infant pairs using interviews, questionnaires and observation, Greenberg8 noted that all 16 primiparas in the sample experienced feelings of inadequacy and that feeding was a major focus of the primiparas’ concerns. The activity of feeding is strongly associated with mothering. A new mother’s perception of success with regard to feeding her baby is often the key factor she uses in judging her success as a mother. Although the literature illustrates that infant feeding is a common concern of new mothers, little is available that describes the relationship of feeding method to maternal role adjustment. The purpose of this study was to determine how the method of infant feeding used by primiparas was related to maternal role adjustment in the first month postpartum. Gaining this knowledge may assist nurse cli-
Susan Flagler Virden is currently a postdoctoral research fellow in the Robert Wood Johnson Clinical Nurse Scholars Progmm at the Uniuersity of Rochester. Her research focuses on maternal role transition for tuomen experiencing high risk pregnancies. She is on leave from her position as Assistant Professor in the School of Nursing at the University of Washington. She received her undergmduate degree in nursing from UCLA and her gmduate degrees in Family Health Care Nursing from the University of California, San Francisco. She is a member of ANA, Sigma Theta Tau, and NAACOG.
32
nicians and researchers to better understand one of the multiple factors impacting the transition into the maternal role. METHOD
The research question was addressed by conducting additional analyses on data collected for an experimental study to determine the effect of providing primiparas with information about infant behavior during their postpartum hospitalization on maternal role adequacy one month after birth.g The experimental treatment was not responsible for any significant differences between groups with regard to maternal anxiety or mother-infant mutuality scores. Also, the distribution of women using a given feeding method was similar between the control and experimental groups. For these reasons, the determination was made that group assignment for the experimental study would not distort the investigation regarding feeding methods; therefore, data from the entire sample was used.
of age, with 72% of the sample being 25 years or older. All subjects were married (93%) and/or living with the father of the baby. The majority of the sample were Caucasian (60%), 18% were Asian, 10% were Black, and the remaining 12% represented other ethnic groups. This dispersion reflects the ethnic diversity present in the area where this study was conducted. The formal education of the subjects ranged from high school diploma (17%) to graduate degree (8%), with the majority of the sample (83%) having at least some college. At one month postpartum, 33 primiparas (55% of the sample) were breastfeeding their infants, 13 (22%) were bottlefeeding their infants, and 14 (23%) were using a combination of breast and bottlefeeding for their infants. Comparison of these three groups on demographic characteristics revealed no significant differences with regard to age, educational background, prenatal classes, ethnicity (Caucasian or noncaucaSian) and previous experience with infants.
Sample
Measures
The subjects were 60 primiparas who had given birth vaginally to healthy, full-term infants at one of the two hospitals in a large urban area in California. Twenty-nine subjects received obstetric care at a university-affiliated teaching hospital where the majority of maternity patients are clinic patients. The remaining 31 subjects received their obstetric care at a private hospital where all maternity patients are private patients. All subjects had a normal obstetric course throughout pregnancy, labor and delivery, and postpartum. Also, the majority of the sample (88%) had attended prenatal classes. The sample’s previous experience with infants ranged from “none” (20%) to “a great deal” (18%) with the remaining 62% reporting “vey little” or “some.” The primiparas were 20-30 years
Maternal anxiety and mother-infant mutuality were used as measures of maternal role adjustment. The selection of these variables rests with the assumptions that difficulty in adjustment is accompanied by more anxiety and that mother-infant mutuality is a central factor in maternal adjustment.10 Maternal anxiety and mother-infant mutuality were measured by two subscales from the maternal attitude scale (MAS) developed by Cohler, Weiss, and Grunebaum.‘l The MAS is a Likert-type measure containing 233 items. Cohler’s pretests of the MAS involved over 500 middle and working class mothers. Each item met criteria of item-scale correlation significant at the 0.01 confidence level, significant correlation with one or more items in the given subscale, and face validity.
Journal of Nurse-Midwifery
??
Vol. 33, No, 1, January/February 1988
The MAS was based on Sander’s theory of the development of mother-child relationships. Sander described the mother’s initial adaptation as involving the appropriateness of her behavior to the infant’s state and behavioral cues and her ability to adjust her mothering activities to the infant’s needsi The MAS Issue One subscale consisting of 10 items addresses this initial adaptation. The summated score on this scale will be referred to as the mutuality score in keeping with Sander’s use of this term. Higher scores on this scale indicate greater mother-infant mutuality. Test-retest reliability after one month for this scale was 0.69. l1 The second measure of maternal role adjustment is the 14-item subscale for maternal anxiety that Cohler and his associates derived from factor analysis of the MAS item pool. The summated score on this scale represents the degree of the mother’s anxiety related to child rearing. Higher scores on this scale indicate less maternal anxiety. Testretest reliability after one month was 0.73 for this scale. The items from the two subscales were combined into one questionnaire. The method of infant feeding was determined by the subject’s response to a demographic questionnaire item that requested them to indicate whether they were breastfeeding, bottlefeeding, or using a combination of breast and bottlefeeding.
RESULTS
The mean scores and standard deviations for maternal anxiety and mother-infant mutuality for each feeding method group are shown in Table 1. The results of an analysis of variance of the maternal anxiety scores revealed a significant main effect related to method of infant feeding [F(2,57) = 4.8, p 4 .Ol]. As seen in Table 1, the primiparas who breastfed their infants had a higher mean score indicating less anxiety than the mothers who bottlefed their infants. Women who used a combination of breast and bottlefeeding had a mean maternal anxiety score in between the breast-only and bottle-only groups. The results of an analysis of variance in the mutuality scores also revealed a significant main effect related to feeding method [F(2,57) = 15.8, p c .Ol I. As shown in Table 1, mothers who breastfed had a higher mean score indicating greater mother-infant mutuality than the mothers who bottlefed their infants. Again, the group of mothers who used a combination of both methods had a mean score in between the other two groups. Additional analysis was conducted on the mutuality scores to determine if the lo-item scale was biased in
TABLE 1
Descriptive statistics for mutuality and maternal anxiety scores grouped by infant feeding method
Procedure
Subjects were recruited from the postpartum units of two urban hospitals. Informed consent was obtained. The questionnaire containing the two MAS subscales was administered in the subject’s home four to six weeks after the birth. At this time, each subject also completed the questionnaire eliciting feeding method and demographic characteristics.
favor of breastfeeding mothers in that five items on this scale related specifically to breastfeeding. The means and standard deviations for the mutuality subscores for the breastfeeding-related items and the nonbreastfeeding-related items grouped by infant feeding method are shown in Table 2. Results from analysis of variance for the breastfeeding-related items indicated a significant main effect related to feeding method [F(2,57) = 12.7, p G .Ol]. As seen in Table 2, the mothers who breastfed or used a combination of breast and bottlefeeding had higher mean mutuality subscores for the breastfeeding-related items than did the group of mothers who bottlefed. Results of the analysis of variance for the nonbreastfeeding-related items also revealed a significant main effect due to feeding method [F(2,57) = 5.9, p s .Ol]. Refer to Table 2 to note that mothers who breastfed had a higher mean mutuality subscore from nonbreastfeeding-related items than the mothers that bottlefed or used both methods. These findings indicate that breastfeeding at one month postpartum is associated with a better adjustment to the maternal role, as evidenced by having a higher degree of mother-infant mutuality and less maternal anxiety about childrearing.
Maternal Anxiety
Mutuality Feeding method
n
M
SD
M
SD
Bottle Combination
13 14
38.5 44.4
6.5 5.9
55.6 64.1
16.3 8.5
Breast
33
50.6
7.2
65.7
7.1
Note: Larger values indicate greater mutuality and less maternal anxiety. Analysis of variance for mutuality and maternal anxiety scores by infant feeding method revealed F(2, 57) = 15.8, p s .Ol andF(2, 57) = 4.8, p s .Ol, respectively. For the maternal anxiety scores, the variances for the groups are not homogeneous due to the large dispersion of scores in the bottlefeeding group, and this is not consistent with the assumptions for analysis of variance. An alternative test, KruskaLWallis, a nonparametric counterpart for analysis of variance, indicated no significant differences between the groups with regard to the maternal anxiety scores (x2 = 5.3, p = .07). The findings should be viewed accordingly.
Journal of Nurse-Midwifery ??Vol. 33, No. 1, January/February 1988
33
EDITOR I am writing in regard to “Vaginal Birth after Cesarean Section” which appeared in the “Clinical Practice Exchange”, Journal of Nurse-Midwijey Vol. 32, No. 1, January/February 1987. I am presently in charge of a general clinic and midwifery service in the interior of Liberia, about 2-4 hours by road from a hospital and doctor, where surgery can be done. The travel time is influenced by the current road condition as affected by the rainy season. We also have a mission plane which can only fly during daylight hours. Air time to the hospital is 30 minutes. Frequently patients come to register with us for delivery, having a history of previous cesarean section. Some of these have had vaginal deliveries following the cesarean section. We always advise these women
36
to deliver in the hospital because of the possibility of complications arising. Information contained in this article has caused me to question the necessity of sending these women for hospital delivery. The statements “Most so-called ruptures are asymptomatic myometrial separations with little or no bleeding, that occur gradually, without pain, causing no threat to either mother or baby,” and “. . . No deaths from a ruptured cesarean section scar have been reported for more than 20 years,” would suggest that we could safely deliver these women in our facility. The women who we advise to deliver in the hospital frequently do not choose to do so, but rather go to a “country midwife” or to a different clinic for delivery. I would appreciate your input as to the necessity of advising hospital delivery for the
Journal of Nurse-Midwifery
women with a history of cesarean section considering our location and accessibility to a hospital in case of complications. I will appreciate hearing ideas on this matter. Thank you. (Miss) Rachel Schildroth, CNM, EiSN Mid-Liberia Baptist Mission Box 58 Monrovia, Liberia West Africa
EDITOR’S NOTE: The Editorial Board wishes to emphasize that the publication of controversial viewpoints does not imply their endorsement by JNM. Unfortunately, the Editors are not in a position to counsel readers on clinical practices. However, those CNMs who would like to respond to Miss Schildroth are invited to do so.
??Vol.
33, No. 1, January/February 1988 0091~2182/&3/$3.50
THE CLINICAL NURSE-MIDWIFEASSCIENTIST*
Joyce J. Fitzpatrick, Phq FAAN
ABSTRACT Our nursing discipline is confronted by many changes in the health care delivery system. It is proposed that we should unite, identify common goals for the profession, and support changes in our educational programs and professional socialization processes to achieve our goals. Nurse-midwives are recognized for their leadership in advanced clinical practice. They are encouraged, therefore, to provide leadership in further development of nursing science and professional practice. A three-by-three matrix, consisting of three process and three content dimensions is proposed. The process dimensions include (a) collaboration with colleagues in nursing; (b) preparation of more nurse researchers; and (c) collaboration with those from other disciplines. Content dimensions that are explored include (a) basic research on the experience of health throughout life; (b) applied research focused on evaluation of clinical interventions; and (c) health policy research and analysis. It is advocated that we build programs of research in each of these areas, Examples of relevant research are presented and discussed.
I believe that nursing is both a science and a profession. As members of a discipline with these two components, we share overall responsibility for the development of both aspects. We must all be committed to the joint goals of development of our science and our profession. We must educate scientists and professionals. Our scientists in nursing must be cognizant of the societal expectations and demands of a profession. Our professional practitioners must not only use the knowledge available, but demand the development of new knowledge. Further, I believe that the ultimate strength of our discipline in improving the health care of people everywhere can
*Adapted from a paper presented at the American College of Nurse-Midwives’ 32nd Annual Convention, Orlando, Florida, May 7, 1987. Address correspondence to: Joyce J. Fitzpatrick, PhD, FAAN, Professor and Dean of Nursing, Case Western Reserve University, Frances Payne Bolton School of Nursing, 2121 Abington Road, Cleveland, OH 44106.
Journal of Nurse-Midwifery
??Vol.
only be realized as we unite our nursing profession. We must be prepared to support radical changes in our educational programs and our professional socialiition if we want to achieve new goals. Now is the time for radical change. We must take advantage of the uncertainty and change in the health care delivery system, in the financing of health care, and in the scientific community. We must redefine health as wholeness and orient our practice to achieving that goal At the same time, we must refocus our nursing science on the discovey of the human patterns that are manifest throughout the life process. Whereas it is much easier to let someone else be in charge, I believe that we must have a core group of nurse leaders who can affect change. I believe that nurse-midwives are, in many ways, far ahead of the rest of the nursing profession. They have already solved some of the difficult practice issues that still challenge nurses in other clinical areas. Therefore, they have the freedom and luxuy and, perhaps, the responsibility to
33, No. 1, January/February
Copyright 0 1988 by the American College of Nurse-Midwives
1988
move all of us forward in new directions. CNMs can be the leaders for the new view of nursing and health. Enough about beliefs. I would now like to address a few basic questions. Why science? Why research? What does knowledge development have to do with the clinical nurse-midwife? Science thrives by asking impertinent questions and getting revolutionary answers. It is time for some revolutionary answers about health and health care delivery. Whereas science consists of an organized body of abstract knowledge arrived at by research and logical analysis, the art of nursing is the imaginative and creative use of nursing knowledge in human service. The role of science is fundamental in our society. We respect and value science even though it changes our views on reality and, some would say, changes reality itself. Our society is in awe of science; it influences our culture and the social fabrics of our lives. Science is widely supported economically in our society. This year alone, gov-
37 0091-2182/88/$3.50
Susan Flagler Virden,
RN, DNS
ABSTRACT The benefits of breastfeeding
for the infant are well known.
Much less is known,
how-
choice of feeding method is related to her maternal role adjustment during the initial weeks postpartum. Mother-infant mutuality and maternal anxiety scores of 60 first time mothers were examined using analysis of variance techniques. Method of infant feeding (breast, bottle, or combination) was found to be responsible for a significant amount of the variance in both scores. At one month postpartum, women who breastfed their infants had scores indicating less anxiety and more mutuality than the women bottle feeding their infants. An interpretation of the results using role theoy concepts provides a possible explanation of the relationships found. Differences in the character of interactions involved with breast and bottle feeding may influence other aspects of maternal role transitions. ever, about how the woman’s
The advantages of breastfeeding for the infant’s health and mother’s emotional bond to the infant are widely accepted by perinatal health professionals. Yet for social, cultural, and personal reasons, some women will elect to bottlefeed their neonates. While a large body of knowledge exists on the nutritional and immunological benefits of breastfeeding for the infant,’ much less is known about how the woman’s choice of feeding method influences her initial weeks as a mother. Feeding represents a substantial part of the infant care responsibilities a new mother must assume. Especially for primiparas, the mother’s
Address correspondence to: Susan F. Virden, Research Fellow, Clinical Nurse Scholars Program, School of Nursing, Helen Wood Hall, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642. This project was funded in part by the University of California San Francisco Graduate Division and the Alpha Eta Chapter of Sigma Theta Tau.
Journal of Nurse-Midwifery
??Vol.
perception of success with infant feeding is taken as an assessment of her ability to mother. How is the method selected for the frequent and essential activity of feeding related to the new mother’s initial adjustment? The purpose of this investigation was to explore the relationship between method of infant feeding-breast, bottle, or combination of breast and bottle-and the degree of maternal anxiety and mother-infant mutuality evident at one month postpartum. Infant care is an area of concern expressed by new mothers.*9 Many first time mothers have feelings of inadequacy associated with their lack of knowledge about infant care. Using a combination of interviews and quantitative measures, Leifefi conducted a longitudinal study of the psychological changes of 19 primiparas from the first trimester of pregnancy through the seventh month postpartum. Most of the women experienced anxiety during the postpartum period about their ability to
33, No. 1, January/February
Copyright 0 1988 by the American College of Nurse-Midwives
1988
provide adequate care for the baby. In another longitudinal study of 57 first time parents, Shereshefsky, Liebenberg, and Lockman found that most women experienced some uncertainty and anxiety about understanding their infant’s behavior and a sense of inadequacy about meeting the infant’s needs. In a study involving 64 couples with their first child, Robert@ examined the impact of infant behavior that necessitated action by the parent (obligatory infant behavior) on the ease of role transition and parental perception of the role competence. The amount of obligatory infant behavior was negatively correlated with ease of transition into parenthood (r = - .32) and parental perceptions of role competence (r = -.27). The greater amount of infant behavior that required action on the parent’s part the lower was the parent’s perception of adequacy in the role. Feeding is frequently a particular area of concern for new mothers. In 31 0091-2182188/$03.50
their analysis of telephone calls made by new parents to a health care facility, Sumner and Fritsch7 found that the majority of calls (62%) were made by primiparas and that nearly one-third of all questions were about feeding. In an earlier study, Adams2 interviewed 40 primiparas to determine their concerns about infant care. Feeding was found to be one of the major areas of concern throughout the first month. In studying the interactional behavior of 58 mother-infant pairs using interviews, questionnaires and observation, Greenberg8 noted that all 16 primiparas in the sample experienced feelings of inadequacy and that feeding was a major focus of the primiparas’ concerns. The activity of feeding is strongly associated with mothering. A new mother’s perception of success with regard to feeding her baby is often the key factor she uses in judging her success as a mother. Although the literature illustrates that infant feeding is a common concern of new mothers, little is available that describes the relationship of feeding method to maternal role adjustment. The purpose of this study was to determine how the method of infant feeding used by primiparas was related to maternal role adjustment in the first month postpartum. Gaining this knowledge may assist nurse cli-
Susan Flagler Virden is currently a postdoctoral research fellow in the Robert Wood Johnson Clinical Nurse Scholars Progmm at the Uniuersity of Rochester. Her research focuses on maternal role transition for tuomen experiencing high risk pregnancies. She is on leave from her position as Assistant Professor in the School of Nursing at the University of Washington. She received her undergmduate degree in nursing from UCLA and her gmduate degrees in Family Health Care Nursing from the University of California, San Francisco. She is a member of ANA, Sigma Theta Tau, and NAACOG.
32
nicians and researchers to better understand one of the multiple factors impacting the transition into the maternal role. METHOD
The research question was addressed by conducting additional analyses on data collected for an experimental study to determine the effect of providing primiparas with information about infant behavior during their postpartum hospitalization on maternal role adequacy one month after birth.g The experimental treatment was not responsible for any significant differences between groups with regard to maternal anxiety or mother-infant mutuality scores. Also, the distribution of women using a given feeding method was similar between the control and experimental groups. For these reasons, the determination was made that group assignment for the experimental study would not distort the investigation regarding feeding methods; therefore, data from the entire sample was used.
of age, with 72% of the sample being 25 years or older. All subjects were married (93%) and/or living with the father of the baby. The majority of the sample were Caucasian (60%), 18% were Asian, 10% were Black, and the remaining 12% represented other ethnic groups. This dispersion reflects the ethnic diversity present in the area where this study was conducted. The formal education of the subjects ranged from high school diploma (17%) to graduate degree (8%), with the majority of the sample (83%) having at least some college. At one month postpartum, 33 primiparas (55% of the sample) were breastfeeding their infants, 13 (22%) were bottlefeeding their infants, and 14 (23%) were using a combination of breast and bottlefeeding for their infants. Comparison of these three groups on demographic characteristics revealed no significant differences with regard to age, educational background, prenatal classes, ethnicity (Caucasian or noncaucaSian) and previous experience with infants.
Sample
Measures
The subjects were 60 primiparas who had given birth vaginally to healthy, full-term infants at one of the two hospitals in a large urban area in California. Twenty-nine subjects received obstetric care at a university-affiliated teaching hospital where the majority of maternity patients are clinic patients. The remaining 31 subjects received their obstetric care at a private hospital where all maternity patients are private patients. All subjects had a normal obstetric course throughout pregnancy, labor and delivery, and postpartum. Also, the majority of the sample (88%) had attended prenatal classes. The sample’s previous experience with infants ranged from “none” (20%) to “a great deal” (18%) with the remaining 62% reporting “vey little” or “some.” The primiparas were 20-30 years
Maternal anxiety and mother-infant mutuality were used as measures of maternal role adjustment. The selection of these variables rests with the assumptions that difficulty in adjustment is accompanied by more anxiety and that mother-infant mutuality is a central factor in maternal adjustment.10 Maternal anxiety and mother-infant mutuality were measured by two subscales from the maternal attitude scale (MAS) developed by Cohler, Weiss, and Grunebaum.‘l The MAS is a Likert-type measure containing 233 items. Cohler’s pretests of the MAS involved over 500 middle and working class mothers. Each item met criteria of item-scale correlation significant at the 0.01 confidence level, significant correlation with one or more items in the given subscale, and face validity.
Journal of Nurse-Midwifery
??
Vol. 33, No, 1, January/February 1988
The MAS was based on Sander’s theory of the development of mother-child relationships. Sander described the mother’s initial adaptation as involving the appropriateness of her behavior to the infant’s state and behavioral cues and her ability to adjust her mothering activities to the infant’s needsi The MAS Issue One subscale consisting of 10 items addresses this initial adaptation. The summated score on this scale will be referred to as the mutuality score in keeping with Sander’s use of this term. Higher scores on this scale indicate greater mother-infant mutuality. Test-retest reliability after one month for this scale was 0.69. l1 The second measure of maternal role adjustment is the 14-item subscale for maternal anxiety that Cohler and his associates derived from factor analysis of the MAS item pool. The summated score on this scale represents the degree of the mother’s anxiety related to child rearing. Higher scores on this scale indicate less maternal anxiety. Testretest reliability after one month was 0.73 for this scale. The items from the two subscales were combined into one questionnaire. The method of infant feeding was determined by the subject’s response to a demographic questionnaire item that requested them to indicate whether they were breastfeeding, bottlefeeding, or using a combination of breast and bottlefeeding.
RESULTS
The mean scores and standard deviations for maternal anxiety and mother-infant mutuality for each feeding method group are shown in Table 1. The results of an analysis of variance of the maternal anxiety scores revealed a significant main effect related to method of infant feeding [F(2,57) = 4.8, p 4 .Ol]. As seen in Table 1, the primiparas who breastfed their infants had a higher mean score indicating less anxiety than the mothers who bottlefed their infants. Women who used a combination of breast and bottlefeeding had a mean maternal anxiety score in between the breast-only and bottle-only groups. The results of an analysis of variance in the mutuality scores also revealed a significant main effect related to feeding method [F(2,57) = 15.8, p c .Ol I. As shown in Table 1, mothers who breastfed had a higher mean score indicating greater mother-infant mutuality than the mothers who bottlefed their infants. Again, the group of mothers who used a combination of both methods had a mean score in between the other two groups. Additional analysis was conducted on the mutuality scores to determine if the lo-item scale was biased in
TABLE 1
Descriptive statistics for mutuality and maternal anxiety scores grouped by infant feeding method
Procedure
Subjects were recruited from the postpartum units of two urban hospitals. Informed consent was obtained. The questionnaire containing the two MAS subscales was administered in the subject’s home four to six weeks after the birth. At this time, each subject also completed the questionnaire eliciting feeding method and demographic characteristics.
favor of breastfeeding mothers in that five items on this scale related specifically to breastfeeding. The means and standard deviations for the mutuality subscores for the breastfeeding-related items and the nonbreastfeeding-related items grouped by infant feeding method are shown in Table 2. Results from analysis of variance for the breastfeeding-related items indicated a significant main effect related to feeding method [F(2,57) = 12.7, p G .Ol]. As seen in Table 2, the mothers who breastfed or used a combination of breast and bottlefeeding had higher mean mutuality subscores for the breastfeeding-related items than did the group of mothers who bottlefed. Results of the analysis of variance for the nonbreastfeeding-related items also revealed a significant main effect due to feeding method [F(2,57) = 5.9, p s .Ol]. Refer to Table 2 to note that mothers who breastfed had a higher mean mutuality subscore from nonbreastfeeding-related items than the mothers that bottlefed or used both methods. These findings indicate that breastfeeding at one month postpartum is associated with a better adjustment to the maternal role, as evidenced by having a higher degree of mother-infant mutuality and less maternal anxiety about childrearing.
Maternal Anxiety
Mutuality Feeding method
n
M
SD
M
SD
Bottle Combination
13 14
38.5 44.4
6.5 5.9
55.6 64.1
16.3 8.5
Breast
33
50.6
7.2
65.7
7.1
Note: Larger values indicate greater mutuality and less maternal anxiety. Analysis of variance for mutuality and maternal anxiety scores by infant feeding method revealed F(2, 57) = 15.8, p s .Ol andF(2, 57) = 4.8, p s .Ol, respectively. For the maternal anxiety scores, the variances for the groups are not homogeneous due to the large dispersion of scores in the bottlefeeding group, and this is not consistent with the assumptions for analysis of variance. An alternative test, KruskaLWallis, a nonparametric counterpart for analysis of variance, indicated no significant differences between the groups with regard to the maternal anxiety scores (x2 = 5.3, p = .07). The findings should be viewed accordingly.
Journal of Nurse-Midwifery ??Vol. 33, No. 1, January/February 1988
33
EDITOR I am writing in regard to “Vaginal Birth after Cesarean Section” which appeared in the “Clinical Practice Exchange”, Journal of Nurse-Midwijey Vol. 32, No. 1, January/February 1987. I am presently in charge of a general clinic and midwifery service in the interior of Liberia, about 2-4 hours by road from a hospital and doctor, where surgery can be done. The travel time is influenced by the current road condition as affected by the rainy season. We also have a mission plane which can only fly during daylight hours. Air time to the hospital is 30 minutes. Frequently patients come to register with us for delivery, having a history of previous cesarean section. Some of these have had vaginal deliveries following the cesarean section. We always advise these women
36
to deliver in the hospital because of the possibility of complications arising. Information contained in this article has caused me to question the necessity of sending these women for hospital delivery. The statements “Most so-called ruptures are asymptomatic myometrial separations with little or no bleeding, that occur gradually, without pain, causing no threat to either mother or baby,” and “. . . No deaths from a ruptured cesarean section scar have been reported for more than 20 years,” would suggest that we could safely deliver these women in our facility. The women who we advise to deliver in the hospital frequently do not choose to do so, but rather go to a “country midwife” or to a different clinic for delivery. I would appreciate your input as to the necessity of advising hospital delivery for the
Journal of Nurse-Midwifery
women with a history of cesarean section considering our location and accessibility to a hospital in case of complications. I will appreciate hearing ideas on this matter. Thank you. (Miss) Rachel Schildroth, CNM, EiSN Mid-Liberia Baptist Mission Box 58 Monrovia, Liberia West Africa
EDITOR’S NOTE: The Editorial Board wishes to emphasize that the publication of controversial viewpoints does not imply their endorsement by JNM. Unfortunately, the Editors are not in a position to counsel readers on clinical practices. However, those CNMs who would like to respond to Miss Schildroth are invited to do so.
??Vol.
33, No. 1, January/February 1988 0091~2182/&3/$3.50
THE CLINICAL NURSE-MIDWIFEASSCIENTIST*
Joyce J. Fitzpatrick, Phq FAAN
ABSTRACT Our nursing discipline is confronted by many changes in the health care delivery system. It is proposed that we should unite, identify common goals for the profession, and support changes in our educational programs and professional socialization processes to achieve our goals. Nurse-midwives are recognized for their leadership in advanced clinical practice. They are encouraged, therefore, to provide leadership in further development of nursing science and professional practice. A three-by-three matrix, consisting of three process and three content dimensions is proposed. The process dimensions include (a) collaboration with colleagues in nursing; (b) preparation of more nurse researchers; and (c) collaboration with those from other disciplines. Content dimensions that are explored include (a) basic research on the experience of health throughout life; (b) applied research focused on evaluation of clinical interventions; and (c) health policy research and analysis. It is advocated that we build programs of research in each of these areas, Examples of relevant research are presented and discussed.
I believe that nursing is both a science and a profession. As members of a discipline with these two components, we share overall responsibility for the development of both aspects. We must all be committed to the joint goals of development of our science and our profession. We must educate scientists and professionals. Our scientists in nursing must be cognizant of the societal expectations and demands of a profession. Our professional practitioners must not only use the knowledge available, but demand the development of new knowledge. Further, I believe that the ultimate strength of our discipline in improving the health care of people everywhere can
*Adapted from a paper presented at the American College of Nurse-Midwives’ 32nd Annual Convention, Orlando, Florida, May 7, 1987. Address correspondence to: Joyce J. Fitzpatrick, PhD, FAAN, Professor and Dean of Nursing, Case Western Reserve University, Frances Payne Bolton School of Nursing, 2121 Abington Road, Cleveland, OH 44106.
Journal of Nurse-Midwifery
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only be realized as we unite our nursing profession. We must be prepared to support radical changes in our educational programs and our professional socialiition if we want to achieve new goals. Now is the time for radical change. We must take advantage of the uncertainty and change in the health care delivery system, in the financing of health care, and in the scientific community. We must redefine health as wholeness and orient our practice to achieving that goal At the same time, we must refocus our nursing science on the discovey of the human patterns that are manifest throughout the life process. Whereas it is much easier to let someone else be in charge, I believe that we must have a core group of nurse leaders who can affect change. I believe that nurse-midwives are, in many ways, far ahead of the rest of the nursing profession. They have already solved some of the difficult practice issues that still challenge nurses in other clinical areas. Therefore, they have the freedom and luxuy and, perhaps, the responsibility to
33, No. 1, January/February
Copyright 0 1988 by the American College of Nurse-Midwives
1988
move all of us forward in new directions. CNMs can be the leaders for the new view of nursing and health. Enough about beliefs. I would now like to address a few basic questions. Why science? Why research? What does knowledge development have to do with the clinical nurse-midwife? Science thrives by asking impertinent questions and getting revolutionary answers. It is time for some revolutionary answers about health and health care delivery. Whereas science consists of an organized body of abstract knowledge arrived at by research and logical analysis, the art of nursing is the imaginative and creative use of nursing knowledge in human service. The role of science is fundamental in our society. We respect and value science even though it changes our views on reality and, some would say, changes reality itself. Our society is in awe of science; it influences our culture and the social fabrics of our lives. Science is widely supported economically in our society. This year alone, gov-
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