Introduction
Maternal fetal attachment is defined as “the extent to which women engage in behaviours that represent an affiliation and interaction with their unborn child” (Cranley, 1981). Lower maternal fetal attachment scores have been associated with poorer health practices including continuing cigarette smoking in pregnancy, and the risk of intrauterine fetal growth restriction is proportionate to the number of cigarettes smoked (Reynolds et al 2017).
It was Kennell, Slyter, and Klaus’s (1970) studies on the massive grief seen by mothers of infants who died during birth that was one of the first empirical suggestions that a prenatal connection between a mother and her unborn child existed, thus fuelling the creation of the construct of prenatal attachment. For the past 28 years there has been increasing recognition that the relationship between a mother and her child develops while the child is not yet born, a fetus (Alhusen, 2008). Cranley (1981) stated that during the 9 months of gestation “integral to that development is the consideration of the woman’s identity, her role identity, the identity of her developing fetus, and perhaps most important, the relationship between herself and the fetus”.
The relationship between maternal attachment and ultrasound have been investigated in the literature, with the focus of the literature to date comparing two-dimensional scans to four-dimensional scans, and to our knowledge very few studies have been conducted prior to fetal movement, at the first antenatal visit (Alhusen, 2008).
The two main tools utilised to evaluate the degree of maternal attachment are the 16-item Maternal Fetal Attachment Scale (Modified MFAS) (Cranley et al, 1981), and the maternal antenatal attachment scale (Condon, and Corkindale, 1997).
The MFAS, is a self-report questionnaire, that has been shown to correlate positively with higher socioeconomic status and a stable relationship with a good support system. In contrast, there is negative correlation between maternal attachment, and lower socioeconomic status and postpartum depression.
When assessing attachment, it is important to take into consideration maternal anxiety and stress. The PSS is used widely to assess this. It is a quick validated 10-item stress assessment instrument that assesses perceived stress in the last month via a questionnaire, with individual scores ranging from 0-40, with higher scores indicating higher perceived stress.
The aim of this study was to assess the level of attachment women feel towards their unborn child at the time of their dating ultrasound. In addition to this, the questionnaire examined health behaviours (such as cigarette smoking) and social characteristics (such as pregnancy intention and level of education) and if there was any association between these factors and maternal fetal attachment.
Methods
Women were recruited at their convenience, during their first prenatal visit, after sonographic conformation of an ongoing viable intrauterine pregnancy during the month of July 2018. Written consent was obtained. Women who were less than eighteen years old or women unable to speak or comprehend English were excluded. Clinical and sociodemographic details were obtained via the K2 database that was computerised by a trained midwife, which included age, marital status, occupation, and smoking and alcohol habits reported at the time of the first visit and maternal body mass index and parity. The CSO Standard Employment Status Classification was used to categorize occupations into subgroups. Data from the questionnaire was entered into Microsoft Excel, coded and transferred to SPSS version 24 for statistical analysis. Descriptive statistics were used to compare the general characteristics of the study cohort and independent samples t-test was used to compare mean MFAS and PSS scores according to maternal characteristics. MFAS and PSS scores were assessed for normality with evaluation of skewness, kurtosis and histogram plots, and both variables were found to be normally distributed. Ethical approval was granted by the Hospital Research Ethics Committee.
The questionnaire which comprised of 3 components (see appendix 1);
(1) Modified Maternal Fetal Attachment Scale (MFAS)
It was Cranley (1981) that established the first self-report validated questionnaire, The MFAS, that is used to measure the level of attachment between a mother and her unborn child, the fetus. The MFAS consists of 24 items that are arranged into 5 subscales relating to 5 aspects of the mother-fetal relationship; (1) differentiation of self from the fetus; (2) interaction with the fetus; (3) attributing characteristics and intentions to the fetus; (4) giving of self; (5) role taking, which are all ranked on a 7-point Likert scale (1 definitely no to 7 definitely yes). For the purpose of our study we modified the MFAS by removing specific questions irrelevant to our group (8 items) as this was conducted in early pregnancy, relating to fetal movement and is now ranked on a 4-point scale (0 definitely no to 4 definitely yes). Furthermore, we added a question regarding the feelings of the mother after her first antenatal ultrasound and how it affected her “After seeing the baby on the Ultrasound for the 1st time, it has changed my feelings towards the pregnancy?”. The higher the score the higher the MFA, with a maximum MFAS of 68 points possible.
(2) Perceived Stress Scale
Perceived stress is when an individual’s capability to cope is exceeded by the environments demands (Cohen, 1983). Cohen’s (1983) reliable and validated 10-item scale measures the degree to which certain elements in the last month, including feelings and thoughts, in one’s life are acknowledged as stressful.
Thus, it plays a part in analysing concerns about the role of measured stress levels in the etiology of disease and behavioural disorders, and it has been proven that higher PSS scores are linked with failure to quit smoking (Cohen 1983). The higher the PSS score the greater the stress.
(3) Detailed Education Information, and alcohol and smoking information, which included the Fagerstrom Test for nicotine dependence for those who reported as current smokers.
The Fagerstrom Test is an instrument used to test the level of addiction to nicotine, the higher the Fagerstrom Test score, the greater dependency on nicotine.
The hospital database provides minimal information on educational attainment, thus additional questions were included such as the age when they finished full time education and the highest level of education completed to date.
Results
Maternal characteristics are presented in Table 1. Of the 90 women approached, 80 women returned and adequately filled out the questionnaire. The mean age was 31.2 (SD 4.9), the mean BMI was 27.2 (SD 6.5), 77.5% (62) were of Irish ethnicity, 46.3% (37) were nulliparous, while 75% (60) planned their pregnancy, and 15% were persistent smokers (12) (see Table 1).
The average age on completion of full-time education was 20.5 years old, with 26.3% engaged in professional employment, 48.8% in unskilled employment, 12.5% reported they were homemakers, and 8.8% were unemployed. The mean gestation was 12.3 weeks (SD 2.1) at the time of the questionnaire.
There were a total of 12 persistent smokers (15.8%), 11 of whom answered the Fagerstrom level of nicotine dependence score. Of these 11 women, 3 exhibited a low level of nicotine dependence with a score <4, 2 women exhibited a moderate dependence (score 4-6) and there were 6 women who reported a high level of dependence.
The mean MFAS was 49.0 (SD = 6.6). The differences in the MFAS stratified according to the maternal characteristics are shown is Table 2. The only factor of significance was unplanned pregnancy intention with a low MFAS (p value <0.05). Maternal age, marital status, smoking status, maternal parity, previous pregnancy loss, and educational attainment did not influence the MFAS.
The new question added to the MFAS was “After seeing the baby on the Ultrasound for the 1st time, it has changed my feelings towards the pregnancy”. Of the 80 respondents, 57.5% of women answered yes or definitely yes while 41.3% reported unsure/ no/ or definitely no. Of women who reported that ultrasound changed their feelings about the pregnancy, they were more likely to have a higher PSS (with 33/47 (70.2%(33)) women with a PSS ≥14 reporting this compared to 13/42 (40.6%(13)) women with a PSS <14) (P=0.011). No difference was detected regarding impact of ultrasound according to maternal age, parity and previous pregnancy loss.
Table 3 shows the PSS, analysed according to the maternal characteristics. The mean PSS score was 15.6 (SD=5.7). Women who did not plan their pregnancy reported a higher PSS (mean 18.8 (SD 5.8) compared to 14.6 (SD 5.3) for those who plan ned their pregnancy (p<0.005). Maternal age, age at completion of education, marital status, parity, and smoking status did not influence PSS.
Discussion
The MFA score was lower amongst women who were <35 years of age, amongst those with an unplanned pregnancy, and those with a previous pregnancy loss. Interestingly many women reported a change in their feelings after the scan, stating it increased their feelings towards the pregnancy, demonstrating that it is an important part of antenatal care.
The PSS was found to vary according to pregnancy intention with women who planned their pregnancy reporting a lower PSS (P<0.005).
A literature review on MFA (Alhusen’s, 2008) identified five studies that assessed the relationship between ultrasound and maternal fetal attachment and concluded that it has a positive effect on attachment. However, four of these studies were conducted at a gestation of >24 weeks, with patient numbers between 52 and 142 (Rustico, 2005, Righetti, 2005, Pretorius, 2006, and Boukydis, 2006). Three of the four studies were investigating if there was a difference between maternal attachment after two-dimensional ultrasound or four-dimensional ultrasound was used. In addition, all four studies analysed MFA via a Maternal Antenatal Attachment Scale (MAAS) by Cranley et al. The fifth study occurred in early pregnancy, however it consisted of a small sample size (n=24) and utilised the MAAS (Sedgmen et al 2006).
In recent years there have been two further studies identified in the literature (de Jong‐Pleij, 2013, and Benzie, 2018) that investigated the relationship between ultrasound and maternal fetal attachment. The former study analysed MFA in 3rd trimester mothers using the MAAS before ultrasound and two weeks after ultrasound, which concluded ultrasound had a positive impact (P<0.0001) with an increase in bonding post ultrasound. The latter study investigated the difference between three-dimensional and four-dimensional ultrasound using the MAAS score, and examined mothers between twenty-eight and thirty weeks.
These studies have investigated the impact that ultrasound has on MFA yet to our knowledge the effect it may have for mothers at their first dating ultrasound has not been studied to date.
After searching the literature, to our knowledge there is no cut-off level for the PSS-10 in pregnancy. However, Yokokura et al (2017) study assessed the validity of the PSS-10 amongst pregnant women and postpartum women and found that pregnant women have a higher PSS score than non-pregnant women (Chaaya et al, 2010).
In Hart and McMahon’s (2006) study they examined the impact of depression and anxiety on MFA and concluded that women who were characterised as having low quality of fetal attachment had significantly higher levels of anxiety and depression. Thus, these considerations alone show the importance of screening and a need for higher supports for the mothers to avail of, which would be a good tool to see who is most at risk. In addition, following Nonnenmacher et al (2016) study which reported that postnatal parenting stress was associated with the woman’s perinatal mental health including low self-esteem, anxiety and depression, further follow up postpartum would be advised. The relationship between a mother and her unborn child has been linked with several consequences which include the mother’s well-being and mental health during the pregnancy, and the postpartum relationship between mother and child, and the child’s psychological and physical health (Doster 2018). In the study conducted by Delavari et al (2018) it was found that MFA is a factor that contributes to postpartum depression and that a greater importance should be placed on the preparation of the pregnant woman in accepting their maternal role in order to enhance MFA and lower postpartum depression (PPD). Furthermore, Alhusen (2008) concluded in their study that the factors that deemed supportive to MFA were associated with high socioeconomic status including timely and comprehensive prenatal care, good support systems, and stable relationships. However, research in MFA in ethnic minorities is worthy of further investigation.
The strengths of the study were that it was a well characterised study population. Furthermore, the antenatal history was prospectively recorded at the time of the antenatal visit. Questionnaires utilised within the survey were validated with the exception of the new question added to the MFAS based on their feelings after ultrasound, and additional smoking information was collected using The Fagerstrom Test. The questionnaire was conducted immediately after the first ultrasound to avoid recall bias.
Limitations of this study include that it is a relatively small sample size. A further limitation is that convenience recruitment rather than the preferable consecutive recruitment was used, however the latter was not possible with a single researcher. The study relied on self-reported smoking status and did not utilise biochemical verification of smoking status with carbon monoxide or cotinine (Reynolds et al 2017).
Conclusions
This study explored the effect of ultrasound on maternal feelings at the first antenatal visit. It can be concluded that ultrasound appears to have a positive effect on maternal attachment towards their unborn child. Utilising the PSS, it was found that unplanned pregnancy is associated with a higher level of stress. In addition, the MFAS was lower in women <35 years old, those with unplanned pregnancy and with a history of pregnancy loss.
The MFAS and PSS are quick, validated tools that could be utilised to identify women who require additional supports in pregnancy. The impact of ultrasound in early pregnancy is positive with respect to maternal attachment and further research on this in a larger sample size is required to investigate this further.
