The effect of maternal–fetal attachments skills training among unintended primigravida women: a randomized controlled trial

Abstract

Background and objectives

An unintended pregnancy can lead to an unfavorable relationship between the mother and infant and also include pregnancies that, although unintended, become wanted and may not have the same risks. This study aimed to investigate the effect of attachment training on maternal and fetal attachment in women with unintended pregnancy.

Method

This clinical trial study was conducted in 2019 on 84 women (two groups of 42 subjects) with unintended pregnancies (at least 28 weeks in the third trimester of pregnancy) in selected clinics affiliated with Shiraz University of Medical Sciences. Cranley’s Maternal–Fetal Attachment Scale (MFAS) was completed before and after the intervention in both groups; a demographic information questionnaire was filled out and written consent forms were signed before the intervention in both groups. Then, attachment training classes were conducted for 6 sessions of 90 min in the intervention group, while the control group received only routine pregnancy care. Chi-square, Fisher and independent t-test were used to analyze the data.

Findings

The mean scores of maternal–fetal attachment before attachment training in the experimental (57. 24 ± 5.03) and control groups (57.29 ± 6.96) were not significantly different (P = 0.86). Based on the results of independent t-test, the mean scores of maternal–fetal attachment after training in the intervention (66.43 ± 1.76) and control (57.14 ± 5.03) groups were significantly different (P = 0.0001).

Conclusion

The findings of this study showed the positive effect of education on the attachment behaviors of mothers with unintended pregnancies. Therefore, it is recommended that attachment skills training should be used in prenatal training programs.

Trial registration

Iran Randomized Clinical Trial Center registration IRCT20130710013940N5, Date of first trial registration: 2019.02.02.

Introduction

Unwanted pregnancies are considered a serious public health problem in developed and developing countries and include unwanted and unplanned pregnancies [1,2,3]. Seventeen percent of American women experience more than one unintended pregnancy and it can be said that 45% of pregnancies in America are unwanted [4]. The rate of unintended pregnancies in poor women is 82.1% in New York, 49% in Canada, and 46.2% in Japan [5]. The prevalence of unwanted pregnancies in Iran is about 8–32% [5]. Unwanted pregnancy results in adverse outcomes for maternal and neonatal physical and mental health [6]. Women who continue unintended pregnancies until term are more likely to receive late pregnancy care and have fewer pregnancy visits, smoke more and are at higher risk for depression and anxiety [4]. Pregnancy complications such as gestational hypertension and diabetes are also detected later [7]. Women with unwanted pregnancy, may also not breastfeed at all or breastfeed for a short time, and sometimes they decide to terminate the pregnancy, leading to the need for abortion services. In addition, some of them seek illegal abortions, which may lead to unsafe abortion and some life-threatening complications which can also lead to increased costs [2, 4]. Pregnancy is a period of complex bio-psychological changes during which the development of attachment bonds to the fetus plays a major role [2, 8]. Unintended pregnancy is a risk factor for less maternal–fetal attachment (MFA) and lower levels of mental health [9,10,11]. Unintended pregnancy outcomes, whether leading to abortion or continuing pregnancy, are serious and will cause significant problems for the mother, her husband, and, if the pregnancy continues, for the infant [1, 2]. MFA is the mother’s sense of intimacy, gentleness, protection, and concern for the child’s health, and is characterized by the mother’s behaviors including looking, smiling, touching, and talking to the infant [12]. Also, mothers with increased MFA are more inclined to engage in health behaviors during pregnancy, such as continuing prenatal care, being willing to learn about the fetus and participate in childbirth preparation classes, increasing MFA, and increasing breastfeeding, all of which lead to satisfactory pregnancy outcomes and improve maternal and infant health [4, 13]. Numerous methods are used to increase MFA, such as training, providing information and training on stress management, mental imagery, and fetal movement counting; counseling; providing couples with child-care knowledge, expressing feelings to the fetus through letter writing, and talking to the fetus [14, 15]. Research shows that interventions that encourage mothers to care and perform health behaviors increase MFA. One meta-analysis study. showed that different interventions increase MFA in general (P-value = 0.008) [15]. Researchers have found that forming prenatal classes to teach and perform maternal–fetal interactive behaviors, breathing techniques, and some exercise by the mother can increase MFA [16, 17].

The results of a study showed that the educational courses during pregnancy had a positive effect on attachment during pregnancy [17]. In general, unwanted and unintended pregnancies increase the physical and psychological complications of the mother and infant and impose more financial burden on the health system [11]. It should be noted that in Iran, due to the legal prohibition of abortion, the probability of continued pregnancy compared to non-Muslim countries is higher. This can reduce attachment and result in adverse consequences of continuing pregnancy for the mother and fetus and has an impact on family health and ultimately society [1]. It is necessary to know the effect of interventional methods that cause maternal attachment, such as education and counseling. This study examined the effect of training on MFA in women with unintended pregnancies in Shiraz, Iran.

Study design and sampling

Our manuscript reporting adheres to CONSORT guidelines for reporting clinical trial. This clinical trial study, was conducted in 2019 on 84 primigravida women with unintended pregnancies at least 28 weeks in the third trimester of pregnancy (Based on the mothers' self-report) referred to selected perinatal clinics in Shiraz, Iran, and approved by the Ethics Committee of Shiraz University of Medical Sciences. The sample size was considered 70 people (35 people in each group) after reading relevant articles [18], consulting with statisticians, and using the following formula, which increased to 84 people (42 in each group). after considering 20% attrition.

α = 0.05 (first type error) β = 0.20, second type error (S1:4.21, S2:4.89)

$${n}_{1}= {n}_{2}=\frac{{\left({z}_{1-\frac{\alpha }{2}}+ {z}_{1-\beta }\right)}^{2}{\left({{s}_{1}}^{2}+ {{s}_{2}}^{2}\right)}^{2}}{{d}^{2}} d={\mu }_{1}-{\mu }_{2}$$

Samples were selected through convenience sampling from among eligible pregnant women referring to three selected medical centers in Shiraz, Iran, within six months from the start of the study. Participants were assured that they could leave the study at any time and that they could refuse to answer questions. In this study, individuals were divided into two groups using the permutation block method (blocks size: 4). In this method, A represents the individual receiving the intervention and B represents the individual in the control group. The researcher visited the selected centers daily and selected eligible women with unintended pregnancies, and randomly divided them into two groups.

The inclusion criteria were women with unintended pregnancies ( at least 28 weeks), no mental disorders (psychosis, schizophrenia) which has been proven based on the mothers' personal report and examination of their medical records, the ability to attend training classes, completion of a written consent form, and lack of attendance in any training classes including physiological childbirth. The exclusion criteria were unwillingness to continue cooperation, the occurrence of any pregnancy problems during the study (preterm delivery, placental abruption, etc.), and irregular participation in training classes (2 or more absences).

Data gathering instruments

Data collection tools were interview and demographic information forms, Cranley’s Maternal–Fetal Attachment Scale (MFAS) to assess attachment score.

Demographic information questionnaire

The questioner includes information about couples (age, occupation, education, etc.), information related to pregnancy (, gestational age and number of pregnancies, abortion, date of the first day of the last menstrual period, dead child, birth history of a baby with congenital malformation, BMI, etc.) [19].

MFAS questionnaire

It was first used by Cranley and its reliability and validity were approved [20].

Khoramrody approved the reliability of the Persian version of MFAS using Cronbach’s alpha [7], and quoted by Setodeh and Ghodrati who reported an alpha of 0.98 [21, 22].

MFAS examines the mother’s behavior with the fetus in 5 dimensions with a score of 24 to 72: 1- Role taking (4 statements); 2- Interaction with the fetus (5 statements); 3- Attributing characteristics to fetus (6 statements); 4- Differentiation of self from fetus (4 statements); 5- Giving of self (5 statements). Women were asked to rate each phrase between 1 and 3 (yes = 3, I do not know = 2, no = 1) based on their feelings.

At first, individuals received MFAS if they met the inclusion criteria and entered the study after obtaining written consent. For sampling, the researcher first referred to selected centers daily to collect the samples; eligible mothers with unintended pregnancies were selected using targeted convenience sampling; they signed the consent form and filled out the demographic questionnaire before the intervention. Also, MFAS was completed by 84 mothers.

Intervention implementation

First, the questionnaires were completed before the intervention in both groups, then the intervention group, which included pregnant women with unintended pregnancies with inclusion criteriawas divided into two groups of 42 people (Fig. 1) and training classes were organized for intervention group at one of three medical centers, where they received prenatal care. Having introduced herself and having explained the project objectives, the researcher attracted people to participate in the project. The intervention included maternal and fetal attachment skills training and examining MFA before and after the intervention in 40–60 min.

Fig. 1

CONSORT guideline for the study

In each session from 6 session, the group training was discussed and the mothers were evaluated in group discussions to ensure that they had completely learned the training. The educational contents (according to previous study [19]) are briefly presented in Table 1. There was no intervention for the control group and mothers regularly referred to hospitals for routine pregnancy care. MFA was filled out by the participants at the baseline, after 4 weeks of training, and at the end of 38 weeks. SPSS-25 software was used for data analysis.

Table 1 The educational contents of the training sessions

Results

Referring to COSORT diagram in this study, 84 pregnant women with unintended pregnancies (42 subjects in each group) participated and the results are as follows.

Demographic information

The mean age of the mothers was 29.49 ± 4.28 in the intervention group and 29.17 ± 6.1 in the control group. The most frequent level of education was a high school diploma with 17 (40.5%) cases in the control group and 24 (57.5%) cases in the intervention group. The most frequent level of education of the spouses was a high school diploma with 19 (45.5%) cases in the control group and 22 (52.4%) cases in the intervention group (Table 2).

Table 2 Basic characteristics of the study participants

The mean MFA scores in the control group at the baseline and after the intervention were 57.29 ± 6.96 and 57.14 ± 5.03, respectively. These scores were 57.24 ± 5.03 and 66.43 ± 1.76 in the intervention group, respectively (Table 3). There was a significant difference in the estimated mean of MFA scores between the intervention and control groups after the intervention (P < 0.0001) (Table 3). The difference indicated that 70.2% of the covariance of scores after training was because of attachment training on the MFA score. Therefore, education has increased MFA after training (Table 4).

Table 3 Comparison of maternal–fetal attachment before and after training in the control and intervention groups (P-value)

Table 4 Analysis of covariance to investigate the effect of attachment training on attachment score in the post-training phase

Figure 2 shows a significant difference between the control group (57.29 ± 6.96 to 57.14 ± 5.03) and intervention groups (57.24 ± 5.03 to 66.43 ± 1.76) before and after training.

Fig. 2

Bar chart of comparison of maternal–fetal attachment before and after training in control and intervention groups

Discussion

The present study investigated the effect of attachment skills training on MFA in women with unintended pregnancies who were referred to selected perinatal clinics.

The control and experimental groups did not have a statistically significant difference in terms of demographic information (expect for the difference in the income level of the two intervention and control groups, which can be caused by the difference in the living standards of people in our society) before the intervention. Therefore, it can be said that the changes in attachment levels in women with unintended pregnancies were due to the intervention in the study.

In this study, an educational intervention was performed to investigate the effect of this intervention.

Findings from this study regarding the comparison of the mean scores of MFA before and after training of attachment behaviors showed that the mean score of MFA was higher after training of attachment behaviors with a significant difference from before training. A review study reported that attachment education had a significant relationship with MFA as well as mental health and reduction of maternal anxiety but stated that counseling and education were most effective when they occurred simultaneously [15]. One study, showed that educational programs such as the use of abdominal and fetal touch had a positive effect on MFA in the intervention group compared to the control group [17]. This is consistent with the interventions of the present study. Some studies which aimed at investigating the effect of fetal interaction intervention programs by talking to the fetus and using touch techniques on MFA showed a significant difference in MFA between the two groups. These results showed that the intervention program was effective in improving MFA and indicated the effectiveness of the intervention to promote initial sensitivity to the fetus on increasing MFA [11, 23]. Intended pregnancy and maternal–fetal bonding (MFB) were independently associated with postpartum MFA, but no significant association was found for the association of pregnancy intention with MFB. Also, the lowest amount of MFB after delivery was observed in mothers with unwanted pregnancy [24].

Therefore, it can be concluded that attachment education during pregnancy can play an important role in promoting maternal and fetal attachment.

Several studies on the effect of fetal touch during pregnancy on MFA and maternal-infant attachment showed that maternal attachment behaviors were significantly improved in the intervention group [15]. Facello showed that MFA played a significant role in the health of pregnant women and unborn babies. In addition, maternal attachment is a critical component of maternal identity and is essential for the development of the child’s growth and health [25]. Training and performing some attachment behaviors can increase MFA [16], which in turn can lead to a favorable relationship between mother and infant and better cognitive, emotional, and social development of the child [15, 25]. Some interventions have increased the relationship between the mother and unborn baby [26]. Pregnant mothers tend to engage in health behaviors, especially when they believe that these behaviors will improve the health of their fetuses [26]. MFA is positively associated with health behaviors. One of the ways to increase health behaviors is to teach these behaviors. Education is the basis of all health activities that are particularly important in changing people’s thoughts, behaviors, and habits [26]. Prenatal training has a positive effect on creating prenatal attachment [27]. MFA is an abstract maternal perception of the fetus that potentially exists before birth and relates to the cognitive and emotional ability to perceive another human being. Interventions that increase the relationship between the mother and unborn child include teaching and counseling attachment behaviors such as talking to the fetus, touching the fetus from the abdomen, paying attention to fetal movements, etc. All these behaviors appear to promote attachment and significantly increase MFA [28]. The feeling of fetal movement by the mother is also positively associated with attachment behaviors. Fetal movements may have a positive effect on prenatal attachment because the fetus looks more real to the mother after feeling its movements [29]. Therefore, according to the findings, it is suggested that MFA can be strengthened by providing simple interventions such as fetal touch [24, 29]. MFA protects the mother and fetus through developmental behaviors and prepares them for life after birth [27]. Optimal attachment in early childhood is also recognized as an integral part of a child’s future development [30]. In the present study, the increase in MFA was seen in the intervention group, due to the teaching of attachment behaviors in the third trimester of pregnancy in women with unintended pregnancies. This training may have a significant impact on reducing the risks of reducing tension, anxiety and depression during pregnancy and on forming and creating a safe and healthy attachment for the child [16]. One study, showed that postpartum bonding was stable and higher among women who were planning to become pregnant, regardless of MFB levels. However, for unintended pregnancies, MFB training has a protective effect on postpartum bonding [24].

Limitations

One of the limitations of our study could be that some cases of unwanted pregnancies remain hidden due to women's non-disclosure due to cultural and religious prejudices.

Conclusion

According to the results of this study, it appears that MFA has a positive relationship with health behaviors. Studies also show that prenatal interaction increases postnatal bonding and reduces complications due to a lack of maternal-neonatal bonding. It is hoped that effective educational interventions empower pregnant women with unintended pregnancies via teaching attachment skills and thus reducing the risks associated with unintended pregnancy. Midwives and medical staff, as people who have close contact with the pregnant mothers, can also play a key role in educating and providing these services to the pregnant mother, especially to those with unintended pregnancies. Therefore, it is recommended that caregivers should acquire such skills accurately and correctly to educate these mothers, solve problems, and improve the quality of life of mothers, children, and families.