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The relationship between pregnancy and birth experience with maternal-fetal attachment and mother-child bonding: a descriptive-analytical study | BMC Psychology

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Study design and participants

This descriptive-analytical study was conducted on 228 pregnant women in Tabriz, Iran from February 2022 to March 2023. All pregnant women (singleton) with gestational age 28–36 weeks were included in the study. The exclusion criteria were as follows: history of cesarean section, giving birth for more than three times, history of depression or postpartum depression, use of anti-depressants, known abnormality in the fetus, and the occurrence of a stressful event such as divorce, death, or diagnosis of an incurable disease for a first-grade family member during the last three months.

Sample size

The sample size was calculated as 152 women (SD = 5.87, α = 0.05, d = 0.05) around the mean (18.67) of pregnancy experience through n = Z 1−a/2 sd2/d2 [16]. Considering the effect size due to the cluster sampling method, the calculated sample size was multiplied by 1.5 (final sample size = 228).

Sampling

The sampling method was random cluster sampling. Initially, we prepared a comprehensive list of all health centers in Tabriz, Iran (n = 82). Then, we randomly selected a quarter of these centers. The researchers obtained the list of all pregnant women with gestational age 28–36 weeks. Then, the eligible women in each center were selected using simple random sampling. A written informed consent was obtained from all participants prior to the study, and the questionnaires were completed in two stages: [1] during third trimester of pregnancy through face-to-face interview: [sociodemographic and obstetric characteristics questionnaire, The Pregnancy Experience Scale, and Maternal-Fetal Attachment Questionnaire]; [2] six weeks postpartum: [Postpartum Bonding Questionnaire and Childbirth Experience Questionnaire-2]. The researchers followed up the participants once a month by making a phone call. Due to the COVID-19 pandemic and the reluctance of some women to visit in person, mothers who had access to the internet and social networks completed the questionnaires online.

Data collection tools

To collect data, sociodemographic and obstetric characteristics questionnaire, Pregnancy Experience Questionnaire (PES), Maternal-Fetal Attachment Questionnaire (MFAQ), Childbirth Experience 2.0 (CEQ 2.0), and Postpartum Bonding Questionnaire (PBQ) were used.

Sociodemographic and obstetric characteristics questionnaire

The sociodemographic and obstetric questionnaire consisted of different items such as age, body mass index (BMI), husband’s age, income status, educational status, husband’s education, job, and husband’s job, as well as obstetrical characteristics, including gestational age, number of pregnancies, number of abortions, pregnancy type (wanted or unwanted pregnancy), type of previous birth, place of birth, satisfaction with pervious birth, having complications during pregnancy, having postpartum complication, having skin to skin contact, anthropometric index of the baby, and baby’s sex. The content validity of this questionnaire was assessed and confirmed by an expert panel, including ten experts in the fields of midwifery, reproductive health, obstetrics, and gynecology.

The pregnancy experience scale (PES)

The short version of the PES has 20 items with two subscales: hassles (feelings of discomfort) and uplifts (feelings of happiness) during pregnancy. In this scale, a four-point Likert scale (from “not at all” [score 0] to “very much” [score 3]) is assigned to each item. A higher score indicates more discomfort or happiness in hassles and uplifts subscales, respectively. The reliability coefficient of the whole English version has been reported 0.80 [17]. The psychometrics properties of the Persian version were evaluated in Iran by Ebadi et al. Cronbach’s alpha of the whole scale, uplifts, and hassles subscales were reported as 0.71, 0.77, and 0.67, respectively [18].

Maternal-fetal attachment questionnaire (MFAQ)

This questionnaire consists of 24 questions divided into five subscales: “interaction with the fetus”, “differentiation of self from fetus”, “role taking”, “attributing character istics to the fetus”, and “giving of self”. Scoring is based on a five-point Likert scale and the options include “yes-always”, “yes-sometimes”, “not sure”, “no-rarely”, and “no-never”. The scoring of all questions is from 1 to 5 and in the case of question 20, it is reversed. A higher score indicates better attachment [19]. The validity and reliability of MFAQ in Iran has been confirmed by Abbasi et al. and Cronbach’s alpha coefficient has been reported as 0.80 [20].

Postpartum bonding questionnaire (PBQ)

This questionnaire contains 25 questions and expresses the mother’s feelings and attitude towards the baby. PBQ has four subscales, which subscale 1 reflects impaired bonding (12 items; score range 0 to 60), subscale 2 reflects rejection and anger (7 items; 0 to 35), subscale 3 reflects anxiety about care (4 items; 0 to 20), and subscale 4 is the risk of child abuse (2 items; 0 to 10). The mother expresses her feeling on a 6-point Likert scale (score 0 to 5). Higher scores indicate a more unfavorable relationship [21]. The validation of the Persian version was done by Aflakseir and Jamali, and Cronbach’s alpha coefficient for the components of defective bonding, rejection and anger, care anxiety, and child abuse risk were reported as 0.52, 0.67, 0.70, and 0.74, respectively [22].

Childbirth experience questionnaire 2.0 (CEQ 2.0)

The CEQ [23] has 23 questions related to four subsacles (“own capacity”, “professional support”, “perceived safety”, and “participation”). The responses include “completely agree” (score 1), “often agree” (score 2), “often disagree” (score 3), and “completely disagree” (score 4). A higher average score indicates more positive experience of childbirth. The validation of the Persian version of CEQ 2.0 has been confirmed by Ghanbari et al. The internal consistency and reliability of the tool have bee reported as 0.93 and 0.97, respectively [24].

Data analysis

The data were analyzed using the SPSS software, Version 24.0 (IBM Inc., Armonk, NY, USA). We used descriptive statistics for reporting quantitative and qualitative variables, including mean (standard deviation) and frequency (percent). To determine the relationship between pregnancy and birth experience with MFA and mother-child bonding in univariate analysis, Pearson’s correlation coefficient (normal distribution) and Spearman’s correlation coefficient (non-normal distribution) tests were used. In the multivariate analysis, general linear model was used by adjusting socio-demographic and obstetrics characteristics (all variables with p < 0.1 were enterd in the model). A p-value less than 0.05 was considered as statistically significant.

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