Care of the Newborn by Ten Teachers

Hilary Lumsden, Debbie Holmes, Hilary Lumsden, Debbie Holmes

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781482213133
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Caring for the well newborn is an essential element of everyday midwifery practice. Providing a comprehensive guide to the problems associated with newborn babies, Care of the Newborn by Ten Teachers is a key textbook for trainee midwives. The ten teachers involved in writing this book are drawn from all over the UK and bring together a w

CHAPTER 1	PARENTING – ATTACHMENT, SEPARATION AND LOSS
	Sandra Sandbrook

Attachment

The birth of a sick or premature baby

Loss and bereavement

Attachment and loss

Caring for bereaved parents

References

Further reading

OVERVIEW

This chapter explores the attachment relationship parents develop with their baby. Attachment is an interactional process that starts as acquaintance during pregnancy and develops through reciprocal interaction to become an exceptional, enduring and important relationship. Midwives should be aware of the many factors that may affect the developing relationship during pregnancy, childbirth and the early days following birth. The development of the relationship between the parents and their baby has implications for the parents if they are separated from their baby due to illness resulting in admission to a neonatal unit or due to the baby’s death.

This chapter will examine the possible psychological implications for the parents when they are separated from their baby due to illness or prematurity and how midwives and nurses can provide support to give the woman or couple confidence in their ability to parent. It ends with a discussion on attachment and loss, the devastation that can result from bereavement at the beginning of life. Grief and mourning will be considered, together with how the midwife can sympathetically facilitate the process of mourning and provide empathetic support.

Attachment

When perinatal and infant mortality rates were high and infant death was the norm, parents did not expect to rear all their children to maturity. Child-rearing practices emphasized discipline and were aimed at promoting survival and moral strength. As mortality rates improved, with the expectation that the majority of children would survive childhood, the emphasis changed from survival to providing sensitive child-rearing practices that would promote the physical and psychological well-being of the child.

Sigmund Freud acknowledged that within successful child-rearing the mother-child relationship was of primary importance. He further identified that early childhood experiences were critical as they could affect the normal psychological functioning of the adult. This was reinforced by John Bowlby’s work following the Second World War on the profound emotional and cognitive consequences of maternal deprivation during the early years of a child’s life. In his Report for the World Health Organization in 1951, Maternal Care and Mental Health, Bowlby stated that essential for a child’s mental health is a reciprocal ‘warm, intimate and continuous relationship’ with a mother or caregiver (Figure 1.1). Bowlby is considered the ‘Father of Attachment’ and this is the beginnings of attachment theory that has evolved through research in the twentieth and twenty-first century.

The attachment relationship

Attachment describes the unique and enduring relationships each individual seeks to forge with its caregivers and a select group of special individuals. This relationship ensures survival, facilitates both communication and socialization and assists cultural transmission. Initially this intimate relationship begins as maternal-fetal attachment during pregnancy and is then developed through reciprocal interactions between the infant, caregivers and a special group of chosen individuals during childhood. Indeed there is empirical evidence revealing that the majority of children during their first year of life become attached to a small group of familiar people whom the child categorizes into a hierarchy of attachment figures - usually with the child’s parents being the most important. In most cultures the child’s attachment group consists of parents, siblings, grandparents, aunts, uncles and daycare providers.

Figure 1.1 The warm and intimate early mother-child relationship

Attachment has been described as an interactional process that begins as acquaintance and develops towards the unique and enduring attachment relationship (Goulet et al., 1998). The acquaintance phase begins during pregnancy as the expectant woman seeks to get to know her ‘baby’ through assigning meanings to the physical and technical signs she experiences: the increasingly strong fetal movements, listening to the fetal heartbeat and visualizing the fetus on ultrasound scans. This is reinforced following birth with powerful sensori-motor interactions activated through embracing, rocking and maintaining prolonged visual contact with her baby. The infant seeks physical and psychological closeness through clinging, following and calling behaviours, and if these are appropriately satisfied both parties experience reciprocal feelings of love, security and joy. In the carer these feelings ensure altruistic commitment to the infant, placing the infant at the centre of his or her life. The reciprocal pleasure and synchronicity of the interaction serves as a catalyst for the continued strengthening of the attachment relationship.

Attachment is very important to the child’s physical, social and psychological well-being. The success of the individual’s ability to form close attachment relationships is fundamental to his or her ability to develop and sustain all subsequent relationships throughout life. Bowlby suggests that relationship patterns are transmitted through social interaction across the generations. Interactions between child and caregiver are internalized and become almost a blueprint for subsequent relationships. These initial attachment relationships act as a basis for expectation, belief and evaluation of intimate relationships across the individual’s lifespan.

Attachment relationships remain important throughout a person’s life. In adulthood stressful life events cause individuals to seek their secure attachment figures for help, soothing and safety. As with infants the adults will exhibit anguish if an attachment figure becomes unavailable. The loss of this attachment relationship can be catastrophic at any time during an individual’s lifespan, constituting a potent stressor. This suggests that attachment security remains important into adulthood.

Secure attachment

Mary Ainsworth (1963, 1967) through rigorous empirical work identified and explained the concept of secure attachment. She noted the importance of a parent’s sensitivity to their infant’s cues and that this sensitivity is essential to the successful development of the attachment relationship. Secure attachment is crucial to provide safety and comfort to a child that is tired, distressed or presented with a challenging situation; the lack of opportunity to develop selective attachments may damage the child’s social and emotional development. A secure attachment figure provides the child with a safe environment to explore their world and allow them a healthy mental development. Bowlby found that secure attachment facilitated the development of internal working models that socialize the child and allow them to make sense of the world they live in, responding appropriately and safely to the myriad social and environmental cues. These increasingly complex models operate outside consciousness and are formed through continued interpersonal and environmental transactions. Secure attachment also facilitates the development of the child’s self-belief. Optimal parenting style, described as responsive, reassuring and comforting, promote the child’s autonomy and sense of self-confidence and worth.

Attachment as a developmental process

Attachment is a developmental process that continues throughout the life. For many years it was considered that birth marked the beginnings of the relationship between parents and baby; it is now recognized, however, that the attachment relationship begins during pregnancy.

(i) Maternal-fetal attachment

Maternal-fetal attachment is an emotional response to the growing life within that develops as the pregnancy becomes more tangible. The woman becomes increasingly preoccupied with the physical realities of the pregnancy, actively focusing her attention on the developing life inside her. It would appear that the woman’s affectionate behaviour towards her fetus develops with each progressive trimester. Initially women fantasize about their fetus, but as pregnancy progresses they become more actively involved with their ‘baby’, stroking and talking to their pregnant abdomens, often giving their ‘baby’ a pet name. As pregnancy advances the woman perceives the fetus in increasingly human terms, attributing characteristics and personality traits to it. The physical reality and experiences of pregnancy appears to positively encourage and intensify maternal attachment. Studies have shown that quickening, ultrasound visualization, the growing pregnant abdomen and progressively strong and distinctive fetal movements enhance attachment.

This developing maternal-fetal attachment throughout the trimesters has been aptly illustrated by Raphael-Leff (2005) as constituting three progressive phases: belief in the pregnancy, belief in the fetus and ultimately belief in a baby who will survive his or her birth.

There are many factors that appear to influence the development of the maternal-fetal attachment: the woman’s own experiences of being parented, social support, the support of a compassionate partner and previous personal experiences of pregnancy and childbirth. Personal experiences of being parented fundamentally affect the individual’s ability to parent. Once internalized and operating at an unconscious level the working model of attachment becomes a blueprint for future parenting. This constitutes intergenerational attachment. Parenting attitudes, behaviours and models are passed from generation to generation, with early experiences of secure selective attachment being associated with a greater capacity to be well-functioning parents.

Pregnancy is the catalyst that stimulates the woman to explore attachment relationships, particularly evaluating her relationship with her mother. Pregnant women actively seek increased contact with their mothers, particularly in the final trimester. Research has shown that women who have affectionate, loving relationships with their mothers are more able to establish and maintain positive attachment (Siddiqui et al., 2000). It must be acknowledged, however, that individual women will have both positive and negative parenting experiences and it would be over-simplistic to suggest that experiences of poor parenting result in poor maternal-fetal/infant attachment. If a woman has a clear understanding of her experiences of being par-ented and is able to fully discuss its impact with another attachment figure, supportive partner or within a therapeutic relationship, she will be able to develop maternal-fetal attachment and ultimately provide sensitive and responsive parenting.

Accommodation to pregnancy and subsequent attachment behaviours is influenced by the woman’s social, financial and health status. Inequalities and inadequacies may cause the woman to be so preoccupied with her dilemma that she is unable to respond effectively to the developing relationship. The woman’s satisfaction with her social networks and economic circumstances can have profound effects on the developing attachment relationship, competing with her ability to focus on her pregnancy and baby.

The transition to parenthood is a critical period in an individual’s life, causing substantial lifestyle and role changes. Responsive, sensitive and appropriate social support can have a positive effect and encourage the development of attachment. Social support can be from a variety of people: friends, colleagues, helping healthcare professionals, family and partners. However it is not simply the provision of support, it is the woman’s satisfaction with the quality of support provided that is most influential in promoting maternal-fetal attachment. Practical support provided by a partner is especially valued; doing household chores, shopping and generally paying close attention to the pregnant woman’s health and well-being, especially if this behaviour is new, is very beneficial for the developing attachment relationship.

It would appear that the most influential social support is from a loving and empathetic partner. Bowlby (1988) noted that expectant mothers had a strong desire to be cared for and supported by their partners. He suggested that the experience of being loved facilitates and enhances the woman’s ability to love. It has been found that women with positive and sustained support from their partners adapt more easily to pregnancy. A supportive relationship strengthens and maintains the woman’s constructive feelings about motherhood and the fetus. Gjerdingen and Chaloner (1994) found that the partner’s sensitive, caring and appropriate practical help strongly impacted on the woman’s sense of emotional well-being and self-confidence, which results in a reduction in the incidence of postnatal depression. Siddiqui et al. (1999) found that the woman’s partner’s attitude and reaction to her pregnancy are powerful contributors to the woman’s adjustment to pregnancy, her relationship to her fetus and mothering behaviour. The support of a partner can positively affect the woman’s caregiving functions, providing a secure base from which she can explore and rectify any previous experiences of insecure attachment, allowing her to concentrate on her pregnancy and develop attachment to her fetus. This security is provided through loving support and practical assistance during pregnancy, actively participating in some functional caregiving capacity.

It should also be noted that previous childbearing experiences will affect the woman’s ability to concentrate on her pregnancy and develop an emotional attachment to her fetus. It would appear that within the first trimester of pregnancy most women are at times ambivalent towards the fetus. It is common knowledge that miscarriage within the first 12 weeks of pregnancy is not unusual; women are sometimes hesitant of becoming emotionally attached to a fetus that may not be viable. This does not mean they have not developed feelings and aspirations for their pregnancy and will not be bereaved should miscarriage occur. However, if the woman has already experienced a miscarriage her fear of becoming emotionally attached is aggravated and she...