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i
THE ROLE OF EDUCATIONAL PROCESS
DURING ROUTINE OBSTETRIC ULTRASOUND
EXAMINATION IN MATERNAL-FETAL
ATTACHMENT
BY
NWOGU, ULOMA BENEDICTA (PG/M.Sc/03/37826)
A DISSERTATION SUBMITTED TO THE DEPARTMENT OF
MEDICAL RADIOGRAPHY AND RADIOLOGICAL SCIENCES
FACULTY OF HEALTH SCIENCES AND TECHNOLOGY,
COLLEGE OF MEDICINE,
UNIVERSITY OF NIGERIA, ENUGU CAMPUS
IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE
AWARD OF SCIENCE DEGREE (M.Sc), IN MEDICAL IMAGING
DECEMBER 2011
ii
DEDICATION
This work is dedicated to my loving husband, Iheanyi and my four kids- Chidera,
Chimamanda, Chidinma and Baby Iheanyi. I love you all so much.
iii
APPROVAL PAGE
NAME: NWOGU ULOMA B. (PG/M.Sc/03/37826)
DEGREE: MASTER OF SCIENCE (M.Sc) IN MEDICAL
IMAGING
TITLE OF DISSERTATION: THE ROLE OF EDUCATIONAL PROCESS
DURING ROUTINE OBSTETRIC
ULTRASOUND EXAMINATION IN
MATERNAL-FETAL ATTACHMENT.
EXAMINING COMMITTEE
………………………… …………………………
DR C.U EZE PROF. K. K. AGWU
HEAD OF DEPARTMENT SUPERVISOR
………………………….......
EXTERNAL EXAMINER
…………………………...
DATE OF APPROVAL
iv
ACKNOWLEDGEMENT
This study could not be completed without the assistance of many people. My deepest
gratitude goes to my husband and friend Mr. Iheanyi Nwogu for his boundless love
and care.
I am heartily thankful to my indefatigable supervisor, Professor K.K. Agwu, whose
encouragement, patience, guidance and support contributed immensely to the success
of this study.
I am highly indebted to Dr S.O.I Ogbu for both his encouragement and analyzing the
data of this work. I am also grateful to my head of department, Dr C.U. Eze for his
support and motivation; Mrs F.U.Idigo, Mrs Angel Anakwue, the rest of my
colleagues and the staff of Radiology department, UNTH, for their encouragement
and assistance during this research work.
I wish to acknowledge Mrs. G. Affam of Anun Medics Sonovision, New Haven,
Enugu, for her encouragement and support throughout the time of this research work.
My thanks also goes to all the experts who helped to validate all the questionnaires
used in this work especially Dr. Mrs. C. Ndiokwelu of the Nutrition & Dietetics
Department, University of Nigeria Teaching Hospital, Ituku-Ozalla, for her patience
and understanding.
Lastly, I offer my regards and blessings to all those who supported me in any way
during the completion of this project especially to Mrs. Josephine Nzekwe for typing
the manuscript.
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TABLE OF CONTENTS
............................................................................................................. Page
TITLE PAGE ........................................................................................................... i
DEDICATION .................................................................................................. ii
APPROVAL PAGE ................................................................................................. iii
ACKNOWLEGDEMENT ....................................................................................... iv
TABLE OF CONTENTS ......................................................................................... v
LIST OF TABLES .................................................................................................. vi
ABSTRACT .................................................................................................. viii
1.0 CHAPTER ONE: INTRODUCTION
1.1 BACKGROUND OF THE STUDY ............................................................ 1
1.2 PURPOSE OF THE STUDY ....................................................................... 4
1.3 SIGNIFICANCE OF THE STUDY............................................................. 5
1.4 HYPOTHESES ............................................................................................ 5
1.5 SCOPE OF THE STUDY ............................................................................ 6
1.6 DEFINITION OF TERMS .......................................................................... 6
2.0 CHAPTER TWO: LITERATURE REVIEW
2.1 EDUCATIONAL PROCESS DURING ULTRASOUND .......................... 8
2.2 MATERNAL-FETAL ATTACHMENT (MFA) ......................................... 9
2.2.1 THE MEASUREMENT OF MFA .............................................................. 11
2.3 MATERNAL HEALTH PRACTICES ........................................................ 12
2.3.1 MATERNAL DIETARY HABITS ............................................................. 12
2.3.2 EFFECT OF ALCOHOL USE IN PREGNANCY ...................................... 13
2.3.3 ANTENATAL CARE .................................................................................. 15
3.0 CHAPTER THREE: RESEARCH METHODOLOGY
3.1 RESEARCH DESIGN ................................................................................. 17
3.2 POPULATION, SAMPLE AND SAMPLING PROCEDURES................. 17
3.2.1 AREA OF STUDY ...................................................................................... 17
3.2.2 TARGET POPULATION ............................................................................ 17
3.2.3 SUBJECT SELECTION CRITERIA .......................................................... 17
3.2.4 SAMPLE SIZE ............................................................................................ 18
3.2.5 SAMPLING TECHNIQUE ......................................................................... 19
3.3 ETHICAL APPROVAL .............................................................................. 19
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3.4 METHOD OF DATA COLLECTION ........................................................ 20
3.4.1 EQUIPMENT .............................................................................................. 20
3.4.2 INSTRUMENT USED FOR DATA COLLECTION ................................. 20
3.4.3 PROCEDURE FOR DATA COLLECTION ............................................... 22
3.9 DATA ANALYSIS ...................................................................................... 23
4.0 CHAPTER FOUR: PRESENTATION OF RESULTS
4.1 MATERNAL DEMOGRAPHIC AND CLINICAL DATA........................ 25
4.2 MFA SUBSCALE SCORES ....................................................................... 27
4.3 TEST OF HYPOTHESIS ONE ................................................................... 29
4.4 MATERNAL NUTRITIONAL/DIETARY STATUS ................................ 30
4.5 TEST OF HYPOTHESIS TWO .................................................................. 33
4.6 TEST OF HYPOTHESIS THREE............................................................... 36
5.0 CHAPTER FIVE: DICUSSION, SUMMARY, CONCLUSION &
RECOMMENDATION
5.1 DISCUSSION OF FINDINGS .................................................................... 40
5.2 SUMMARY OF FINDINGS AND CONCLUSION ................................... 47
5.3 RECOMMENDATIONS ............................................................................. 48
5.4 LIMITATIONS OF THE STUDY............................................................... 49
REFERENCES ............................................................................................ 50
APPENDICES ............................................................................................. 57
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LIST OF TABLES
Table 1 Maternal Demographic Characteristics............................................... 25
Table 2 Maternal Clinical Characteristics ........................................................ 26
Table 3 Total Subscale scores of Cranley MFA .............................................. 27
Table 4 ANOVA test on pre-MFA in relation to maternal characteristics ...... 28
Table 5 Paired t-test on MFA subscales........................................................... 29
Table 6 Paired t-test on MFA total pre- and post-mean scores ........................ 30
Table 7 Pre- and Post-nutritional Status of the respondents ............................ 31
Table 8 Pre- and Post-Maternal dietary habits ................................................. 32
Table 9 t-test on Pre- and Post-Maternal nutritional/dietary Status ................. 34
Table 10 Statistical analysis of Health-Habit items using Chi-square ............... 34
Table 11 Maternal Alcohol consumption Status ................................................ 35
Table 12 t-test on the Pre- and Post- Maternal alcohol consumption ................ 36
Table 13 Chi-square test on the Pre- and Post-Maternal alcohol consumption . 37
Table 14 Antenatal Care Compliance ................................................................ 38
Table 15 Chi-square test on the Pre- and Post-Maternal Antenatal compliance 39
viii
ABSTRACT
This research work was designed to investigate the influence of educational process
during routine obstetric ultrasound on Maternal-Fetal Attachment (MFA) and
maternal behavioural changes in pregnancy. Using a prospective and cross-sectional
design, 289 pregnant women who had singleton and uncomplicated pregnancies, with
no history of mental illness, not primigravidas and whose gestational ages ranged
from 16 weeks to 30 weeks, were enlisted from referrals for routine obstetric scan at
the University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu. The 2-Dimensional
ultrasonography was performed using a real time ultrasound unit, with 3.5 MHz sector
probe and 5 MHz linear probe. Three questionnaires were used in the study and
consisted of the demographic questionnaire, the Maternal-Fetal Attachment Scale
(MFAS) and the Health-Habit questionnaires (HHQ). The demographic questionnaire
was used to collect personal data of the subjects. The MFAS which consisted of 24
items on a 5-point likert scale, was used to assess the influence of the educational
process on MFA. The HHQ, which consisted of 19 items, was used to assess the
influence of the educational process on maternal behavioural changes in pregnancy.
The MFAS and HHQ were distributed to the participants, pre- and post- ultrasound
scan. During the ultrasound examination, the fetal ultrasound image was explained
and discussed with the mother who was allowed to ask questions. Data was
categorised according to maternal characteristics, MFA scores and nutritional/dietary
habits. Percentage responses, frequencies, mean scores and standard deviation of the
demographic data, MFA score, maternal nutritional/ dietary habits scores were
computed and analyzed using the SPSS 15.0 version program. Paired t-test was used
to compare the pre- and post- mean values. ANOVA was used to compare the values
of more than two means. Chi-square was used to compare frequencies of more than
one group. Results indicated that the mothers‟ total MFA pre-mean score increased
significantly (p=0.0001) from 3.34±0.18 to a post-mean score of 3.74±0.20, after the
ultrasound experience. The pre-mean scores of all the areas involved in the Health-
Habit Questionnaire (HHQ) also significantly improved after the educational process
during ultrasound examination. The pre-mean health habits regarding maternal
nutritional/dietary status increased significantly (p=0.0001) from 2.51±1.02 to a post-
mean score of 3.04±0.83 while that of maternal alcohol consumption decreased
significantly (p=0.000) from 1.52±0.63 to a post-mean score of 1.13±0.38. The health
habit regarding compliance with antenatal care also significantly improved (χ=70.60;
p=0.0001). These results show that the educational process during routine obstetric
ultrasound positively influences MFA and maternal behaviour during pregnancy.
1
CHAPTER ONE
1.0 INTRODUCTION
1.1 BACKGROUND OF THE STUDY
Maternal-Fetal Attachment (MFA) is a term used to describe the relationship between
a pregnant woman and her fetus (Salisbury et al, 2003). This is the extent to which
women engage in behaviours that represent an affiliation and interaction with their
unborn child (Cranley, 1981). MFA is known to improve maternal care and is
associated with positive neonatal outcomes (Verny & Kelly, 1981, Ji Ek et al 2005;
Facello, 2008). Literature provides empirical evidence that MFA typically increases
as pregnancy progresses, and positive MFA predicts positive birth outcomes
(Cannella, 2005).
Poor neonatal outcome which is largely represented by high maternal and infant
mortality and morbidity rate, still pose a serious challenge in Nigeria (Mukhtar et al,
2007). Poor or non-utilization of antenatal/delivery care and poor dietary habits,
among others have been highly associated with maternal complications and poor
perinatal outcomes (Owolabi et al, 2008; Sanusi and Oredipe, 2002; Mamman et al,
2002).
Routine obstetric sonography has been known to improve neonatal outcome (Saari-
Kemppainen et al, 1990). It assists in the attachment process by accentuating the
individuality and separateness of the fetus and is now globally recognized as one of
the ways through which maternal mortality can be reduced (Durbin, 1999; Mubuuke
et al, 2009). A number of research studies have examined the experience of women
undergoing routine obstetric ultrasound scanning. Their findings suggest that for
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women with normal pregnancies and low risk for complications, viewing the fetus on
ultrasound generally is a most positive, reassuring and significant event (Campbell et
al, 1982).Women usually are eager to see their babies‟ ultrasound image in utero.
Areas that show motion, such as the beating of heart and extremities, get a major
amount of attention and seem to provide mothers with significant reassurance about
the health of their fetus (Kohn et al, 1980). Further studies showed that ultrasound
exams have a “significant psychological effect on parental attitudes toward each other
and the fetus” (Zlotogorski, et al, 1997).
Educational process may be involved in routine obstetric ultrasound (Boukydis, 2002)
which has been proven to be beneficial to obstetric management (Hyde, 1986). This
process involves the sonographer spending just a few extra time (3 minutes) with a
mother-to-be during her 2- or 3-/4-dimensional fetal ultrasound examination to
demonstrate, explain and discuss the fetal ultrasound image (Boukydis et al, 2006)
using language that is simple and appropriate while avoiding “slips of the tongue”
(Lumley, 1990) and giving the mother an opportunity to interact and allowing the
mother to self-initiate behaviour (Boukydis, 2002).
There is a growing body of evidence that a mother viewing prenatal sonograms of her
fetus may or can increase positive feelings towards the fetus (Lumley, 1990), which
influences maternal attachment to the fetus at an early stage of pregnancy (Ji Ek et al,
2005). This educational process was found to be an effective nursing intervention to
promote Maternal-Fetal Attachment since women who received fetal ultrasound
education were found to have a higher MFA than those who did not. (Jee, et al, 2002).
3
However, whether the educational process during routine obstetric ultrasound
influences maternal-fetal attachment in this locality, has not been documented.
It is well known that maternal nutritional status, physical health among others directly
affect the intrauterine fetal environment and are associated with some maternal and
infant health outcomes during and after pregnancy (Lindgren, 2001; Wilkinson and
Tolcher, 2010). However, due to our peculiar socio-economic and cultural
circumstances, that negatively affect perinatal outcome, adequate positive maternal
health practices are yet to be achieved (Sanusi, 2002).
Maternal-fetal attachment has been positively associated with prenatal health
practices, as well as being considered both a developmental task of pregnancy and an
indicator of adaptation to pregnancy (Callister, 2002; Lindgren, 2001). Women on a
healthy diet have greater levels of maternal-fetal attachment than women on an
unhealthy diet. Prenatal interventions, especially the mother‟s viewing of the fetus
during ultrasound examinations, in pregnancies in which there is high psychosocial
risk and active substance abuse have the potential to increase maternal-fetal
attachment and reduce the risk of behaviors that may harm the fetus and compromise
the health status of the pregnancy (Pollock and Percy, 1999).
The viewing of the fetal image via ultrasound in pregnancy before any bodily cues are
experienced has superseded the earlier importance of quickening for the mother‟s
realization of actual life inside the womb (Gloger-Tippelt, 1989; Lumley, 1990) and
may contribute towards stronger feelings of attachment to the unborn child (Lerum
and LoBiondo-Wood, 1989) and enhanced health behavior during pregnancy (Dykes
and Stjernqvist, 2001). The educational process surrounding the visualization of one‟s
own baby during an ultrasound examination accelerates maternal-fetal attachment as
4
is evidenced by the mother‟s improved health practices that include better nutrition
and decreased consumption of nicotine and alcohol (Durbin, 1999). Increased and
strengthened Maternal-Fetal Attachment that results from viewing of the obstetric
ultrasound seemed to be beneficial by reducing potentially harmful maternal
behaviour (Berman et al, 1997). However, whether the educational process during
routine obstetric ultrasound involves a change in health-related behaviour of the
mother in our locality is yet to be ascertained.
This study therefore aims at studying the influence of the educational process that
goes on during routine obstetric ultrasound on maternal-fetal attachment and maternal
behavioural changes during pregnancy in our locality.
The study will provide information that may improve the use of the educational
process during routine obstetric ultrasound and also raise the society‟s consciousness
on the role of the educational process during routine obstetric ultrasound on improved
neonatal outcome.
1.2 PURPOSE OF THE STUDY
The aims of this study are to:
1. Determine if the educational process during obstetric ultrasound examination
influences maternal-fetal attachment in this locality.
2. Determine if the educational process during ultrasound examination influences
maternal health practices as represented by:
a. Maternal nutritional/dietary habits
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b. The intake of alcohol.
c. The compliance with antenatal drugs/care, in this locality.
1.3 SIGNIFICANCE OF THE STUDY
1. The study will provide information that may improve the use of the
educational process during routine obstetric ultrasound.
2. This study will also raise the society‟s consciousness on the role of the
educational process during routine obstetric ultrasound on improved
neonatal outcome.
1.4 HYPOTHESES
(H0)1. The educational process involved in obstetric ultrasound examination has no
significant influence on Maternal-Fetal Attachment.
(H0)2. The educational process involved in obstetric ultrasound examination has no
significant influence on the maternal dietary habits.
(H0)3. The educational process involved in obstetric ultrasound examination has no
significant influence on the maternal intake of alcohol.
(H0)4. The educational process involved in obstetric ultrasound examination has no
significant influence on the maternal compliance to antenatal drugs and care.
6
1.5 SCOPE OF THE STUDY
This study is a prospective study which was carried out between November, 2009 and
August, 2010 at the University of Nigeria Teaching Hospital (UNTH), Ituku, Ozalla,
Enugu. The study population include women between 16-30 weeks of normal
singleton pregnancy who met the selection criteria.
1.6 DEFINITION OF TERMS
The definition of the following terms will serve to clarify the concepts used in this
study:
Routine Obstetric Ultrasonography: Routine obstetric ultrasonography is defined as
a screening procedure which is done on low risk pregnant women (Skupsi et al,
1995). Low risk pregnant women refer to those without clinical indication for
ultrasound. Routine protocol consists of views of anatomic features as well as a
thorough search for detail of any abnormality in anatomy. This consists of fetal skull
and intracranial anatomy, face, heart and chest, abdomen, kidneys, spine, extremities,
placenta, amniotic fluid, uterus and other structures. In obstetric ultrasound practice
the technique can facilitate attempts to evaluate fetal size, fetal maturity, and
fetal/placental position, as well as provide additional diagnostic data.
Diagnostic Toxicity: This is defined by Lumley (1990) as the negative impact of
routine obstetric ultrasound scan produced by incompetent healthcare providers
during the procedure itself. Lumley refers to it as “slips of the tongue” or “incorrect
diagnosis”, identification of structures that cannot be deciphered and language that is
unfamiliar and alarming to mothers.”
7
Maternal-Fetal Attachment/Bonding: The term “bonding” and “attachment” are
used interchangeably. It is described as the maternal feelings of affection and
enduring commitment to the fetus. This is defined by Cranley (1981) as “The extent
to which women engage in behaviors that represent an affiliation and interaction with
their unborn child”.
Maternal Health Behaviour/Practices: These are activities in which the pregnant
woman engages that affect her health and the health of the fetus and later infant
outcomes. Positive health practices include proactive measures such as seeking
prenatal care, eating well, gaining the recommended amount of weight, obtaining
dental care, and abstaining from illegal drugs, and alcohol (Lindgren, 2001).
Ultrasound Educational Process: This process involves spending just a few extra
minutes ( about 3 minutes) with a mother-to-be during her fetal ultrasound exam to
demonstrate, explain and discuss the fetal ultrasound image (Boukydis et al (2006).
Lumley (1990) referred to the educational process in her research as “sonographer
feedback”, and felt it was a critical factor since it accounted for discussion,
explanation, and interpretation of the ultrasound images.
8
CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 EDUCATIONAL PROCESS DURING ULTRASOUND EXAMINATION
The ultrasound room could be considered an interactive teaching environment where
significant discussion with questions and answers occur. The educational process that
occurs during the obstetric ultrasound is an interaction that instils current scientific
knowledge, clinical experience and the visual impact of the unborn baby. Lumley
(1990) referred to the educational process in her research as “sonographer feedback”,
and felt it was a critical factor since it accounted for discussion, explanation, and
interpretation of the ultrasound images. Spending just a few extra minutes with a
mother-to-be during her fetal ultrasound exam can pay off by strengthening her bond
with the unborn baby and quelling her anxiety. The sonographer allows the mother to
view the fetus‟ face, limbs, and trunk
and confirms maternal recognition of structures
and identification of fetal features. The sonographers also allows the mother-to-be
(and father-to-be, if he was there) to ask questions and explore the unborn baby. The
sonographer also provides interpretation of fetal physical behaviour giving the mother
an opportunity to interact and allowing her to self-initiate behaviour such as pressing
on the abdomen, laughing, singing, or speaking to the fetus (Boukydis et al, 2006). .
Durbin (1999) acknowledged that this educational process itself stimulates learning
by stirring interest and bonding and thereby accelerating the learning curve. She
added that “the educational process surrounding the visualization of one‟s own baby
during an ultrasound examination accelerates maternal-fetal bonding as is evidenced
by the mother‟s improved health practices that include better nutrition and decreased
consumption of nicotine and alcohol. The experience or educational process in the
9
ultrasound room leads to maternal-fetal bonding that is important to the attachment
process, producing a loving relationship that has a far-reaching impact. The
ultrasound procedure along with the verbalization that occurs accelerates the learning
curve for the participant. This, in turn, promotes healthy behaviors thus decreasing
maternal and perinatal morbidity. Prenatal interventions, especially ultrasound
examinations, in pregnancies in which there is high psychosocial risk and active
substance abuse have the potential to increase maternal-fetal attachment and reduce
the risk of behaviors that may harm the fetus and compromise the health status of the
pregnancy (Pollock and Percy, 1999).
2.2 MATERNAL-FETAL ATTACHMENT (MFA)
The term „bonding‟ and „attachment‟ both refer to the tie or relationship between two
persons. They are used interchangeably (Chanachote, 2007). The original theory of
maternal-child attachment defined attachment as an emotional tie or psychological
bond to a specific object. Bowlby (1988) defined attachment as an enduring and
specific affective bond that develops overtime between two people.
Cranley is credited with the first formal definition of the construct of Maternal-Fetal
Attachment (MFA) and he defined it as “The extent to which women engage in
behaviors that represent an affiliation and interaction with their unborn child”
(Cranley, 1981). She developed an instrument (a 24-item scale) for the measurement
of MFA called the MFA Scale. She further regrouped these items into five subscales:
Differentiation of self from fetus: This means recognization of the fetus as a single
individual.
10
Interaction with fetus: This means feelings or behaviours of a pregnant woman
toward her fetus by talking to the unborn child, calling her unborn baby a nickname,
stroking her tummy when the baby is kicking.
Attributing characteristics and intentions to the fetus means that a pregnant
woman imagines about the characteristics of the fetus and is interested in her fetus.
Giving of self means feelings or behaviours that a pregnant woman devotes herself to
the fetus such as seeking antenatal care and doing appropriate behaviour during
pregnancy.
Role taking means feelings of interest and intention to her fetus such as fantasizing
about taking care of her baby (Chanchote, 2007; Righetti, 2003) and it generally
refers to the maternal-fetal relationship, which normally develops during the
pregnancy.
MFA is manifested in behaviours that demonstrate care and commitment to the fetus
and include nurturance, comforting, and physical preparation. Maternal-Fetal
Attachment theory proposes that MFA influences maternal health practices and,
therefore, provides a crucial opportunity to improve perinatal health and neonatal
outcomes. Women who abuse substances which put their foetus at risk during
pregnancy might be expected to find it difficult to fulfil many of the tasks like feeling
love or compassion for the foetus or acting in the interests of the foetus and to ensure
its safety. These indicate prenatal attachment (e.g. protecting foetal health) and would
thus be expected to have lower levels of maternal-fetal attachment. Women who
maintained a healthy diet were associated with greater levels of maternal-fetal
attachment (Jesse & Reed, 2004; Lindgren, 2005).
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2.2.1 The measurement of Maternal-Fetal Attachment
Cranley (1981) developed the first antenatal attachment scale, the Maternal Fetal
Attachment Scale (MFAS). The MFAS is a 24-item questionnaire written at the fifth-
grade level requiring 5 minutes for completion. She asked clinicians and childbirth
educators to identify statements made by their patients that implied MFA; the
resulting 37 items were then administered to 71 pregnant women between 35 and 40
weeks gestation. Each question has a 5-point scale (1, definitely no; 5, definitely
yes).The Higher the score, the greater the attachment. The 5 subscales to the MFAS
are Role Taking, Differentiation of Self From Fetus, Interaction With Fetus,
Attributing Characteristics to the Fetus, and Giving of Self. The original validation of
the questionnaire had a coefficient of reliability of 0.85 for the overall questionnaire,
with reliability of the subscales ranging from 0.52 to 0.73. The questionnaire has
adequate psychometric properties. It has been used in at least 50 studies of Maternal-
Fetal Attachment, including one study relating ultrasound scans to maternal-fetal
attachment (Heidrich and Cranley, 1989). Changes of scores in the MFAS before and
after an ultrasound examination indicate changes in maternal-fetal attachment.
Another instrument for measuring MFA, Prenatal Attachment Inventory was
developed by Muller (Muller, 1990). The 29 items of this instrument were designed to
measure affectionate attachment or the personal relationship that develops during
pregnancy between mother and fetus.
Of these described instruments, Cranley‟s MFAS is the most commonly used scale
(Laxton-Kane & Slade, 2002).
12
2.3 MATERNAL HEALTH PRACTICES
The concept of health practices in pregnancy is based on Lindgren‟s predictive model
of health practices (Lindgren, 2001). Lindgren defined maternal health practices as
actions a woman takes during pregnancy that affect her health, the health of the fetus,
and later infant outcomes. Positive health practices include proactive measures such
as seeking prenatal care, eating well, gaining the recommended amount of weight,
obtaining dental care, and abstaining from tobacco, illegal drugs, and alcohol.
Research suggests that Maternal-Fetal Attachment is positively associated with
maternal health practices, neonatal outcomes, and possibly, maternal-infant
attachment. There is also evidence that maternal health practices are associated with
neonatal, childhood, and adult health outcomes. Failure to follow positive health
practices are known to contribute to negative perinatal outcomes (Haslam &
Lawrence, 2004; Jaakkola & Gissler, 2004; Jesse & Reed, 2004; Lindgren, 2005).
2.3.1 Maternal Dietary Habits
The ability of a mother to provide nutrients for her baby depends on her nutritional
status, body size, body composition and metabolism, all of which are being
established throughout the mother‟s own fetal life, childhood and adolescence
(Martin-Gronert and Ozanne, 2006). Brown emphasizes the essential importance of
nutrition in research that suggests “The aspects of nutrition may play a greater role in
immediate and long term health of offspring than was thought previously “ (Brown &
Kahn, 1997). The increased and strengthened maternal-fetal bond that results from the
viewing of the obstetric ultrasound has proven to be beneficial by reducing potentially
harmful maternal behaviour. It has been suggested that this enforced relationships
13
prenatally and could enhance relationships postnatally, all of which are vital for a
normal healthy child in the development of a sense of himself (Berman & Cohen,
1997). While using ultrasound as a tool to sway the mother‟s behavior could be
interpreted as ethically questionable, suggestions have been written by researchers.
They relate the theory that all pregnant women should have high-feedback fetal
sonography to influence parental adherence to prenatal care (Bralow, 1983). Facello
(2008) argued that antenatal attachment influences maternal health practices. The
educational process involved in fetal sonography can assist with improved nutrient
intake. Women who are less attached to their fetus may have more difficulty
following through on these pregnancy-related health practices, and thus may place
more emphasis on the role of powerful others and chance on determining the outcome
of their pregnancy. Women who are less attached to their fetus may have more
difficulty following through on these pregnancy-related health practices, and thus may
place more emphasis on the role of powerful others and chance on determining the
outcome of their pregnancy (Shelley and Turriff-Jonasson,2004).
2.3.2 Effect of Alcohol Use in Pregnancy
Alcohol has long been associated with adverse fetal outcomes. The association
between consumption of large amounts of alcohol and/or use of drugs during
pregnancy and adverse fetal outcomes is well documented (Shu, et al, 1995). Alcohol
is a teratogen (Vorhees and Mellnew, 1987). There has been no teratogenic agent yet
studied in man which has shown a clear threshold effect, where the substance could
be considered safe at a particular level, beyond which its teratogenic effect begins to
take hold, and the alcohol is no exception (Smith ,1979). Alcohol is a low molecular
substance and is therefore quite capable of crossing the placental barrier and entering
14
the fetus, causing the level of alcohol in the fetus to be approximate to that of the
mother. Adverse health effects that are associated with alcohol exposed pregnancies
include miscarriage, premature delivery, low birth weight, sudden infant syndrome,
and prenatal alcohol – related conditions such as fetal alcohol syndrome. Fetal alcohol
syndrome is one of the leading causes of mental retardation, and is directly attributed
to drinking during pregnancy. Fetal alcohol syndrome is characterized by growth
retardation, facial dysfunction such as learning abnormalities and low intelligent
Quotient (IQ) as well as behavioural problems. The dangers of drugs and alcohol goes
back to the times of the early Greeks and Romans who noted that “mothers who were
heavy drinkers bore a much higher rate of deformed and sickly children.
The harmful changes these substances can produce in the unborn‟s environment may
make him fearful. The unborn is most vulnerable to their (drugs) toxic effects early in
pregnancy and that even small amounts of any drug, including common over-the-
counter ones such as aspirin, can be harmful to him (Verny & Kelly, 1981,).
Indigenous Nigerian societies discourage alcohol consumption among women, yet
international trends show alcohol consumption increasing in populations of
developing countries, especially among women. A research carried out, examined the
pattern of alcohol consumption among women in the rural town of Igbo-Ora, located
in the southwestern state of Oyo in Nigeria. A majority of the 300 respondents (64%)
were found to have tasted alcoholic beverages, and over half of these reported current
alcohol use. Current drinkers reported consuming an average of 1.3 bottles (60cl per
bottle) of alcoholic beverage in the week preceding the survey.
15
Short-term effects on maternal health behaviors, including less smoking, less drinking
of alcohol, and more visits to dentists, were detected in a randomized trial when
detailed information was given during ultrasound scan. This trial also suggested that
women's anxiety was actually increased during scans, and then allayed by positive
feedback. ( Albertsen, et al,2003).
2.3.3 Antenatal Care
Appropriate antenatal care services promote safe motherhood and delivery with
improved maternal and neonatal outcome (Awusi et al, 2009). Various studies have
confirmed the positive influence of antenatal care on maternal and perinatal outcomes
irrespective of other maternal characteristics, such as age and parity (Harrison, 1988;
de Jong et al, 1988; Onwudiegwu, 1997; Ekwempu, et al, 1990). Observational
studies support the fact that good quality antenatal care improves pregnancy outcome
and can reduce many risks of death, sickness, and disability for both mothers and
infants ( Kogan et al,1994; Malloy et al 1992; Mustard and Ross 1994). Antenatal
care has therefore been noted to have great potential in recognising the risk mothers
and signs of danger in time so that the lethal complications can be avoided (Lindroos,
2004), yet many women do not attend in Nigeria (Adekanle, 2008). This most often
results in high maternal mortality figures and rising perinatal mortality rates
(Nylander and Adekunle, 1990). The root causes of poor acceptance of antenatal care
with the concomitantly high maternal and perinatal mortality rates include pervasive
poverty, the subordinate role of our women, low literacy levels and the nonexistent
social systems in most developing countries (Adekunle, 1999). Intensive nutritional
education during visits to antenatal clinics is advocated to correct erroneous beliefs
(Jinadu et al, 1983). Obstetric ultrasonography, unarguably, is an important aspect of
16
antenatal care. Antenatal care forms the foundation of all health care. The medical
circumstances of both predict not only immediate neonatal outcome but also long-
term outcome, including intelligent quotient and school performance (McDuffle,
1997).
From the reviewed literature, no work to my knowledge has been done as regards the
influence of the educational process during routine obstetric ultrasound on Maternal –
Fetal Attachment in our own locality. Also documentation on the influence of the
educational process during routine obstetric ultrasound on maternal behaviours like
maternal nutritional/dietary habits, intake of alcohol and compliance with antenatal
drugs and care, is of great importance.
17
CHAPTER THREE
3.0 RESEARCH METHODOLOGY
3.1 RESEARCH DESIGN
This research is a prospective and cross-sectional study.
3.2 POPULATION, SAMPLE AND SAMPLING PROCEDURE
3.2.1 Area of Study
This study was carried out at the University of Nigeria Teaching Hospital (UNTH),
Ituku Ozalla, Enugu.
3.2.2 Target Population
The study includes women between 16-30 weeks of normal singleton pregnancy who
met the selection criteria. This centre was chosen because of its good/proper record
keeping and also relatively low cost of the examination. Also pregnant women were
readily available for scan on daily basis. The gestation age range was chosen because
the anatomical survey of the fetus is established at this time. The subjects supplied the
date of their Last Menstrual Period (L.M.P) while the researcher subsequently
confirming it by scan.
3.2.3 Subject Selection Criteria
Inclusion Criteria
Pregnant women: -
Within 16– 30wks GA
18
With no history of maternal illness.
With singleton pregnancy
Multigravidas – i.e. women who have been pregnant before with their
child/children alive.
Had no complication during pregnancy.
Exclusion Criteria
Pregnant women with mental illness or any other psychological dysfunctions
that may affect relationship.
Women with multiple pregnancies.
Women who waited for long before first conception.
Primigravidas.
It was assumed that these last two groups above would naturally be attached to their
fetus.
3.2.4 Sample Size
For the purpose of this study a survey was conducted at the scan centre and it was
observed that 20% of referrals come for obstetrics scan. Hence 0.2 was used as our
population proportion.
Therefore sample size, n, was derived as follows
n = 2
2)1(
d
ppZ, for a finite population, Colditz et al(1994)
Where n = Sample size
19
Z = 1.96 at 95% confidence interval
d = limit of sampling error
= 5% = 0.05
P = population proportion.
n = 246)05.0(
)2.01(2.0)96.1(
2
2
Boukydis (2002) used a sample size of n = 24, Durbin (1999), used a sample size of n
= 61. Thus a sample size of 300 patients was chosen for this study which is greater
than the minimum sample size of 246 and this will reduce sampling error. 300 women
that met the inclusion criteria were recruited for the study.
3.2.5 Sampling Technique
A convenient sampling was used to enlist subjects into the study. As they reported for
scan, the researcher enlisted as many as met the inclusion criteria and were also
willing to participate.
3.3 ETHICAL APPROVAL AND PROTECTION OF RIGHTS OF
SUBJECTS
Consideration was given to the protection of the participants' rights. Prior to data
collection, the research proposal was reviewed and approved by the University of
Nigeria Hospital Research Ethics Committee (See Appendix F). Participation in the
study was voluntary. The purpose and value of the study, as well as the role of the
participant in the study was explained to her. The consent form (see Appendix E) also
20
explained that participants were free to discontinue participation in the study at any
time without jeopardizing in any way their relationship with the clinicians, nurses,
sonographer and/or institution involved. Participants were assured of confidentiality
as all data were obtained using a coding system which was accessible only to the
researcher. In addition, they were informed that results would be reported as group
norms, the researcher would be the only person to have access to the completed
questionnaires, and questionnaires would be destroyed upon the study's completion.
The participants signed the informed consent form before any data was collected.
3.4 METHOD OF DATA COLLECTION
A pilot study was conducted with 10 subjects to determine the length of time for
completion of the questionnaires and to identify any potential problems which might
occur during the data gathering process. Subjects in the pilot study experienced no
difficulties in understanding the instructions on completing the questionnaires.
Therefore, no changes were made in the questionnaires or in the procedure.
3.4.1 EQUIPMENT
This 2-Dimensional ultrasonography was performed using a real time ultrasound unit
(Sonoline, SL-1; 1989; Japan.), with a 3.5 MHz sector probe and 5 MHz linear probe.
3.4.2 Instruments Used For Data Collection
1. Demographic data questionnaire
This was developed by the researcher to collect the personal data of the participants
which include age, marital status, ethnicity, religion, level of education attained,
monthly income, number of pregnancies, number of children alive, planned or
21
unplanned pregnancy, gestation age, history of miscarriage, history of child with birth
defect and fetal movement. Participants just answered by checking lists or filling in
the blanks. See the Demographic Questionnaire in Appendix C.
2. Cranley Maternal-Fetal Attachment Scale (MFAS)
This scale developed by Cranely (1981), consists of 24 individual items relating to
maternal-fetal attachment during pregnancy on a 5-point likert scale of Definitely yes
(5), yes (4), uncertain (3), No (2), Definitely No (1), with a score of 5 having the
highest attachment. All statements were positive except “item 22”. A coefficient of
reliability of .85 was established for the scale with the reliability of the subscales
ranging from .52 to .73. No modification was done on the original MFA scale as the
researcher found it suitable for our environment. This was distributed and filled by the
respondents twice immediately before and after the ultrasound scan. The five
subscales of the Maternal-fetal Attachment Scale with the individual items that make
them up are: role-taking, differentiation of self from the fetus, giving of self,
attributing characteristics and intentions to the fetus and interaction with fetus. See the
Maternal-Fetal Attachment Scale in Appendix B
3. The Health-Habit Questionnaire (HHQ)
This is a researcher-developed questionnaire which was used to collect data. It
consists of 19 items generally relating to dietary habits, alcohol consumption and
general antenatal care. The HHQ was validated by experts in the department of
Nutrition and dietetics. This was distributed before scan and 4 weeks after the
ultrasound scan- to know if the difference in the mother‟s health habit is significant.
The 4 weeks interval was necessary according to (Durbin, 1999) to ensure there
22
would have been enough time to appreciate a change, if any, in the maternal health
practice (Durbin, 1999).
3.4.3 PROCEDURE FOR DATA COLLECTION
To maintain anonymity and consistency, a sequential ID number was written on each
completed questionnaire received both for pre- and post- questionnaires. Thus, there
was no way to link a questionnaire to the individual person. Questionnaires were
reviewed to verify that inclusion criteria were met and recruitment of participants was
suspended when 300 questionnaires were filled and returned. The data collection
procedure was as follows: The patient comes into the reception and is dully registered.
The potential participants were approached and informed about the purpose and the
significance of the information that was being sought for. This would encourage good
compliance and follow-up. The participants who agreed to participate in this study
were now given the consent form to fill. While the participants were taking water to
fill their bladder in readiness for the scan, the demographic questionnaires, the pre-
MFA scale and the pre-HHQ were distributed to them. This process of filling the
questionnaires took approximately 10 minutes. The researcher was available for
clarification if any participant did not understand any part of the questionnaire. The
participants returned the completed questionnaires and were then taken in for their
ultrasound examination. The patient lies on the couch for the ultrasound examination.
The measurement of the fetal parts was then taken as well as the rest of the
information needed by the obstetrician/ clinician that referred her for the scan. The
fetal ultrasound image was then explained and discussed with the mother familiarising
her with the basic anatomy of the fetus by pointing out some of the physical features
and organs of the fetus like the head, face, limbs, heart etc. Conversation between the
23
mother and the sonographer is encouraged by the latter allowing the mother-to-be
(and father-to-be, if he was there) to ask questions. This extra procedure took about 3
minutes for each participant. It is this learning process the mother undergoes about
the fetus and the scan in general that we call the „Educational Process‟. This
educational process was standardised in the sense that the explanation and discussion
of the fetal image to the mother was the same for all the subjects, to ensure
uniformity. The participants filled the Post-MFA questionnaire immediately after the
ultrasound examination and were reminded that they would be required to fill the
post-HHQ 4 wks after. The participants either preferred to come back to the
ultrasound centre or drop an address to locate them with, for the filling of this follow-
up questionnaire. It would be noted here that while some of the post-HHQ
questionnaires were not completed, others were not well completed and therefore
were discarded. A total of 300 questionnaires were distributed out of which eleven
(11) were not adequately filled. Therefore, two hundred and eighty nine
questionnaires were properly completed and returned.
3.5 DATA ANALYSIS
Data was categorised according to age, educational level, marital status, gestational
age, planned/unplanned pregnancy, MFA scores, Nutritional/dietary habits etc.
Percentage responses, mean scores and standard deviation of demographic data, MFA
score, maternal nutritional/ dietary habits, alcohol intake and compliance with
antenatal drug and care scores were calculated. The total MFA score for each subject
was calculated resulting in potential total MFA scores for the scale ranging from 24-
24
120. The MFAS was further categorised into 5 subscales and the mean score of each
subscale calculated.
Interpretation of the MFA Scores (Cranley, 1981):
Scores of 24.00- 43.00(mean scores of 1.0000-1.7917) means very low
MFA.
Scores of 43.01- 62.00(mean scores of 1.7921-2.5833) means low MFA
Scores of 62.01- 81.00(mean scores of 2.5838-3.3750) means Fair MFA
Scores of 81.01- 100.00 ( mean scores of3.3754-4.1671) means high MFA
Scores of 100.01- 120.00( mean scores of 4.1671-5.0000) means very high
MFA.
Paired t-test was then used to compare the pre- and post- mean values. Analysis Of
Variance (ANOVA) was used to compare the values of more than two means. Chi-
square was used to compare frequencies of more than one group. These data were
analyzed tested for possible statistical significance at p<0.05 using the SPSS 15.0
version program.
An increase in the nutritional status/dietary habits mean scores would interpret a
positive change. A decrease in the alcohol intake mean scores would interpret a
positive change. An increase in the compliance to antenatal care would interpret a
positive change.
25
CHAPTER FOUR
4.0 PRESENTATION OF RESULTS
4.1 Maternal Demographic and Clinical Data
Most of the respondents were 25 – 29 years age group and married. 75.8% of the
respondents were Igbos while 52.6% attained tertiary education as shown in table 1
below.
Table 1: Maternal Demographic Characteristics
S/N Characteristics Sub groups/ Types Number of
respondents
Percent (%)
1. Maternal Age < 19yrs
20-24 yrs
25 - 29yrs
30 - 34yrs
35-39yrs
>40 yrs
7
41
150
66
23
2
2.4
14.2
51.9
22.8
8
7
2. Marital Status Single
Married
Divorced
Engaged
36
201
5
47
12.5
69.6
1.7
16.3
3. Ethnicity Igbo
Yoruba
Hausa
Others
219
30
18
22
75.8
10.4
6.2
7.6
4. Level of Education Nil
Primary
Secondary
Tertiary
3
36
98
152
1.0
12.5
33.9
52.6
5. Monthly Income less than N10,000
N10,000 - N50,000
N60,000 - N100,000
> N100,000
80
100
90
19
27.7
34.6
31.1
6.6
6. Religion Christianity
Islam
Others
255
30
4
88.2
10.4
1.4
26
The maternal clinical characteristics are presented in Table 2. 31.8% of the
respondents had three pregnancies. The gestational ages of the respondents were
evenly distributed between 21-25wks and 26-30weeks. 61.2% of the respondents had
their pregnancy planned while 63.3% had felt their fetus move.
Table 2: Maternal Clinical Characteristics
S/N Characteristics
Sub Groups/ Types No. of
Respondents
Percent
(%)
1. Number of pregnancy 2
3
4
5
>5
83
92
72
32
10
28.7
31.8
24.9
11.1
3.5
2. No. Of Children alive 1
2
3
4
>4
58
72
56
62
41
20.1
24.9
19.4
21.5
14.2
3. Gestation Age: 16 - 20 wks
21 - 25 wks
26 - 30 wks
94
90
105
32.5
31.1
36.3
4. Planning of pregnancy: Planned
Unplanned
177
112
61.2
38.8
5. History of miscarriage Yes
No
53
236
18.3
81.7
6. Child With Birth Defect Yes
No
18
271
6.2
93.8
7. Fetal Movement Yes
No
Not sure
183
76
30
63.3
26.3
10.4
27
4.2 MFA SUBSCALES SCORES
The mean and standard deviation on the five subscale scores of the MFA scale (pre-
test and post-test ) were calculated for the total group of respondents. The highest
mean scores appeared to be in the subscale of „Giving of self to the fetus‟. The
subscale with the least mean scores in both the pre-test and the post-test was in the
area of interaction with fetus. Increases in the mean scores were found in almost all
the sub scales with marked increase in the areas of „Attributing characteristics to the
fetus‟ and „Roletaking‟ as seen in Table 3.
Table 3: Total Subscale Scores of Cranley Maternal-Fetal Attachment
Subscales of MFA No. Of
respondents
Mean:
pre-test(S.D)
Mean:
post-test(S.D)
1. Roletaking 289 3.40(0.45)
4.24(0.44)
2. Differentiation of self
289 3.83(0.50) 3.90(0.43)
3. Interaction with the fetus 289 2.27(0.43)
2.74(0.56)
4. Attributing Characteristics
to the fetus
289
2.95(0.39)
3.28(0.40)
5. Giving of self 289 4.25(0.40)
4.55(0.26)
Total MFA 289 3.34(0.18)
3.74(0.20)
Statistical analysis was applied using Analysis Of Variance (ANOVA), in relation to
on the Maternal – Fetal Attachment pre-test scores. The result shows that maternal
28
age, marital status, education level, number of pregnancy, number of children,
gestational age, religion, ethnicity, and monthly income had no significant
influence(p>0.05) on the pre-MFA scores as shown in table 4.
Table 4: ANOVA Test on Pre- MFAS in relation to Maternal Characteristics
Maternal Characteristics ANOVA F-value
p-value
Age
1.91 0.09
Marital Status
1.09 0.35
Ethnicity
0.19 0.90
Education Level
0.82 0.49
Monthly Income
0.06 0.98
Religion
1.55 0.21
No. Of pregnancy
0.61 0.66
No. Of Children
1.00 0.41
Gestation Age
0.48 0.62
Fetal Movement
0.89 0.41
*p> 0.05
Paired t-tests on the MFA subscales and the total attachment score showed marked
significant differences in all the subscales (p=0.00) except that of differentiation of
self (p=0.08). See Table 5.
29
Table 5: Paired t-tests on MFA Subscales
Subscales of MFA No. Of
Respondents
Mean:
pre-test(S.D)
Mean:
post-test(S.D)
t-value p-value
1. Roletaking 289 3.40(0.45)
4.24(0.44) -22.18 0.00
2. Differentiation of
self
289
3.83(0.50)
3.90(0.43)
-1.75
0.08
3. Interaction with
the fetus
289
2.27(0.43)
2.74(0.56)
-13.15
0.00
4. Attributing
Characteristics
to the fetus
289
2.95(0.39)
3.28(0.40)
-9.90
0.00
5. Giving of self 289 4.25(0.40)
4.55(0.26) -10.86 0.00
4.3 TEST OF HYPOTHESIS ONE ((H0)1)
(H0)1: The educational process involved in obstetric ultrasound examination has no
significant influence on maternal-fetal attachment.
(H1)1. The educational process involved in obstetric ultrasound examination has a
significant influence on maternal-fetal attachment.
30
TEST FOR POSSIBLE DIFFERENCES BETWEEN THE MEAN SCORES OF
THE PRE- AND POST-MFA MEAN SCORES.
The MFA pre-test mean score was 3.34±0.18 while the post-test mean score was
3.74±0.20. Paired t-test showed a significant difference (p<0.05) between the pre-test
mean score and the post-test mean as in table 6.
Table 6: Paired sample t-test on MFA total pre- and post- mean scores
MFA Mean(S.D) t-value Sig.(2-tailed)
Pre-test
Post-test
3.34(0.18)
3.74(0.20)
-25.27
0.00
Therefore, the null hypothesis is rejected and the alternative which states that the
educational process involved in routine obstetric ultrasound examination has
significant influence on maternal-fetal attachment, accepted.
4.4 MATERNAL NUTRITIONAL STATUS/DIETARY HABITS
Tables 7 and 8 represent the respondents‟ nutritional status/dietary habits both prior to
the ultrasound (pre-test) and after the ultrasound (post-test).
31
Table 7: Pre- and Post Nutritional Status of Respondents
Health-Habit Item No. of
Respondents
(pre-test)
Percent
(%)
No. of Respondents
(post-test)
Percent
(%)
1. Start day with
adequate meal Yes
No
269
20
93.1
6.9
283
6
97.9
2.1
2. How soon after
waking is the meal
taken: 30mins-1hr
1-2hrs
2-3hrs
3-4hrs
28
78
111
52
10.4
29
41.3
19.3
47
145
62
29
16.6
51.2
21.9
10.2
3. How often this
meal is taken
weekly: Rarely or never
2-3 times per week
4-5 times per week
Almost always
93
96
58
42
32.2
33.2
20.1
4.5
39
88
61
101
13.5
30.4
21.1
34.9
4. Eat a variety of
food from all basic
food groups: Yes
No
77
212
26.6
73.4
145
144
50.2
49.8
5. Fraction of
nutrition you
perceive you get:
0-¼
¼ -½
½-¾
¾-1
60
77
97
55
20.8
26.6
33.6
19.0
18
38
146
87
6.2
13.1
50.5
30.1
6.Rate nutritional
intake: worse than usual
no change
better than usual
exceptional
90
67
107
25
31.1
23.2
37.0
8.7
29
41
156
63
10.0
14.2
54.0
21.8
32
Table 8: Pre- and Post- Maternal Dietary Habits
Health-Habit Item No. of Respondents
(pre-test)
Percent
(%)
No. of Respondents
(post-test)
Percent
(%)
7.Amount of milk/product
consumed daily:
60mls
120mls
240mls
480mls
88
91
68
42
30.4
31.5
23.5
14.5
77
116
77
19
26.6
40.1
26.6
6.6
8.Amount of fruits taken daily:
0-1 servings
2-3 servings
4-6 servings
7 or more servings
130
88
62
9
45.0
30.4
21.5
3.1
71
135
71
12
24.6
46.7
24.6
4.2
9.Amount of vegetables taken
daily:
0-1 servings
2-3 servings
4-6 servings
7 or more servings
61
151
70
7
21.1
52.2
24.2
2.4
9
198
66
16
3.1
68.5
22.8
5.5
10.Cereals taken daily:
Bread
wheat/products
Maize/products
Rice/products
Others
41
35
69
134
10
14.2
12.1
23.9
46.4
3.5
43
20
78
139
9
14.9
6.9
27.0
48.1
3.1
11.Amount of cereal taken:
1-2 slices/0-1 med.bowl
3-4 slices/2-3 med.bowl
5-6 slices/4-5 med.bowl
>6 slices
101
132
51
5
34.9
45.7
17.6
1.7
86
148
49
6
29.8
51.2
17.0
2.1
12.Amount of meat,
fish/alternatives taken daily:
0-30g
60-90g
120-150g
270g
129
116
41
3
44.6
40.1
14.2
1.0
38
176
68
7
13.1
60.9
23.5
2.4
33
4.5 TEST OF HYPOTHESIS TWO (H0)2)
(H0)2. The educational process involved in routine obstetric ultrasound examination
does not have any significant influence on the maternal nutritional/dietary
habits.
(H1)2. The educational process involved in obstetric ultrasound examination has any
significant influence on the maternal nutritional/dietary habits.
TEST FOR POSSIBLE DIFFERENCES BETWEEN THE PRE- AND POST-
NUTRITIONAL/DIETARY STATUS.
Tables 9 and 10 present the statistical change in maternal behaviour involving
nutrition. The Health Habit questions 5,7,8,9 and 12 (see Appendix D) were analysed
using t-test (pre- and post-test design).This test looks at the differences between the
pre-test and post-test data. Statistical significance was noted in “percentage of
nutrition you perceive you get” (p =0. 00), “amount of fruits taken daily” (p =0.00),
“amount of vegetable taken daily”(p=0.00) and “amount of meat, fish/alternative
taken daily”(p=0.00).There was no significant difference in question 7 (“number of
servings of milk or milk products daily”) (p=0.17) even though there was a slight
improvement in milk intake. Item 11, (“amount of cereal taken”) showed no
significant difference (p=0.13) between the pre- and post-scan response. Table 10
shows the statistical analysis of Health Habit Questions 3, 4 and 6 by Chi square. All
items showed significant differences between the pre- and post- responses.
34
Table 9: t-test of the Pre- and post-Maternal nutritional/dietary status.
Health-Habit Item Mean(S.D):
Pre-test
Mean(S.D):
Post-test
t-value p-value
5.Fraction of nutrition you
perceive you get:
2.51(1.02) 3.04(0.83) -9.35 0.00
7.Amount of milk/product
consumed daily:
2.22(1.04) 2.13(0.88) 1.38 0.17*
8.Amount of fruits taken
daily:
1.83(0.87) 2.08(0.81) -6.18 0.00
9.Amount of vegetables
taken daily:
2.08(0.74) 2.31(0.62) -6.91 0.00
11.Amount of cereal taken:
1.86(0.76) 1.91(0.74) -1.53 0.13*
12.Amount of meat,
fish/alternatives taken
daily:
1.72(0.74) 2.15(0.67) -14.72 0.00
*p=Not significant
Table 10: Statistical Analysis of Health Habit Questionnaire using chi-square.
Health-Habit Item Chi-square value Df p-value
3. How often this meal is taken
weekly.
46.90
3
0.00
4. Eat a variety of food from all
basic food groups:
33.80
1
0.00
6. Rate nutritional intake: 63.10 3 0.00
Therefore, the null hypothesis, (H0)2, is rejected which states that the educational
process involved in obstetric ultrasound examination does not have any significant
influence on the maternal dietary habits.
35
Table 11 indicates the respondents‟ alcohol consumption assessment, both pre- and
post-test. Appreciable reduction, in valid percent, was seen in the respondents who
take alcohol from the pre-test to the post-test. A change, increase in valid percent was
also seen in the respondents who do not take alcohol. On the amount of alcohol taken
each week, the number of respondents who indicated to have consumed 4 or more
servings of alcohol reduced from 71.4% to 10.7%, while the number who consumed 3
or less servings increased from29.1% to 89.3%. On the respondents attempt on
changing health behaviour in relation to alcohol, the respondents who disagreed with
the statement: “Tried everything possible to reduce alcohol consumption”, increased
from 63.7% to 83.9% whereas those who agreed with it reduced from 36.4% to 16.1%
after the scan.
Table 11: Maternal Alcohol Consumption
Health-Habit Item No. of
Respondents
(pre-test)
Percent
(%)
No. of
Respondents
(post-test)
Percent
(%)
13. Do you take alcohol? Yes
No
110
179
38.1
61.9
56
233
19.4
80.6
14.Amount of alcohol taken: 1-3 servings
4-6 servings
7-9 servings
>9 servings
32
48
21
9
29.1
43.6
19.6
8.2
50
5
1
-
89.3
8.9
1.8
-
15.Tried everything possible to
reduce alcohol consumption: strongly disagree
somewhat disagree
somewhat agree
strongly agree
28
42
21
19
25.5
38.2
19.1
17.3
20
27
6
3
35.7
48.2
10.7
5.4
36
4.6 TEST OF HYPOTHESIS THREE (H0)3)
(H0)3. The educational process involved in obstetric ultrasound examination does
not have any significant influence on the maternal intake of alcohol.
(H1)3. The educational process involved in obstetric ultrasound examination has any
significant influence on the maternal intake of alcohol.
Tables 12 and 13 demonstrate the statistical change in maternal behaviour involving
alcohol consumption. The Health Habit question 14 was analysed using t-test (pre-
and post-test design). Statistical significance was noted (p=0.000). Table 14 shows
the statistical analysis of Health Habit Questions 13 and 15 by Chi square. The two
items showed significant differences between the pre- and post- responses.
TEST FOR POSSIBLE DIFFERENCES BETWEEN THE PRE- AND POST-
ALCOHOL CONSUMPTION STATUS.
Table 12: t-test of the Pre- and post-Maternal alcohol consumption status
Health-Habit
Item
Mean(S.D)Pre-test Mean(S.D)Post-test t-value p-value
14. Amount of
alcohol taken:
1.52(0.63)
1.13(0.38)
4.96
0.00
37
Table 13: Chi-square test of the Pre- and post-Maternal alcohol consumption
status
Health-Habit Item
Chi-square value Df p-value
13. Do you take alcohol?
25.2 3 0.00
15. Tried everything possible to reduce
alcohol consumption.
7.83
3
0.05
The null hypothesis, (H0)3, which states that the educational process involved in
obstetric ultrasound examination does not have any significant influence on the
maternal intake of alcohol, is therefore rejected.
Table 14 shows the respondents antenatal care compliance. 44.6% attended antenatal
clinics prior to the ultrasound exam while 78.5% attended one month after. 29.4% of
the respondents did not attend antenatal clinics prior to the ultrasound exam while
12.5% of them attended one month after. The number of respondents who were not
regular with antenatal visit reduced from 75 to 26. There was appreciable increase in
the use of prenatal vitamins and nutritional supplement. The respondents who took
herbal drugs reduced from 41 to 15. Prior to the test, 197 respondents took drugs that
were not prescribed by their doctor while the number reduced to 96 after the test. 92
respondents did not take drugs that were not prescribed by their doctor prior to the test
while 193 did not take drugs that were not prescribed by their doctor.
38
Table 14: Antenatal Care Compliance
Health-Habit Item Frequency
(pre-test)
Percent (%) Frequency
(post-test)
Percent (%)
16. Do you attend your
antenatal classes: Yes
No
Not always
129
85
75
44.6
29.4
26.0
227
36
26
78.5
12.5
9.0
17. Drugs taken during this
pregnancy: Vitamin/haematinics
Nutritional supplement
Herbal drugs
193
55
41
66.8
19.0
14.2
210
64
15
72.7
22.1
5.2
19. Take drugs that were not
prescribed by doctor: Yes
No
197
92
68.2
31.8
96
193
33.2
66.8
TEST OF HYPOTHESIS THREE (H0)3)
(H0)4. The educational process involved in obstetric ultrasound examination does
not have any significant influence on the maternal attitude (compliance) to
antenatal care.
(H1)4. The educational process involved in obstetric ultrasound examination has any
significant influence on the maternal attitude (compliance) to antenatal care.
TEST FOR POSSIBLE DIFFERENCES BETWEEN THE PRE- AND POST-
ANTENATAL COMPLIANCE STATUS.
Table 15 shows statistical analysis of the items relating to compliance with antenatal
care. The result showed that there was significant difference in pre- and post-test
responses in the overall respondents‟ compliance with antenatal care.
39
Table 15: Chi-square test of the pre- and post-Maternal antenatal care
compliance.
Item
Chi-square value Df p-value
16. Do you attend your antenatal
classes:
70.6
2
0.00
19. Take drugs that were not
prescribed by doctor:
70.6
1
0.00
The null hypothesis, (H0)4, which states that the educational process involved in
obstetric ultrasound examination does not have any significant influence on the
maternal attitude (compliance) to antenatal care, is therefore rejected.
40
CHAPTER FIVE
5.0 DISCUSSION
The main purpose of this study was to determine the influence of the educational
process during obstetric ultrasound on maternal-fetal attachment and by implication,
maternal behavioural changes in pregnancy.
There are several key influences that appear to be relevant in influencing maternal-
fetal attachment by using ultrasound, including recognition of the fetal form (Fletcher,
et al, 1983; Boukydis, 1981) which can increase maternal understanding of fetal
behaviour and development, and the ability to reduce maternal anxiety during the scan
(Zlotogorski, et al, 1997) and all these influences seem to play a role in the results of
this study.
The influence of the educational process involved in routine obstetric ultrasound
examination on maternal-fetal attachment: The null hypothesis, (H0)1, for this
study, which states that the educational process involved in routine obstetric
ultrasound examination has no significant influence on maternal-fetal attachment, was
rejected as the findings of this study revealed that the educational process during
obstetric ultrasound positively influenced maternal-fetal attachment. This is made
evident by the fact that the mothers‟ MFA scores increased significantly from a pre-
mean value of 3.34 to Post-mean value of 3.74 with p<0.00. This finding is in
agreement with that of Durbin (1999) who noted that the educational process involved
in routine obstetric ultrasound examination significantly influenced maternal-fetal
attachment. In a study by Kohn, et al (1980), results indicated a significant increase in
maternal-fetal attachment evidenced by questionnaires and interviews. Both verbal
41
and nonverbal responses to an increased awareness of the baby within and its viability
and wholeness were noted.
These authors further concluded that some of the women evidenced attachment
behaviors and the desire to share the experience with others. Since none of the
maternal characteristics appeared to have any significant effect on their MFA scores
as was also seen by Kemp and Page (1987), it can strongly be assumed that the
educational process during ultrasound can explain the change in the MFA scores.
When the individual items of the MFAS were categorised into 5 subscales, all the
subscales except “Differentiation of self from fetus”, showed significant difference in
mean scores after the routine ultrasound examination (p=0.08). The subscale with the
highest post-MFA scores was “Giving of self”. The second and third Subscales with
the highest scores were “Roletaking” and “Differentiation of self from the fetus”. This
result is similar to that of Chanachote‟s (2007) and Kala‟s(2001) who found out that
pregnant women in their 2nd
and 3rd
trimesters demonstrate high MFA scores in the
areas of “Giving of self”, “ Roletaking” and “Differentiation of self from the fetus”.
Similarly, Bloom(1998) who used the same MFA scale to measure maternal-fetal
attachment, found that pregnant women in 2nd
and 3rd
trimesters score high in “
Roletaking” and “Differentiation of self from the fetus”. Durbin (1999) in her findings
noted “ Roletaking”, “Giving of self” and “Differentiation of self from the fetus” in
that order.
The two subscales that were the least scored of MFA scale were “attributing
characteristics” and “interaction with the fetus” although they showed good scores.
This is also consistent with Durbin‟s findings with “attributing characteristics”
42
ranking the least. This may be because some “attributing characteristics and
interaction with the fetus” such as “I poke my baby to get him/her to poke back” and
“I wonder if the baby can hear inside of me” are not usual occurrences. Some women
feared they could hurt their babies if for instance they poked them. Another possible
reason according to Chanachote (2007) was that they felt embarrassed talking to an
unborn baby.
The fetal ultrasound provides a one-to-one consultation focus with the fetus as the
individual and the mother the spokes person. The fetal ultrasound itself is important
because the educational process renders a solace and personal consciousness and
contentment that reaches the mother‟s inner being in addition to the medical benefits
of anatomical survey of the fetus. A greater sensitivity of attachment to the fetus was
felt among mothers who received ultrasound examination that included educational
comments from the sonographer (Kohn, et al, 1980). Further studies showed that
ultrasound exams have a “significant psychological effect on parental attitudes toward
each other and the fetus” (Zlotogorski, et al, 1997). Klaus (1995) stated that scanning
for parental pleasure, i.e. bonding should be considered as a part of the obstetric
ultrasound examination. The scanning for reassurance does not depend on the
ultrasound image per se but on the expectation created and the interpretation put onto
it.
The findings of this study have implications for sonographers as they relate to the
expanding body of knowledge regarding the concept of prenatal maternal attachment.
The sonographer while scanning pregnant women in the prenatal period can take
advantage of these findings to positively reinforce attachment behaviors such as
talking to the fetus and patting the pregnant abdomen to convey caring for the fetus.
43
Thus the sonographer through patient education and anticipatory guidance can help
pregnant women strengthen their feelings and behaviors of attachment to their fetus
and may also serve to enhance other behaviors indicative of maternal-fetal
attachment.
Furthermore, because pregnant women in this study indicated their tendency to
increased maternal-fetal attachment behaviors after the educational process during
their ultrasound examination, this might lead to the reduction of abortion cases.
Maternal Characteristics in relation to MFA: The result of this study revealed that
some maternal characteristics such as age, marital status, level of education, monthly
income, number of pregnancy, gestation age, planned/unplanned pregnancy and fetal
movement had no influence on the maternal responses to MFA items. Maternal age
did not influence MFA scores. This is in line with the finding of Chanachote (2007)
and Facello (2008) but not consistent with that of Durbin (1999), Condon &
Corkindale (1997), Fuller, et al (1993) and Koniak-Griffin (1988). Kemp (1987)
found no significant relationship between the attachment scores and educational level,
age, race and whether the pregnancy was planned or not.
Gestation age did not influence the MFA scores and is consistent with that of Durbin
(1999) and Hjelmstedt, et al(2006). Condon (1993) also found no correlation between
gestational age of pregnancy and antenatal attachment using the MAAS (Condon,
1993). However, Chanachote (2007) found had contrary finding that gestational age
did influence the MFA scores.
Planning of pregnancy also did not influence MFA in this study. This is in congruent
with the results of Jongpranee (1997), Chanachote (2007) and Facello (2008). In
contrast, Bobak & Jensen (1992) found that mothers who planned their pregnancies
44
had higher MFA scores than those who did not. Koniak-Griffin (1998) reported that
planning of pregnancy was the best predictor of MFA in adolescents.
The finding that Income did not affect the respondents MFA scores is consistent with
Cranley (1981) and Chanachote (2007).
The influence of the educational process involved in routine obstetric ultrasound
examination on the maternal dietary habits: The null hypothesis, (H0)2, which
states that the educational process involved in obstetric ultrasound examination has no
significant influence on the maternal dietary habits, was rejected. The educational
process involved in fetal sonography can assist with improved nutrient intake because
nutrition appeared to show marked improvement 4weeks after the ultrasound (Durbin,
1999). This is consistent with this study as majority of the areas involved in the
Health-Habit Questionnaire significantly improved except in the items that addressed
the amount of milk/product consumed daily and amount of cereal taken, with p-values
0.170 and 0.128 respectively though there was improvement in their responses
4weeks after the ultrasound. This could be attributed to the fact that the women‟s
income may not have been able to take care of the extra cost of diary product and
cereal they are expected to consume daily due to the prevailing level of poverty.
Condon & Hilton, (1988) also had findings consistent with that of this study by
stating that antenatal attachment not only influenced positive health practices but also
served to moderate the effects of negative health practices. Women with poorer health
practices also had lower attachment scores than those women with healthier maternal
health practices (Lindgren, 2003).
45
The Health Habit Questionnaire showed no significance in relation to nutritional
status when the subjects were assessed based on age, gestational age, gravid and fetal
movement. This is not congruent with Durbin‟s findings in terms of age. On the
contrary, significance was apparent in some items relating to nutritional status when
the groups were divided by educational level, marital status, planned pregnancy and
monthly income. For instance, applying income, the questions 3(How often adequate
meal(breakfast) is taken weekly) and 8(Amount of fruits taken daily), were
significantly influenced after the ultrasound. This finding is consistent with that of
Durbin (1999). Using marital status, only question 5(Percentage of perceived nutrition
intake) was significantly improved while question 7(Amount of milk/product
consumed daily) only was significantly improved when applied in relation to planning
of pregnancy.
Three areas significantly improved in nutritional status in terms of educational status.
They are items 7, 8 and 12. The finding that maternal health practices especially in
terms of nutrition are positively associated with income and education is supported by
literature (Bowlby, 1969; Huth-Bocks, et al, 2004; Laxton-Kane & Slade, 2002;
Facello, 2008). Level of education is a complex issue, as women who are less
educated tend to be young, single, and of low income. Thus, level of education
implies much more than how much schooling a woman has and provides
opportunities for intervention at many levels including public policy. Providing
opportunities for pregnant women to obtain higher levels of education such as
completing high school or greater is imperative. Education influences pregnancy
health practices by empowering women and thus, impacts future generations. Changes
in maternal health practices may provide opportunities to intervene when women
46
exhibit problems with Maternal Fetal-Attachment. Educating women about positive
health practices may be effective in promoting antenatal attachment.
The influence of the educational process involved in obstetric ultrasound
examination on the maternal intake of alcohol: The null hypothesis was rejected as
the educational process involved in obstetric ultrasound examination had a significant
influence on the maternal intake of alcohol. The finding in this study showed that
there was significant reduction in the intake of alcohol, in respondents who admitted
taking alcohol during pregnancy. This by implication increased the percentage of
those that indicated not to take alcohol. Statistical analysis of item 14, “amount of
alcohol taken” showed a significant reduction (p=0.00) in the number of respondents
who took alcohol, 4weeks after the scan. This is in keeping with Lumley‟s (1990)
finding that revealed short-term effects of ultrasonography on maternal health
behaviors‟ including less smoking, less drinking of alcohol and more visits to the
dentists when detailed information was given to the pregnant women during the scan.
Nabhan and Faris (2010) found that women who had a high feedback during
ultrasound were more likely to stop smoking and to avoid alcohol during pregnancy.
The Health Habit Questionnaire showed no significance in relation to maternal intake
of alcohol when the subjects were assessed based on age, gestational age, gravid,
marital status, educational level, income, planned or unplanned pregnancy and fetal
movement. The researcher may therefore assume that the significant change was
probably due to the high feedback of the ultrasound. The sonographers and health care
professionals play a major role in the impact of the obstetric ultrasound. The
insightful sonographer should therefore, have a firm understanding of human
psychology as well as anatomy and physiology.
47
The influence of the educational process involved in obstetric ultrasound
examination on the maternal attitude to antenatal drug and care: The study
showed that there was significant improvement (p=0.00) in pre- and post-test
responses in the respondents‟ compliance with antenatal care. The null hypothesis,
(H0)4, was therefore rejected. The number of respondents who attended antenatal
classes increased while those who either did not attend or were not regular both
reduced. This agrees with Durbin (1999) who noted that behavioural change that
occurs in the mother during the ultrasound exam can be measured in terms of
improvement in prenatal care following the scan. The improvement in the compliance
of the respondents with antenatal care may be due to their level of education which
influences their level of understanding of the negative implication non attendance
might cause. While it unlikely that this target will be achieved in the short run, the
importance of antenatal visits has to be recognized as a critical part of reproductive
health strategy.
Building on this positive experience for pregnant women of viewing their fetus via
ultrasonography with the educational process that accompanies it, the sonographer
may find this an optimal opportunity also to emphasize other important areas of
maternal health practices such as appropriate dietary habits, avoidance/abstinence of
drugs and compliance with prescribed prenatal visits.
5.1 SUMMARY AND CONCLUSION
The results of the study indicate that:
1. The maternal-fetal attachment is positively influenced by the educational process
that goes on during routine obstetric ultrasound. This research finding supports the
48
fact that maternal-fetal attachment plays an important role in the health of
pregnant women and their unborn babies. Maternal-fetal attachment is an
important component of maternal identity and is essential in promoting healthy
growth and development in children. This finding would add in no small way to
the growing body of knowledge that will help develop interventions specific to
impaired maternal-fetal attachment.
2. Maternal health practices are positively influenced by the educational process that
goes on during routine obstetric ultrasound.
Analyzing maternal-fetal attachment and the educational process that goes on during
obstetric ultrasound, evidence from this study supports the theory that these two
variables are directly related. Mothers demonstrated a higher level of attachment to
their fetus following the educational process during obstetric ultrasound.
Maternal-fetal attachment has been shown to alter maternal life-style and behaviours
thus proving beneficial to the fetus. Quantitative data in relation to nutrition/dietary
habits showed a convincing and significant relationship between the educational
process during obstetric ultrasound and overall maternal health practices.
5.2 RECOMMENDATIONS FOR FURTHER RESEARCH
This research work serves as a preliminary study, which lays the foundation for future
endeavors in this area especially in this locality.
A study that would:
1. Examine the influence of obstetric ultrasound on paternal-fetal attachment
appears important.
49
2. Compare Maternal-Fetal Attachment scores (MFAS) and scores from the
Neonatal Perception Inventory (NPI), a questionnaire designed to measure
mothers‟ perceptions of their infants, to detect significant correlations.
3. Describe the differences between prenatal attachment behaviors of multiparas
who have experienced ultrasonography in a previous Pregnancy and
primiparas who have not had this experience.
5.3 LIMITATIONS OF THE STUDY
The sampling in this study was selected by convenience sampling and therefore
cannot represent general population. Moreover the population is somewhat
homogenous. The majority of the participants were between the ages of 25 and 29,
married, Igbos, Christians, multiparas and who were experiencing planned
pregnancies.
A second limitation related to the large number of multiparas who served as subjects,
is the possibility that they experienced ultrasonography with a previous pregnancy.
Therefore, it is plausible that multiparas' reactions to a second or third
ultrasonography were significantly different from their reactions to the
ultrasonographies experienced with their first pregnancies. Here again, the study did
not control for this variable nor were multiparas asked if they experienced
ultrasonography with a previous pregnancy.
50
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Appendix A
Maternal-Fetal Attachment Scale
Please respond to the following items about yourself and the baby you are expecting.
There are no right or wrong answers. Your first impression is usually the best
reflection of your feelings.
Make sure you mark only one answer per sentence.
I think or do the following: Definitely
Yes
Yes Uncertain No Definitely
No
1. I talk to my unborn baby.
2. I feel all the trouble of being pregnant is worth it.
3. I enjoy watching my tummy jiggle as the baby
kicks inside.
4. I picture myself feeding the baby.
5. I‟m really looking forward to seeing what the
baby looks like.
6. I wonder if the baby feels cramped in there.
7. I refer to my baby by a nickname.
8. I imagine myself taking care of the baby.
9. I can almost guess what my baby‟s personality
will Be from the way he/she moves around.
10. I have decided on a name for a girl baby.
11. I do things to try to stay healthy that I would not
do if I were not pregnant.
12. I wonder if the baby can hear inside of me.
13. I have decided on a name for a boy baby.
14. I wonder if the baby thinks and feels “things”
inside of me.
15. I eat meat & vegetables to be sure my baby gets
a good diet.
16. It seems my baby kicks and moves to tell me it‟s
eating time.
17. I poke my baby to get him/her to poke back.
18. I can hardly wait to hold the baby.
19. I try to picture what the baby will look like.
20. I stroke my tummy to quiet the baby when there
is too much kicking.
21. I can tell that the baby has hiccups.
22. I feel my body is ugly.
23. I give up doing certain things because I want to
help my baby.
24. I grasp my baby‟s foot through my tummy to
move it around.
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Appendix B
Items from the Subscales of Maternal-Fetal Attachment Scale
MFA Subscale Item
Role Taking 4.I picture myself feeding the baby
8. I imagine myself taking care of the baby.
18. I can hardly wait to hold the baby.
19. I try to picture what the baby will look
like.
Differentiation of Self from Fetus 3. I enjoy watching my tummy jiggle as the
baby kick inside.
5. I‟m looking forward to seeing what the
baby looks like.
10. I have decided on a name for a girl
baby.
13. I have decided on a name for a boy
baby.
Interaction with Fetus 1. I talk to my unborn baby.
7. I refer to my baby by a nickname.
17. I poke my baby to get him/her to poke
back.
20. I stroke my tummy to quiet the baby
when there is too
much kicking.
24. I grasp my baby‟s foot through my
tummy to move it
around.
Attributing Characteristics to the Fetus 6. I wonder if the baby feels cramped in
there.
9. I can almost guess what my baby‟s
personality will be from the way she/he
moves around.
12. I wonder if the baby can hear inside of
me.
14. I wonder if the baby thinks and feel
things inside of me.
16. It seems my baby kicks and moves to
tell me it‟s eating time.
21. Can tell that my baby has the hiccups.
Giving of Self 2. I feel all the trouble of being pregnant is
worth it.
11. I do things to try to stay healthy that I
would not do if I were not pregnant.
15. I eat meat and vegetables to be sure my
baby gets a good diet.
22. I feel my body is ugly.
23. I give up doing certain things because I
want to help my baby.
59
Appendix C
DEPARTMENT OF RADIOGRAPHY AND RADIOLOGICAL SCIENCES
FACULTY OF HEALTH SCIENCES AND TECHNOLOGY COLLEGE OF
MEDICINE, UNIVERSITY OF NIGERIA ENUGU CAMPUS
A questionnaire prepared for a research project on “The role of educational
process during routine obstetric ultrasound examination in maternal-fetal
attachment.
All information given by you will be strictly confidential and will never be used
against you, but for the purpose of this research work only. Your name is not required.
Therefore kindly give sincere opinion without bias by ticking [] on the most
appropriate box, if your response is not listed please write it down in the space
provided.
Where necessary, tick more than one option.
1. Age group
A [ ] 15 – 19 yrs B [ ] 20 – 24 yrs
C [ ] 25 – 29 yrs D [ ] 30 – 34 yrs
E [ ] 35 – 39 yrs F [ ] 40 – 44 yrs
2. Marital status
A [ ] single B. married
C [ ] Divorced D. Others, specify ------------------------------
3. Ethnicity (if Nigerian)
A [ ] Igbo B. [ ] Yoruba
C [ ] Hausa D. Others, specify --------------------------------------
4. Level of education attained: -
A [ ] No Education B [ ] Primary Education
C [ ] Secondary Education D [ ] Tertiary Education
E Others, specify ---------------------------------------------------------------------------
5. Monthly income:
A [ ] < N10,000 B [ ] N10,000-N50,000
C [ ] N60,000-N100,000 D [ ] Others specify..................
6. Religion
A [ ] Christianity B [ ] Islam
C [ ] Traditional E [ ] Others, specify ------------------------------------------
60
7. Number of pregnancy?
A [ ] 1ST B [ ] 2ND C [ ] 3RD
D [ ] 4TH E. [ ] Others, specify.
8. How many children do you have?
A [ ] 1 B [ ] 2 C [ ] 3
D [ ] 4 E. Others, specify.
9. When was your last menstrual period (L.M.P) -------------------------------------------
10. Was this a planned pregnancy?
A. [ ] Yes B. [ ] No
11. Have you had a child with a birth defect or genetic problem?
A. [ ] Yes B. [ ] No
12. If yes, “10” above, please describe ---------------------------------------------------------
13. Have you felt this baby move.
A. [ ] Yes B. [ ] No
61
Appendix D
HEALTH-HABIT QUESTIONNAIRE
This section is about your usual eating habits:
1. What foods do you usually take for breakfast?
---------------------------------------
2. How soon after waking up do you usually take this meal:
A [ ] 30 mins-1hour B [ ] 1-2hours
C [ ] 2-3hours D [ ] 3-4hours
3. How often in the week do you take any of the above meals?
A [ ] rarely or never
B [ ] 2-3 times per week
C [ ] 4-5 times per week
D [ ] Almost always.
4. Do you feel you eat a variety of foods from all the basic food groups each
day?(show leaflet on food square)
A. [ ] Yes B. [ ] No
5. What fraction/percentage of daily nutrition needed for good health for you and
your baby do you perceive you eat?
A. [ ] 0-1/4(0 – 25%) B. [ ] 1/4-1/2 (26 – 50%)
C. [ ] ½-3/4(50 – 75%) D. [ ] 3/4-1(75 – 100%)
6. How would you rate your food intake during the past month as compared to
normal?
A. [ ] Worse than usual B. [ ] No change
C. [ ] Better than usual D. [ ] Exceptional
7. What amount of milk/dairy products do you consume daily? (show cup)
A. [ ] ¼ cup(60mls) B.[ ] ½ cup(120mls) C.[ ] 1 cup(240mls) D.[ ] 2
cups(480mls)
8. What amount of fruits do you eat daily? (show picture and leaflet on food square)
A. [ ] 0 -1 B. [ ] 2- 3 C. [ ] 4 – 6 D. [ ] 7 or more
9. What amount of vegetables do you eat daily?(show picture and leaflet on food
square)
A. [ ] 0 -1 B. [ ] 2- 3 C. [ ] 4 – 6 D. [ ] 7 or more
10. Which of these cereals do you take on an average day?
A. [ ] Bread B. [ ] Wheat and its product C. [ ] maize and its products
D. [ ] Rice and its product E. [ ] Others specify
62
11. What amount of the said cereal do you consume on an average day?(show sample)
--------------------------------------------
12 On the average, what amount of meat, fish, or alternatives do you eat daily?(show
sample)
A [ ] little or no meat, fish or alternatives (0 – 1 piece) ( 0 – 30g)
B [ ] 2-3 pieces (60 – 90g)
C [ ] 4-5 pieces (120-150g)
D [ ] 6 pieces or more (27g)
13. Which of these drinks do you take?
A, [ ] Beer B. [ ] Wine C. [ ] Palm wine D. [ ] Hard liquor
E. [ ] None
If you ticked option ‟E‟, go to No 16.
14. Each week, what quantity of drinks containing alcohol do you
consume?(show sample) (1.5oz(4.5cl) of hard liquor,12oz(36cl) of beer and
4oz(12cl) of wine are each considered 1 serving)
A [ ] 1-3 servings
B [ ] 4-6 servings
C [ ] 7-9 servings
D [ ] More than 9 servings
15. I have tried everything possible to reduce the amount of alcohol I drink?
A. [ ] strongly disagree C [ ] somewhat agree
B [ ] somewhat disagree D [ ] strongly agree
16. Do you attend your antenatal checkups/classes?
A. [ ] Yes B [ ] No C [ ] Not always
17. Which of these do you take routinely during this pregnancy? (please indicate type)
A [ ] Vitamins and haematinics (routine drugs) B. [ ]
Nutritional supplement C [ ] Herbal drugs D. [ ] Others specify-------
18. With what do you take the drugs?
A [ ] water B [ ] tea C [ ] coffee D [ ] milk E [ ]
Others specify----------------
19. I do take drugs that were not prescribed by my doctor.
A. [ ] Yes B. [ ] No
63
Appendix E
CONSENT FORM
By signing this form, I agree that (Please tick {} to confirm):
The study has been explained to me. { }
I have had the opportunity to consider the information, ask questions and have
had these answered satisfactorily. { }
The procedure in terms of timing, frequency and the nature of data has been
explained to me. { }
Possible harm and discomforts and possible benefits of this study have been
explained to me. { }
My participation is voluntary and that I am free to withdraw at any time,
without giving any reason, without my medical care or legal rights being
affected. { }
I have a choice of not answering any specific questions. { }
I am free now, and in the future, to ask any questions about the study. { }
I have been told that confidentiality of all data will be maintained throughout
the study and no information that would identify me will be released or printed
without asking me first. { }
I understand that I will receive a signed copy of this consent form. { }
I hereby consent to participate in this study:
Name of Participant: ____________________________________
Signature & Date: ---------------------------------------------------------
Name of witness: ----------------------------------------------------------
Signature & Date: ---------------------------------------------------------
Name of Researcher: -----------------------------------------------------
Signature & Date: --------------------------------------------------------
64
APPENDIX F
ETHICAL CLEARANCE
65