The Protective Influence of
Maternal-Fetal Attachment on
Health Behaviors among
HIV-Infected Women
Julieta P. Hernandez, LCSW
University of Miami
PhD Candidate, Florida International University
Strengthening Connections Conference
Sep 10-12, 2012
Austin, Texas
Objectives
• Learn about the psychosocial environment of
HIV-infected pregnant women
• Understand the conceptual link between MFA
and maternal health behaviors
• Learn about the protective role of MFA against
poor maternal health behaviors and suboptimal
infant care
• Identify psychosocial contexts modifying the
protective role of MFA.
2
Women living with HIV/AIDS
• 1/4 people living with HIV/AIDS in US are women
• Minority women are disproportionately affected
by HIV/AIDS
• Most new infections occur during childbearing
age by heterosexual transmission
3
HIV Diagnosis in US Female Population,
in 46 States, by Race/Ethnicity, 2010
Female Population
N = 122,846,284
B/AA
12%
Hisp/La
14%
HIV Dx
N = 9868
O
4%
Other
7%
White
67%
B/AA
63%
White
17%
Hisp/La
16%
http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/slides/Women.pdf
4
Diagnoses of HIV Infection, 2010
(46 States & 5 US Dependent Areas)
Age at Diagnosis (in years)
13-19
20-24
25-34
N= 474
N =1110
N=2574
%
%
%
%
%
Injection drug use
8.0
9.7
12.5
13.7
18.0
Heterosexual contact
92.0
90.2
87.4
86.2
82.0
Other
0.0
0.1
0.0
0.1
0.3
Total
100.0
100.0
100.0
100.0
100.0
Transmission Category
35-44
≥45
N=2603 N=3407
http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/slides/Women.pdf
5
AIDS Diagnoses in US Women, 2010
Race/Ethnicity
American Indian/Alaska Native
Rate/
100,000 pop
44
4.6
Asian
70
1.2
Black/African American
5422
33.7
Hispanic/Latino
1224
7.1
10
5.4
1275
1.5
197
13.1
8242
6.4
Native Hawaiian/Other Pacific Islander
White
Multiple races
Total
No.
http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/slides/Women.pdf
6
Deaths among Females with HIV
Diagnosis, 46 States, 2009
Race/ethnicity
No.
Rate
American Indian/Alaska Native
26
2.8
Asian
19
0.4
3571
23.8
754
4.5
1
1.0
White
957
1.1
Multiple races
167
12.2
Black/African American
Hispanic/Latino
Native Hawaiian/Other Pacific Islander
Total
5496
http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/slides/Women.pdf
7
HIV-infected pregnant women
• Coping with HIV disease and preparing for
motherhood
• Fewer perinatally infected children
• More HIV-infected pregnant women
• Evolving unique characteristics of HIV-affected
families
http://www.actagainstaids.org/promote/ottl/brochures.html
8
http://hab.hrsa.gov/livinghistory/images/programs/part-d-highlights.gif
9
Vulnerability of HIV-affected mother-infant
dyads
•
•
•
•
•
Poverty
Depression or anxiety
Drug use
Social isolation
Intimate partner
violence
10
Protective factors in high-risk motherinfant dyads
• Family functioning
• Emotional and concrete
support
• Nurturing and
attachment
relationships
• Skilful parenting
11
Maternal-Fetal Attachment (MFA)
• Behaviors, thoughts, and feelings in women
representing affiliation and interaction with
unborn child
• Desire to protect the fetus from harm: core
emotion and altruistic function in MFA
12
MFA: an unexplored protective factor?
• MFA begins the parentchild relationship
• Protecting the fetus
from harm blends with
practicing all required
maternal health
behaviors
13
Maternal Health Behaviors
• Pregnancy care results in positive pregnancy
outcome
• HIV medication adherence prevents motherto-child HIV transmission
14
Maternal Health Behaviors
• Infant care
adherence to HIV
screening
appointments
confirms successful
prevention of
vertical transmission
15
Optimal HIV Medication Adherence in
Pregnancy
•
•
•
•
Barriers
Drug use
Parenting stress
Single parent status
Unplanned pregnancy
Facilitators
• Positive appraisal of
pregnancy
• Marital, family or
social support
• Concerns about
welfare of fetus or
newborn
16
MFA & Maternal Health Behaviors
• The concept of maternal-fetal attachment
orients inquiry toward relationship and
protection, underscoring the importance of
the child’s beginnings—embedded in multilayered familial and social environments—to
shape future development.
17
The Dissertation Study
18
The Dissertation Study
19
Conceptual Framework
• Strengths-based perspective (Saleebey, 1992)
• Socio-ecological theory (Bronfenbrenner, 1979;
Shonkoff & Phillips, 2000)
• Biopsychosocial model of maternal stress
processes in pregnancy (Dunkel Schetter et al.,
2011)
• Theory of the caregiving system (Solomon &
George, 1996)
20
Multiple IRB processes
FIU
IRB
JHS
CRRC
UM
IRB
NIH
COC
21
Research Hypothesis
Pregnancy
Care
DV1
MaternalFetal
Attachment
IV1
+
+
+
Pregnancy HIV
Med Adherence
DV2
Infant Care
Adherence
DV3
22
Predictor Variables
IV2: History
of drug use
IV3: Marital
partner
status
IV4:
Planned
pregnancy
status
IV5: Time of
HIV
diagnosis
23
Research Hypothesis
Pregnancy Care DV1
HIV Med Adherence DV2
Infant Care DV3
IV1
IV5
IV4
IV2
IV3
IV1= maternal-fetal attachment, IV2= history of drug use, IV3= marital partner
status, IV4 = planned pregnancy status, and IV5= timing of HIV diagnosis
24
The PRIM Team
25
The PRIM Team
26
The MFCP PRIM Clinic
• The Prenatal Immunology (PRIM) outpatient JHS
clinic, staffed by UM OB/GYN Department
• Concurrent prenatal and HIV care
• Mental health assessments and behavior
management sessions on stress reduction and
partner disclosure strategies.
• Infant care group sessions
US Department of Health and Human Services Panel on Treatment of HIV-infected Pregnant
Women and Prevention of Perinatal Transmission
27
The Pediatric Team
28
The MFCP Screening Clinic
• 1st , 2nd , 4th visits (2, 4, 16 wks) – Virological tests
performed on HIV-exposed infants to establish
presumptive & definite HIV diagnosis exclusion.
• 3rd visit – discontinue infant’s HIV medication
prescribed at birth & counsel parent on virological
test results
• Mandated DCF report by clinic staff of nonattendance of any scheduled appt
29
Methodology
• Prospective observational design
• 92 HIV-infected English/Spanish speaking ≥ 24
weeks pregnant women recruited over 12
months from PRIM clinic
• Survey socio-demographic and predictor
variables (IV2-5)
• Measure MFA (IV1) with MFAS (Cranley, 1981)
30
Methodology
• Measure pregnancy care (DV1) with HPQ-II
(Lindgren, 2005)
• Abstract HIV medication adherence (DV2) and
infant care adherence (DV3) data from medical
records
31
Data Analysis
• Preliminary analyses: accuracy of data entry,
assumptions of multivariate analyses, missing
data, outliers
• Bivariate analyses: Pearson correlation, Chi
square tests.
• Multivariate analyses: standard and direct logistic
multiple regression
32
Limitations
&
Solutions
• Feasible to obtain
necessary sample size?
• Recruitment maximizes
inclusion
• Sample approximates
entire local population
• Exclusion of certain
pregnant women with
HIV
• Instruments translated
into Spanish
33
Limitations
• Social desirability bias
of self-reporting
instruments
• Sample skewed to
woman already in
prenatal care
• Cross-sectional
measures: Time 1 data
&
Solutions
• Self-administration in
familiar & comfortable
clinic environment
• Study design features
optimize internal
validity
34
Relevance for Social Work &
Vulnerable Families
• Theory: conceptual link between MFA and protection
against suboptimal infant care
• Practice: perinatal mental health interventions to
promote resilience and protect against parental
disruptions
• Policy: preventive or promotional public health
policies on early child development
35
Progress Report
• Data collection began July 19, 2012
• Study well received by PRIM clinic staff and
pregnant women
• As of August 10, 2012 18 women have been
invited to participate
• 12 consented and 6 declined participation
• No maternal or infant medical charts have been
abstracted
36
Thank you
37
References
•
•
•
•
•
Bardeguez, A. D., Lindsey, J. C., Shanon, M., Tuomal, R. E., Cohn, S. E., Smith, E.
Stek, A., Buschur, S., Cotter, A., Bettica, L., & Read, J. S. (2008) Adherence to
antiretrovirals among US women during and after pregnancy. Journal of
Acquired Immune Deficiency Syndrome, 48, 408-417.
Brofenbrenner, U. (1979). The ecology of human development: Experiments by
nature and design. Cambridge, MA: Harvard University Press.
Cranley, M. S. (1981). Development of a tool for the measurement of maternal
attachment during pregnancy. Nursing Research, 30, 281-294.
D’Auria, J. P., Christian, B. J., & Miles, M. S. (2006). Being there for my baby:
Early responses of an HIV-infected mother with an HIV-exposed infant. Journal
of Pediatric Health Care, 20 (1), 11-18.
Dunkel Schetter, C. (2011). Psychological science on pregnancy: Stress
processes, biopsychosocial models, and emerging research issues. Annual
Review of Psychology, 62, 531-558.
38
References
•
•
•
•
•
English, D. J., Thompson, R., Graham, J. C., Briggs, E. C. (2005). Toward a definition
of neglect in young children. Child Maltreatment, 10, 190-206.
Helfer, R. E. (1987). The perinatal period, a window of opportunity for enhancing
parent-infant communication: An approach to prevention. Child Abuse & Neglect,
11, 565-579.
Lindgren, K. (2005). Testing the Health Practices in Pregnancy Questionnaire-II.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 465-472.
Mellins, C. A., Chu, C., Malee, K., Allison, S., Smith, R., Harris, L., Higgins, A., Zorrilla,
C., Landesman, S., Serchuck, L. & Larussa, P.(2008). Adherence to antiretroviral
treatment among pregnant and postpartum HIV-infected women. AIDS Care,
20(8), 958-968.
Napravick, S., Royce, R., Walter E., & Lim, W. (2000). HIV-1 infected women and
prenatal care utilization: barriers and facilitators. AIDS Patient Care and STDs,
14(8), 411-420.
39
References
• Saleeby, D. (1992). Biology’s challenge to social work: embodying the
person-in-environment perspective. Social Work, 37 (2), 112-118.
• Sandbrook, S.P., & Adamson-Macedo, E. N. (2004). Maternal-fetal
attachment: Searching for a new definition. Neuroendocrinology Letters,
25(Suppl.1), 169-182.
• Shonkoff, J.P., & Phillips,D.A.(Eds.).(2000). From neurons to neighborhoods:
The science of early child development. Wahington, DC:National Academy
Press.
• Solomon, J., & George, C. (1996). Defining the caregiving system: Toward a
theory of care-giving. Infant Mental Health Journal, 17(3), 183-197.
40
Julieta P Hernandez, LCSW
Mailman Center for Child
Development
Social Work Division
Phone: 305 243 6864
Fax: 305 243 6865
jhernand@med.miami.edu
41