Transcript The Protective Influence of Maternal

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.
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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
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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
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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
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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
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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
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http://hab.hrsa.gov/livinghistory/images/programs/part-d-highlights.gif
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Vulnerability of HIV-affected mother-infant
dyads
•
•
•
•
•
Poverty
Depression or anxiety
Drug use
Social isolation
Intimate partner
violence
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Protective factors in high-risk motherinfant dyads
• Family functioning
• Emotional and concrete
support
• Nurturing and
attachment
relationships
• Skilful parenting
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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
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MFA: an unexplored protective factor?
• MFA begins the parentchild relationship
• Protecting the fetus
from harm blends with
practicing all required
maternal health
behaviors
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Maternal Health Behaviors
• Pregnancy care results in positive pregnancy
outcome
• HIV medication adherence prevents motherto-child HIV transmission
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Maternal Health Behaviors
• Infant care
adherence to HIV
screening
appointments
confirms successful
prevention of
vertical transmission
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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
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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.
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The Dissertation Study
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The Dissertation Study
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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)
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Multiple IRB processes
FIU
IRB
JHS
CRRC
UM
IRB
NIH
COC
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Research Hypothesis
Pregnancy
Care
DV1
MaternalFetal
Attachment
IV1
+
+
+
Pregnancy HIV
Med Adherence
DV2
Infant Care
Adherence
DV3
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Predictor Variables
IV2: History
of drug use
IV3: Marital
partner
status
IV4:
Planned
pregnancy
status
IV5: Time of
HIV
diagnosis
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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
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The PRIM Team
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The PRIM Team
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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
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The Pediatric Team
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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
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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)
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Methodology
• Measure pregnancy care (DV1) with HPQ-II
(Lindgren, 2005)
• Abstract HIV medication adherence (DV2) and
infant care adherence (DV3) data from medical
records
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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
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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
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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
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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
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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
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Thank you
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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.
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References
•
•
•
•
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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.
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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.
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Julieta P Hernandez, LCSW
Mailman Center for Child
Development
Social Work Division
Phone: 305 243 6864
Fax: 305 243 6865
[email protected]
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