PREVENTION IN PERINATAL CARE

An intercultural comparative research about men’s and women’s expectations during the prenatal period, in a preventative approach of parental education

convention UdS / INPES n° 133/09 DAS

Presented by the

RESEARCH TEAM ON PRENATAL CARE

（Responsible scientifique Claude SCHAUDER
Dir. Serge Lesourd）
Research Unit in Psychology: Subjectivity, Knowledge and Social bonds
Welcome committee 3071
University of Strasbourg
Faculty of Psychology and the Science of Education
12 rue Goethe 67000. Strasbourg

GENERAL BACKGROUND

RESEARCH BACKGROUND

For many years, the relationship between the occurrence of a large number of disturbances and pathologies in children and the way the parents (or other adults) welcome their children and take care of them has been well referenced . Today we are aware that if the bonding between the child and his parents fails to occur, it leads to suffering which is expressed through subjective and/or family disruption and developmental and behavioural disorders since birth and during childhood and adolescence.

Professionals of the health and social sectors chose to intervene as soon as possible, especially before some mental troubles and other pathologies occur. Hence, they have set up (or are planning to set up), various preventive actions, already during the perinatal period, which take into consideration the importance of early bonding between the newborn and his surroundings.

These initiatives are the result of a large number of researches made in various clinical, medical and psychological domains over the past fifty years. Some of them, mainly the earliest ones aimed at reducing death rate, prematurity, and perinatal death in general but also the psychopathological consequences which can affect both the mother and the child.. Other studies, for instance, about “painless delivery” , played an important role in the accompaniment, the delivery and the welcoming of the new-born babies. . While some studies focused more on the pathogenic consequences of some professional practices, others focused on the importance of the parents’ presence and the importance of early relationship and education in the etiology of psycho-affective developmental troubles, behavioural troubles and the children’s and the adolescents’ development.

Since 1950, after these studies, psychotherapeutic experiments were conducted with mothers whose suffering had been recognized. Psychotherapies of both the mother and the child as well as different forms of counselling including the father followed.

The aim of the other research was to screen the parents or families who are considered as “vulnerable”. The “risk assessment scales” initially used in this method are considered as ethically questionable, not very reliable from a scientific viewpoint and probably likely to induce stigmatizing or paradoxical effects. Thus some procedures consisted in organizing sessions and allowing parents to express their feelings, to talk about their personal problems, their ill-being and their suffering which could affect the secure and well-structured bond with the future baby have replaced the previous method. Thanks to these sessions, the concerned women (and couples) can be referred to specialists.

The 2005-2007 perinatal plan and PNP

In France, the 2005-2007 perinatal project sets up a policy of prevention for dysfunctional premature relationships between parents and children. For this project, an uneventful pregnancy and the child’s well-being rest upon a complete medical follow up and a structured preparation to birth and parenting. The aim of this follow-up is to contribute to the general improvement of the health of the pregnant women, of the ones who have given birth and of the new born babies”. This text underlines that in order to achieve successful parenting, there should be an exchange of information and experience about the young children’s needs and demands, about the construction of bonds, about the babies’ crying, particularly when the reasons of their crying are misunderstood, etc. and that « quality support given at the earliest possible stage during pregnancy and after birth helps to prevent abuse and mental disorders in infants and adolescents”

The aim of this project is to: .

help prepare couples to experience birth and to welcome their child through educational sessions, adapted to the needs and expectations of every woman and future father;

allow the early detection of the couple’s problems

support the parents by giving them information, references, (educational and emotional) tools on how to create a bond between their child and themselves, thus allowing the child to develop in a positive way …”

That’s why a doctor or a midwife automatically proposes a clinical interview to the parents on an individual or couple basis during the first term of pregnancy.

THE RESEARCH TOPIC

The research on the efficiency of these preventive actions conducted in this field has proved to a great extent that this project can only be successful if the needs and the expectations of the users who are supposed to benefit from these actions are met but also if the chosen methods are relevant.

AIM OF THIS STUDY

Our research aims at clarifying and studying at length what could be women’s and men’s expectations about becoming a parent and about the construction of the bond with their children during the perinatal period.

Another objective of this study is to show how the response to these expectations partakes of:

a change in economical, social and health aspects in their lifestyle
a professional intervention : medical, social, psychological or educational follow-up
specific individual and personal elaborations originating in the psychic elements and the landmarks transmitted by the family and the culture

This study belongs to the specific transversal framework of our research unit in psychology: subjectivity, knowledge and social bonds which emphasises whenever possible a multidisciplinary approach to the research topic and started this project. The latter follows various research focused on the transformation of the way psychological suffering and the problems encountered in the construction of one’s identity are expressed. These new ways have been observed by all the practitioners in the psychopathological field (in all theoretical references). These studies became more specific in our unit’s research between year 2003 and 2005 along with the collaboration of Louvain La Neuve University (Pr. P. de Neuter), Marc Bloch University of Strasbourg (Pr. Maurice Blanc) and University of 8-Saint Denis (Pr. Laurence Gavarini). The first International Conference on social bonding disorders was organised by our research unit in March 2006 in Strasbourg has put forward the first results.

This project has been developed following the international collaboration that our research unit has organised for several years with Brazilian, Canadian and Italian teams who are also interested in this research topic.

There are two levels for the expected results:

1. Theoretical level

A theoretical level which aims at completing and upgrading the knowledge we have about :

the individual psychological work essential both for the mother and the father, for the process of becoming parents and the construction of bonds with the future child during the perinatal period
the physical and psychopathological consequences of the possible flaws in this work

2. Practical Level

A practical level which aims at :

improving the tools used to diagnose the problems that the parents have to face during this period
optimizing caretaking
making suggestions in order to allow more efficient early prevention when necessary

METHODOLOGY

In order to reach our objective, that is, to clarify and study at length what could be women’s and men’s expectations during the perinatal period and to gain more knowledge of what determines the psychological, medical, social, societal, cultural, historical and economical aspects, this study will be divided into two main lines :

A) Research mainlines:

1. Diachronic

This enables us to take into account the inevitable time dimension and its effects on the subject. Indeed both the subjectivation process and the process that might alter it evolve with time. All the studies conducted on child development have demonstrated this, as well as those affecting the process of becoming adults and more particularly during important life crises such as becoming a parent (see for example, the work done on clinical post-partum depression or post-partum psychosis).

The first mainline allows to study the individual and singular dimension of the subjective construction of being a parent in relation with its history. That’s why we will focus on the evolution of the concerned women’s and men’s expectations and representations in a longitudinal way:

During the time the parents expect the child, the parental relationship being regarded from the imaginary viewpoint. We’ll make interviews:
- At the beginning of pregnancy (less than 12 weeks, which is the legal time delay for abortion)
- During pregnancy (between the 4th and 6th month, when ultrasound scans and antenatal tests are used to test for “normality”)
- At the end of the pregnancy (after 8 months, when delivery is expected)

Then after the child is born, when the parental relationship is confronted to the real presence of the child (real child/imaginary child).We will organize some interviews:
- During the weeks right after birth (before one month) in order to understand how the bond is created
- And eventually after about twenty months in order to understand the family relationships when the child starts to become independent.

2. Synchronic

This will allow us to compare the characteristics noted during each of these periods in a given cultural and socio-economical background to those obtained during the other periods.

The second mainline will enable us to study the collective dimension of becoming a parent. This will mean comparing the psychological elaboration of women and men of different countries and of different socio-economical backgrounds seen in this study.

Establishing comparative criteria

1) Comparison within each country

For each country, (Italy, Canada, Brazil, Argentina, Russia, China and France) we will analyse the differences between what pregnant women (or couples) from different socio-cultural backgrounds say. We have to consider that though the culture homogenises family relationships, the social class will make a difference in the roles and functions in the parents-children relationship. They will be recruited in the outpatient consultations of the cities’ general hospitals or gynaecology-obstetrician services, and others in rural regions and in poor suburbs.

2) Comparison between the countries

between the discourses of women and men from equivalent socio-economical environments living in another European country ( Italy) where we believe that the family roles representations we study were traditionally more differentiated than in France but that evolve in the same way as in our country.
between the discourses of women and men from equivalent socio-economical environments living in Canada, in Italy, in Russia, in Argentina, in China and in Brazil. These modern countries are on different continents and they also have very different cultural traditions.

This research will be done by teams of researchers in close collaboration with our research unit.

Data will be collected through semi-directive research interviews in a specific population where confidentiality will be absolutely respected. The interviews will be first recorded and then completely transcribed in order to allow full study. The data will be analysed by spotting and studying in detail the various elements of their discourses (enounced and enunciation). These elements reflect how every mother’s psyche envisions and elaborates on the topic that’s being evoked.

C) Perspectives on the expectations with perinatality preventive offers

We will complete this work by putting into perspective what the analyses of these expectations and the existing preventive offers will reveal.

We will focus more particularly on the ones which give priority to the current guidelines and which aim at preparing and educating parents. This concept is quite vague. Indeed, besides being a descriptive term for “the parental condition”, it also has a prescriptive meaning which leads us to consider « being a parent » no longer as a consequence of the parent-child bond but more as a “skill”, a “capacity” for which some conditions are required. We will try to see how this kind of preparation may be appropriate for these expectations. We’ll also try to find out how this concept partakes of a contingent social and anthropological construction inducing the above expectations.

STUDY SAMPLE

If possible, in each chosen country, 3 groups of 10-15 pregnant women during their first trimester randomly selected among those who came for consultation in the chosen services and who have accepted to participate in this study : a group of women living in cities, another group living in the rural regions and a third group from poor suburbs. The men could also be interviewed.

For each country, we will have in all 30-45 women in the sample (+ men). We will meet these persons again at each of the steps described earlier that is 225 interviews.

In order to verify statistically the significance of the social, economical and cultural differences brought to the fore in this study, this research could be completed by a quantitative survey using a self-administered questionnaire by a much larger sample of women (or couples). This epidemiologically oriented survey will be set up by using the answers obtained during the qualitative stage which requires financing. (We will ask for other funds for this complementary survey because it will require an important statistical work for which material and workers will be needed).

PRACTICAL MODALITIES

Duration: 3 years

Projected calendar:

1st year

the setting up of the scientific committee ; division of the tasks among the group partners, creation of the semi-directive interview scales ; setting up of groups ; coordination of the research procedures with foreign teams ; first interviews (women and couples during the first then the second term of pregnancy) ; analysis of the data obtained in these interviews.

2nd year:

continuation of the interviews and analysis of the data obtained (women and couples during the 3rd term of pregnancy and post-partum); coordination meeting with the foreign teams; report on these steps.

3rd year:

3rd year: continuation of the interviews and of the data analysis (women and couples after 18 months) ; comparing and sharing information with the foreign research team ; writing the report ; making practical suggestions and complementary research (longitudinal studies on a longer term basis, creation of the questionnaire for the quantitative study by self-administered questionnaires, etc)。