THEORIES RELATED

TO
MATERNAL AND CHILD HEALTH
NURSING
INTRODUCTION

• The Maternal and Child nursing (MCH) is a

subspecialty of nursing that deals with
needs of mothers and children. Theories and
models in MCH provide guidelines for
decision-making the clients. Each model
reveals and orders reality from a particular
perspective. According to Ellis (2003),
nursing models articulate the essence of
nursing across time. Despite the acclaimed
popularity of models and the suggestion that
the use of models is one of the hallmarks of
success in of success in nursing practice
(Fawcett and Carino, 1989), for many
nurses, models and are viewed as distant
and elitist are not always `valued by
practitioners or managers' (Bellman, 1996).
Theories and models are very relevant in
Maternal and Child Health nursing practice.
Nursing Students need
INTRODUCTION

• Nursing models and theories are as old as the

nursing profession itself. Nursing was designed to
meet the needs of various groups and
developmental stages. Nursing model give direction
to nurses working in a particular area and it helps
predict expected outcomes of nursing actions.
Models provide for the identification and labeling
of concepts which allow for recognition and
communication with others (Fitzpatrick, 2005). A
theory is a set of propositions about defined and
related constructs that describe the relationships
among the variables in order to systematically
describe the phenomena of interest (Kerlinger,
1986). Theory involves concepts closely tied to
individuals, groups, situations or events and tries
relationships between them (Fawcett, 1993). When
ideas are less concrete, the ways, phenomena are
viewed and organized is sometimes referred to as
a conceptual model. Conceptual models have
some of the same components as theories, but
are more loosely generally lack the propositions
that identify the existence of relationships between
concepts.
•to understand various models and theories are applicable
in MCH but this chapter will focus more on models and
theories specific to MCH nursing specialty.

•LEARNING OBJECTIVES
•After reading this chapter, learners should be able to.

1)Identify theories and models applicable to maternal

and child health nursing practices.

2)Describe the relevance of bonding and attachment

theories in the care of mother and child.
3)Discuss maternal role attainment theory as a
framework for care.

4)Describe the use of The Mother and Child Integrative

Developmental Care Model in nursing care.
5)Explain concepts used in Barnard's parent-child
interaction model.
Bonding and Attachment Theory

• The term bonding is used most often to

refer to a rapid process, occurring immediately
after birth that reflects mother-to-infant
attachment (not the infant's attachment to the
mother). This process of establishing a bond
between mother and newborn is seen as being
facilitated by physical and skin-to-skin contact
between mother and newborn. Infant suckling,
visual contact between mother and infant and
the mother's fondling of the infant are involved.
Similar behaviours on the part of the father and
infant are said to result in a bond as well
(Sherwen, Scoloveno and Weingerten, 1995).
Bonding and Attachment Theory

• Attachment theory was developed jointly

by John Bowlby and Mary Ainsworth (Ainsworth
and Bowlby, 1991). It was originally developed
by John Bowlby (1907 - 1990), a British
psychoanalyst who tried to explain the intense
distress experienced by infants who had been
separated from their parent. It was then
further developed by Mary Ainsworth. The
theory describes the dynamics of long-term
relationships between humans especially in
families a, long friends.
•Drawing on concepts from ethology,
cybernetics,
Bonding and Attachment Theory

•Information processing, psychology,objects

relation

• developmental theory and psychoanalysts,

John Bowlby formulated the basic tenets of
the theory (Bretherton, 1992).
Bonding and Attachment Theory

• It proposes that the affectional tie between mother, father,

and infant develops out of response patterns that ensure that
infants will be cared for during their years of dependency
(Sherwen, 1995). Although Bowlby and Ainsworth worked
independently of each other during their early careers, both
were influenced by Freud and other psychoanalytic thinkers-
directly in Bowlby's case, indirectly in Ainsworth's. He thereby
revolutionized our thinking about a child’s tie to the mother
and its disruption through separation, and bereavement. Mary
Ainsworth's innovative methodology not only made it possible to
test some of Bowlby's ideas empirically but also helped expand
the theory itself and is responsible for some of the new
directions it is now taking. Ainsworth contributed the of the
attachment figure as a secure base from which an infant can
explore the world (Bretherton, 1992). This attachment between
mother and infant at one year relates to later social and
cognitive development of the child.
Bonding and Attachment Theory

•Early attachment behaviours coming from

the infant are specific to humans and are
elicited by the human adult. As the infant
grows and develops, the responses become
increasingly complex and directed to
particular others in the infant's
environment. The nature of the relation is
mutual- affection which grows in both the
mother/ father and the infant, over time.
Secure attachment between mother and
infant is the basis for trust, which the infant
uses to function eventually as an
independent individual apart from his/her
Bonding and Attachment Theory

•Infants become attached to individuals, who are

sensitive and responsive in social interactions with them and
who remain as consistent caregivers for some months during
the id from about six months to two years of age; this is
known as sensitive responsiveness. When the infant begins
to crawl and walks, they begin to use attachment figures
(familiar people) as a secure base to explore from and
return to Caregivers' responses lead to the development of
patterns of attachment. These, in turn, lead to internal
working models which will guide the individual's
perceptions, emotions, thoughts and expectations in later
relationships (Bretherton and Munholland, 1999).

•If early maternal-infant contact increases maternal

feelings or affection sensitivity to the infant's individual
response style, this should reflect in the patterns of care
giving that influences the quality of attachment at one year.
In other words, bonding may set
Bonding and Attachment Theory

•the stage, in a positive direction, for the developing

patterns of interactions between mother and infant during
the first year and help ensure the attainment of secure
attachment between both mother and infant at one year
and after. Separation during this time, however, does not
prevent subsequent positive patterns of interaction
between mother and infant and the development of
affectional ties over the first year of the infant's life. Because
separation is a clear-cut and undeniable event, its effects on
the child and the parent-child relationship were easier to
document than more subtle influences of parental and
familial interaction Research by developmental psychologist
Mary Ainsworth in the 1960s and 70s reinforced the basic
concepts, introduced the concept of the “secure base” and
developed a theory of a number of attachment patterns in
infants: secure attachment, avoidant attachment was
identified later. In addition, she formulated the concept of
Bonding and Attachment Theory

•One of the major tenets of security theory is that infants

and young children need to develop a secure dependence
on parents before launching out into unfamiliar situations.

•Infants form attachments to any consistent caregiver

who is sensitive and responsive in social interactions with
them. The quality of the social engagement is more
influential than the amount of time spent. Although the
biological mother is usually the principal attachment figure,
the role can be taken by anyone who consistently behaves
in a “mothering" or care giving way over a period of time.
Bonding and Attachment Theory

•Major Concepts
 Attachment: An enduring emotional tie to a special
person characterized by a tendency to seek and
maintain closeness especially during times of stress.
 Attachment in the context of children: The enduring
deep emotional bond between a child and a specific
caregiver
 Separation produces extreme distress in children.
 There are significant long-term adverse effects on the
children as a result of even relatively brief separations.
 Theory emphasizes the role of mother in child's
development where father plays the second fiddle to
mothering.
Bonding and Attachment Theory

•Stages
•Phase of limited discrimination (birth-2 months)
 Baby's innate signals attract caregiver.
 Caregivers remain close by when the baby responds
positively:
•Phase of limited preference (2-7 months)
 Develops a sense of trust that caregiver will respond
when signaled.
 Infants respond more positively to familiar caregivers.
Babies don't protest when separated
from parent Phase of focused attachment and
secure base (7-24 months)
 Babies display separation anxiety.
 Babies protest when parent leaves.
•Phase of goal-corrected partnership (24–36 months)
 Children increase their understanding of
symbols and language improves.
 Children understand that parents will
return.
Maternal Role Attainment Theory

•The Maternal Role Attainment Theory was developed to

serve as a framework for nurses to provide appropriate
health care interventions for non-traditional mothers in order
for them to develop a strong maternal identity. As a head
nurse in paediatrics and staff nurse in intrapartum,
postpartum, and newborn nursery units, Ramona Mercer had
a great deal of experience in nursing care for mothers and
infants. This gave her a strong foundation for creating her
maternal pole attainment theory for nursing.

•This mid-range theory can

be used throughout
pregnancy and postnataI care,
but is also beneficial for adoptive
or foster mothers, or others who
find themselves in the
maternal role
Maternal Role Attainment Theory

unexpectedly. The process used in this

nursing model helps the mother develop an
attachment to the infant, which in turn helps
the infant form a bond with the mother. This
helps develop the mother-child relationship as
the infant grows. The primary concept of this
theory is the developmental and interactional
process, which occurs over a period of time.
In the process, the mother bonds with the
infant, acquires competence in general
caretaking tasks, and then comes to express
joy and pleasure in her role as a mother.
Maternal Role Attainment Theory

The nursing process in the maternal role attainment

theory follows four stages of acquisition. They are:
anticipatory, formal, informal, and personal. The
anticipatory stage is the social and psychological
adaptation to the maternal role. This includes learning
expectations and can involve fantasizing about the role.
The formal stage is the assumption of the maternal role
at birth. In this stage, behaviours are guided by others in
the mother's social system or network, and relying on the
advice of others in making decisions. The informal stage
is when the mother develops hero mothering which are
not conveyed by a social system. She finds what works
for her and the child. The personal stage is the joy of
motherhood. In this stage, the mother finds harmony and
competence in the maternal role. In some cases, he
Maternal Role Attainment Theory

•Maternal role attainment is a process that followed

the four stages in the acquisition roles (adapted from
Thorn and Nardi, 1975).
•Anticipatory: starts with the social and psychological
penialaian on the role by studying the experiences of the
role. Mothers fantasize about the role, dealing with the
fetus in the womb and begin to play a role.

•Formal: starts by assuming the role at the time of

delivery; behaviour is guided by a formal role,
consensual expectations on others in the social system
of the mother.

•Informal: starts as the mother develop a unique way of

relating to the role which is not believed by the social
system
Maternal Role Attainment Theory

•Personal: experience the mother will be

harmony, confidence and competence in the way he
did the role, the role of motherhood is achieved.
•The main focus of the theory of maternal role
attainment which is becoming a mother is a picture of
maternal role attainment process and the process of
becoming a mother with a variety of underlying
assumptions. These models also served as guidelines
for nurses in assessing the infant and its environment, is
used to identify the purpose of the baby, providing
assistance to infants with education and support,
providing services to infants who are unable to perform
self-care and able to interact with the baby and the
environment.
Mercer theoretical concept

•The main assumptions of assumptions of Mercer in maternal role

attainment are as follows:

1. A “core self/herself relatively stable” is required through a long

socialization life, determining how a mother explains in the events,
perceptions on the response of the baby and the other role of
motherhood which she did along with her life situation and the
reality of the world which she must respond.

2. On the other hand, on the socialization of capital, level of

development and innate personal characteristics will also affect
behavioural responses.

3. The role of partner's mother, her baby will reflect the competencies
of mother in the role of motherhood through growth and
development.

4. Infants considered to be an active partner in the process of making

the role of the mothers they will influence and be influenced by the
role.

5. The identity of the mother developing in line with others

maternal love and depend on others.
Mercer theoretical concept

•Mercer theoretical concept can be applied in the care of newborns,

especially in the psychosocial and emotional condition of the newbom
which is still often overlooked. Mercer conceptual model considers that
the nature of the infant affect the identity of the mothering. Response
to the development of newborns who interact with the
development of maternal role identity can be observed from the
pattern of infant behaviour. Differences with Rubin who do the writing
achievement of the role of the points on the acceptance of pregnancy
on postpartum months 1 (first); Mercer saw beyond that which the
period to 12 post partum. Mercer presents a model of four stages that
occur in the process of maternal role attainment during the first year of
motherhood. The four stages are labeled as follows:
a. Physical healing phase, occurs in the first month of birth dairy
b. Phase attainment of the month to 2 to 4 or 5
c. Phase interference occurs from 8 months
d. Stage after the introduction of eight months and year in the future
 The Mother and Child Integrative
Developmental Care Model

•The Mother and Child Integrative Developmental Care

Model is a newly created model that has simplified aspects
from the Universe of Developmental Care Model. Through
valuable caregiver feedback, the Integrative Developmental
Care Model has incorporated a user- friendly interface with the
universe of developmental cares com measures to guide
practice. These core measures/developmental principles are
depicted on petals of a lotus as family involvement, positioning
and nesting, protecting skin, minimizing stress and pain,
optimizing nutrition, and safeguarding sleep. The overlapping
petals model demonstrate the integrative nature of
developmental care (Altimierz, 2011). The infant's sensory
experience in the NICU environment, with its exposure to
bright lights and high sound levels, and frequent stressful
interventions exert harmful effects on the immature brain that
alters its subsequent development. (Als, Duffy, McAnulty, 2004;
Limperopoulos, Gauvreau and O'Leary, 2008).
 The Mother and Child Integrative
Developmental Care Model

•A developmental care approach advocates a broad

range of interventions designed to minimize the negative
impact of such an environment, thereby improving
neurodevelopmental outcomes (McAnulty, Butler, Bernstein,
Als, Duffy and Zurakowski, 2010). This includes controlling
external stimuli such as sound, light, and activity,
encouraging family involvement; and considering
appropriate comforting measures (BLISS, 2005). It also
advocates an individual approach to care that is dictated by
cues from the infant (Als, 2008).

•A 2005 Cochrane review concluded that

developmental care interventions demonstrate some specific
benefit for preterm infants including improved short term
growth and feeding outcomes, decreased respiratory
support, decreased length and cost of hospital stay, and
improved neurodevelopment outcomes to 24 months
corrected gestational age. (Symington and Pinelli, 2005)
 Barnard's Parent-Child Interaction Model

•Kathryn E. Barnard was born 1938 in Omaha Nebraska.

She was a graduate with Bachelor of Science in Nursing in
June 1960, M.Sc. in Nursing 1962 and PhD in the Ecology of
early childhood development from the University of
Washington. Barnard stated that the parent-infant system was
influenced by individual characteristics of each member and
that the individual characteristics were also modified to meet
the needs of the system. She defines modification as adaptive
behaviour.

•A major focus of Barnard's work was the development of

assessment tools to evaluate child health, growth and
development while viewing the parent and child as an
interactive system. In 1977, Barmand began researching
methods for disseminating information about newborns and
young children to parents.
 Barnard's Parent-Child Interaction Model

•The following concepts are used to explain Barnard's model:

 Infant’s Clarity of Cues: Participating in a synchronous,

relationship, the infant must send cues to his/her
caregiver.
 The skills and clarity with which these cues are sent will
make it either easy or difficult for the parent to “read” the
cues and make the appropriate modification of his/her own
behavior. Some of the cues are: sleeplessness, fussiness,
alertness, hunger and satiation, changes in body activity,
confusing cues sent by an infant can interrupt a
caregiver's abilities e.g. crying

 Infants Responsiveness to the Caregiver: As infant must

“send” cues for parents to modify his/her behaviour,
infant must also “read" cues so that he/she can modify
his/her behaviour in return. Obviously if the infant is
unresponsive to the behavioural cues of his/her
caregivers, adaptation is not possible.
 Barnard's Parent-Child Interaction Model

•The following concepts are used to explain Barnard's model:

 Infant’s Clarity of Cues: Participating in a synchronous, relationship,

the infant must send cues to his/her caregiver.
 The skills and clarity with which these cues are sent will make it
either easy or difficult for the parent to “read” the cues and make
the appropriate modification of his/her own behavior. Some of the
cues are: sleeplessness, fussiness, alertness, hunger and
satiation, changes in body activity, confusing cues sent by an
infant can interrupt a caregiver's abilities e.g. crying

 Infants Responsiveness to the Caregiver: As infant must “send” cues

for parents to modify his/her behaviour, infant must also “read"
cues so that he/she can modify his/her behaviour in return.
Obviously if the infant is unresponsive to the behavioural cues of
his/her caregivers, adaptation is not possible.
 Barnard's Parent-Child Interaction Model

 Parents' Ability to Alleviate the Infant Distress: Some cues

sent by the infant signal that assistance from the
parent is needed. The effectiveness of parents in
alleviating the distress of their infants depends upon
several factors.
 Recognize the distress is occurring.
 Know the appropriate action which will alleviate
distress.
 They must be available to put this knowledge of work.

 Parents Social and Emotional Growth Activities: The

ability to initiate social and emotional growth-
fostering activities depends upon more global
parent adaptation.
 Barnard's Parent-Child Interaction Model

 The parent need to be able to play affectionately with the

child, engage in social interactions e.g. as those associated
with eating and in provide appropriate social reinforcement
of desirable behaviours. Parents must be aware of the
child's level of development and be able to adjust his/her
behaviour accordingly. This depends on the parent's
available energy as his/her knowledge and skill.

 Parent's Cognitive Growth fostering activities: The parent must

have a good grasp of the child's present level of
understanding and the parents also have the energy
available to use these skills. The three major concepts of
this theory are:
a.Child – baby
b.Mother – caregiver
c. Environment – physical environment of the family,
father
 CONCLUSION

• Theories germane to MCH nursing continue to be

developed and evolve. Many theories presented in
earlier times have served nursing well as the
discipline has its scope of practice. When care was
mainly centered in the patient-nurse relationship,
many theories were especially pertinent and as
holistic views of patient-environment became greater
concerns, then systems thinking was an asset for
conceptualizing practice. Theories used in the past
continue to have meaning, but nurses need models
that reflect the discipline's ethos and provide a
framework to consider the vocation and goals of
nursing.