Comparison of maternal and paternal fetal attachment in Turkish couples

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1 Midwifery (2010) 26, e1 e9 Comparison of maternal and paternal fetal attachment in Turkish couples A. Ustunsoz, RN, PhD (Lecturer), G. Guvenc, RN, PhD (Lecturer), A. Akyuz, RN, PhD (Associate Professor), F. Oflaz, RN, PhD (Assistant Professor) Gulhane Military Medical Academy, School of Nursing, Ankara, Turkey Corresponding author. address: (A. Ustunsoz). Received 30 December 2008; received in revised form 6 November 2009; accepted 22 December 2009 Abstract Objective: to compare maternal fetal attachment (MFA) and paternal fetal attachment (PFA) in terms of selected variables. Design: cross-sectional study. Setting: three training hospitals in Ankara, Turkey. The study was performed between December 2005 and March Participants: a total of 144 pregnant women and 144 partners participated in the study; the response rate was 98%. Findings: there was a statistically significant difference between MFA and PFA scores (po0.001). A comparison of MFA and PFA scores according to the selected variables (education, employment status, planning of pregnancy, pregnancy risk status) revealed that the MFA scores for pregnant women were significantly higher than the PFA scores of their partners, except for unemployed partners. The MFA (r ¼ 0.24, po0.004) and PFA (r ¼ 0.32, po0.001) scores decreased with increasing age of both pregnant women and their partners. Key conclusions and implications for practice: although partners have lower fetal attachment scores than pregnant women, it is important to recognise factors influencing the attachment of the mother and father towards their fetus. Prenatal midwives and nurses are in a unique position to assess attachment and to intervene to promote attachment behaviours. & 2010 Elsevier Ltd. All rights reserved. Keywords Attachment; Maternal fetal attachment; Paternal fetal attachment Introduction Over the past 20 years, there has been increasing recognition that the relationship between a mother and her child starts to develop before the child is born. The significance of the relationship between a mother and her infant, as conceptualised by the attachment theory, is well documented (Bowlby, 1969). Although Bowlby s later work (1982) focused on the unidirectional infant-to-mother relationship, other researchers have since focused on the motherto-fetus relationship (Cranley, 1981; Bowlby, 1982). Cranley (1981) defined maternal fetal attachmant (MFA) theoretically as the extent to which women engage in behaviours that represent an affiliation and interaction with their unborn child. MFA plays an important role in the health of pregnant women and their unborn babies. Maternal attachment is /$ - see front matter & 2010 Elsevier Ltd. All rights reserved. doi: /j.midw

2 e2 also an important component of maternal identity and is essential in promoting positive adaptation to motherhood (Mercer, 2004). Optimal attachment in early infancy has been identified as an integral component in the future development of a child (Oppenheim et al., 2007). MFA is an important requirement for optimal maternal infant adaptation (Bryan, 2000; Oppenheim et al., 2007). According to Condon, paternal fetal attachment (PFA) is a subjective feeling of love for the unborn child, rather than an attitude or belief about the child, and is at the heart of a man s experience of early parenting (Condon, 1985). Attachment-related studies mainly focus on MFA (Cranley, 1981; Condon, 1985; Lindgren, 2001; Shieh et al., 2001; Ahern and Ruland, 2003; Damato, 2004) and less on PFA (Weaver and Cranley, 1983; Condon, 1985; Buist et al., 2003). However, both the mother and father are attached to the fetus when expecting a baby. Mothers and fathers interact differently with the developing fetus, but evidence for these differences is contradictory. Some studies have shown that mothers have higher attachment to the fetus compared with their partners (Mercer et al., 1988; Lorensen et al., 2004), some studies found higher fetal attachment in the fathers (Schodt, 1989; White et al., 1999), and another study found similar levels of fetal attachment in both parents (Wilson et al., 2000). This study examines the relationship between parental attachment (MFA and PFA) and both demographic and perinatal variables among couples in Turkey. It is important to recognise the factors influencing MFA and PFA because of the effects on the future health and development of the infant. There is evidence, some conflicting, that the demographic variables of maternal age, education and family income may correlate with attachment. Maternal age has not been correlated with prenatal attachment scores in most studies (Cranley, 1981; Lerum and LoBiondo-Wood, 1989; Ustunsoz and Inanc, 2001). However, some studies reported an inverse relationship between maternal age and attachment (Mercer et al., 1988; Zachariah, 1994; Lindgren, 2001). Maternal education has been correlated inversely with prenatal attachment in some studies (Mercer et al., 1988; Lindgren, 2001) but not in others (Wilson et al., 2000; Ustunsoz and Inanc, 2001). Similarly, income was not correlated with prenatal attachment in one study (Cranley, 1981), but was negatively correlated with attachment in another study (Lerum and LoBiondo-Wood, 1989). The perinatal variables selected for this study (i.e. parity, pregnancy risk status, planning of pregnancy) were based on past research findings. Cranley (1981) A. Ustunsoz et al. did not find a relationship between attachment and parity, but Ferketich and Mercer (1994) found that increased parity had a negative effect on attachment. Risk status has (Feldman et al., 1999) and has not (Cranley, 1981; Mercer et al., 1988; Chazotte et al., 1995; Lindgren, 2001; Ustunsoz and Inanc, 2001) been shown to influence maternal attachment. Previous investigators have found planning of pregnancy to be positively correlated with postnatal attachment (Lerum and LoBiondo-Wood, 1989; Damato, 2004). The only Turkish study on MFA was by Ustunsoz and Inanc (2001), and the authors are unaware of any Turkish studies on PFA. Furthermore, only a few studies have evaluated both MFA and PFA together (Mercer et al., 1988; Schodt, 1989; White et al., 1999; Wilson et al., 2000; Lorensen et al., 2004). However, it is important to consider the mother and father together as the attachment of both parents to the fetus is important for the psychosocial development of the child and to increase the harmony of the couple. Prenatal care is a good opportunity to evaluate the attachment of the mother and father to the unborn child. The candidate mothers and fathers are taught procedures that may increase parental fetal attachment during prenatal care such as loving the fetus over the mother s belly and talking to the fetus (Bryan, 2000). Prenatal nurses are in a unique position to assess attachment and to intervene to promote attachment behaviours (Franklin, 2006). Bellieni et al. (2007) showed that prenatal education courses have a positive influence on prenatal attachment. However, some important factors influencing parental attachment, such as mother father relationship, age of parentsto-be, parity of mother/previous experience of fatherhood, high-risk pregnancy, number of existing children, education levels etc., cannot be changed. Nurses may assess the factors that influence parental fetal attachment during prenatal care. If a pregnant woman and/or her partner do not appear to have deep feelings of attachment, nurses can refer her/him for professional counselling. It is hoped that this study may help midwives and nurses who work in the prenatal field to understand the attachment process and to provide comprehensive prenatal care. The purpose of this study was to compare MFA and PFA in pregnant women and their partners in terms of selected factors with the potential to influence prenatal attachment. Specifically, the following questions were examined in this study: What is the relationship between the MFA and PFA scores?

3 e3 What is the relationship between selected variables (education, employment status, planning of pregnancy, risk status) and MFA and PFA scores? evaluated as high-risk pregnancies, while those who did not have any risk factors were evaluated as low-risk pregnancies. Methods Design The study was approved by the appropriate ethics committee. The participants were informed orally about the purpose of the study and the length of time it would take. They were also informed that their responses would be kept confidential, and that they would have the right to withdraw from the study at any time. This cross-sectional descriptive study was conducted at the prenatal care units of three training hospitals in Ankara, Turkey, between December 2005 and March These hospitals provide services to women of varied socio-economic status in Ankara, and it was planned that the study would include a sample that reflected Ankara in general. Maternal health-care services in Turkey are mainly provided by the government-run referral system, composed of health stations in rural areas, health posts in urban areas, health centres and hospitals (C- elik, 2000; Erci, 2003). Participants All eligible pregnant women and their partners in the prenatal care waiting rooms of three hospitals during the period of investigation were invited to participate in the study. The study sample consisted of 144 pregnant women and 144 partners. Parents with the following features comprised the study sample: married couples (Turkish culture does not approve of having children out of wedlock and unmarried pregnant women therefore prefer private doctors. As such, the authors did not encounter any unmarried pregnant women in the state hospitals included in this study); pregnant women and their partners who were at least primary school graduates and were willing to participate in the study; pregnant women (low and high risk) who were in the third trimester (24 36 weeks) and their partners; and pregnant women who had any risk factors (diabetes, pre-eclampsia, multiple pregnancy, stillbirth, history of abortion, etc.) were Measures and data collection Three tools were used for data collection. The first tool was the Demographic Information Questionnaire, which was developed by the investigators based on the existing literature. This questionnaire includes general demographic data (age, education, etc.) and obstetric data (pregnancy week, risk status, etc.). The second tool was the MFA scale (Cranley, 1981), which measures the affectionate attachment between mother and fetus; and the third tool was the PFA scale (Weaver and Cranley, 1983), which measures the affectionate attachment between father and fetus. Both scales have 24 five-point Likert-type items and are self-administered. The scales are scored on a scale of one to five, with five being the most positive statement. Note that the scoring is reversed for Item 22, with Definitely yes scoring one point and Definitely no scoring five points. The mean score is calculated by dividing the sum of the item scores by the number of items answered. Cronbach s alpha for MFA was 0.84 in Cranley s study (1981), and Cronbach s alpha for PFA was 0.86 in Weaver and Cranley s study (1983). Permission was obtained from Cranley to adapt the scales for Turkish culture. Two bilingual faculty members independently translated the scales to the Turkish language and reached similar results. The faculty then met, reviewed the translations together, and agreed on the first draft of the translated tools. The translated Turkish versions of the scales were independently back-translated to English by two bilingual persons. The two back-translations were almost identical and matched the original meaning of the English versions. No changes in wording were needed as a result of back-translation. The tools were then given to four bilingual health professional experts to validate the content of the translated version of the scales and to determine cultural appropriateness. These professional experts were two medical doctors and two nursing faculty members. The experts suggested minor changes in wording and the translated tools were revised accordingly. The instruments were pilot tested with eight couples to assess the clarity of the items. Changes in wording recommended by the couples were incorporated into the final versions of the instruments. Cronbach s alpha was 0.82 for MFA and 0.86 for PFA in this study. These results indicate

4 e4 that the MFA and PFA scales are reliable for Turkish couples. Verbal informed consent was obtained during data collection. Both partners were interviewed separately, often simultaneously, in prenatal care units. Data collection forms were completed during face-to-face interviews. The time taken for participants to complete the questionnaire was approximately minutes. Three couples did not wish to take part in the study for various reasons and were not included. A clinical psychologist was contacted before the study to provide counselling services if any couples were found to have attachment problems. The participants were asked to contact the investigators if they had any questions or worries about the survey. However, no couples requested or needed counselling as determined by the investigators. Statistical analysis The data were analysed statistically using Statistical Package for the Social Sciences Version 15.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were computed for the demographic characteristics. Reliability was assessed using item-total subscale correlations and Cronbach s alpha coefficients. Normal distribution was evaluated using the one-sample Kolmogorov Smirnow test and nonparametric tests were chosen. The relationships between selected variables (education, employment status, planning of pregnancy, risk status) and MFA and PFA scores were evaluated using the Mann Whitney U test. The relationship between MFA and PFA scores according to selected variables was assessed using the Wilcoxon test. The interclass correlation coefficient was determined to analyse the association between MFA and PFA scores. The correlation between MFA and PFA scores for some chosen variables (age, gravida, parity, education) was evaluated using Spearman s correlation and Kendall Tau B tests. A p-value less than 0.05 was accepted as statistically significant for all analyses. Backward linear regression was performed to evaluate factors that affect attachment scores. Findings Out of 147 couples approached, 144 pregnant women and 144 partners participated in the study (144/147 ¼ 98.0%). Demographic and obstetric data are shown in Table 1. The mean age of the pregnant women was years [standard deviation (SD) 5.34], and the mean age of the partners A. Ustunsoz et al. was years (SD 5.89). The education level was high school or higher in 50% of the pregnant women and 18.1% were employed. The respective numbers were 73.6% and 97.9% for the partners. Sixty per cent of the pregnant women were low risk and 40.3% were high risk (Table 1). There was a positive and significant correlation between MFA and PFA (r ¼ 0.86, po0.001) (Table 2). On the other hand, there was a statistically significant difference between MFA and PFA scores (po0.001) (Table 3). A comparison of MFA and PFA scores according to the selected variables revealed that the MFS scores of pregnant women were significantly higher than the PFA scores of their partners, except for unemployed partners (Table 3). There was a significant and negative correlation between the age of the pregnant women and their partners and MFA (r ¼ 0.24, po0.004) and PFA (r ¼ 0.32, po0.001) scores (Table 2). The MFA and PFA scores decreased with increasing age of both pregnant women and their partners. A significant negative correlation was found between MFA and the number of pregnancies and parity, and also between PFA and the number of children of the partner (Table 2). In addition, the MFA scores of nulliparous women were significantly higher than the MFA scores of multiparous women. The PFA scores of the partners of nulliparous women were significantly higher than those of the partners of multiparous women (po0.001) (Table 3). A significant and positive correlation was found between the educational levels of the pregnant women and their partners and the MFA (t ¼ 0.32, po0.001) and PFA (t ¼ 0.26, po0.001) scores (Table 2). The MFA and PFA scores increased with an increasing level of education. In addition, pregnant women and partners educated at high school or a higher level had significantly higher fetal attachment scores that those who had only completed primary or secondary school (po0.001) (Table 3). The PFA scores of the partners of low-risk pregnant women were significantly higher than those of the partners of high-risk pregnant women (p ¼ 0.007). There was no statistically significant difference between pregnancy risk status when compared by MFA score (p40.05) (Table 3). There was a statistically significant difference between planning of pregnancy and MFA (po0.02) and PFA (po0.001) scores. Both MFA and PFA scores were higher in planned pregnancies than in unplanned pregnancies (Table 3). Backward linear regression was performed to evaluate factors which affect MFA and PFA scores. Age, education, employment status, number of pregnancies, number of children, pregnancy risk

5 e5 Table 1 Demographic and obstetric data. Pregnant women Pregnant women s partners n % n % Educational status Primary to secondary school High school to university Employment status Employed Unemployed Pregnancy risk status Low risk High risk Planning of pregnancy Planned Unplanned Mean SD Mean SD Age (years) Number of pregnancies Parity Table 2 Correlations between maternal fetal attachment (MFA) and paternal fetal attachment (PFA) and selected variables. MFA and PFA Correlation coefficient c p 0.86 o0.001 MFA (n ¼ 144) PFA (n ¼ 144) r a p r a p Pregnant woman s age o0.001 Partner s age o0.001 Number of pregnancies 0.42 o0.001 Parity b 0.45 o o0.001 Pregnancy week Pregnant woman s education d t ¼ 0.32 o0.001 t ¼ 0.26 o0.001 Partner s education d t ¼ 0.25 o0.001 t ¼ 0.25 o0.001 a Spearman s Rho test. b Number of children for partners. c Interclass correlation coefficient. d Kendall Tau B test. status and planning of pregnancy were assessed in this analysis. Variables influencing the MFA and PFA scores are presented in Table 4. The MFA score was found to be negatively influenced by the mother s age, although the PFA score was negatively affected by the pregnancy risk status, the father s age and the number of children of the father. The MFA score was most positively correlated with the PFA score, and the reverse was also true (po0.001) (Table 4). Discussion Parental fetal attachment is a naturally occurring event that begins during the prenatal period. The

6 e6 A. Ustunsoz et al. Table 3 Comparison of maternal fetal attachment (MFA) and paternal fetal attachment (PFA) scores by selected variables. MFA (n ¼ 144) PFA (n ¼ 144) Median (min max) Median (min max) Z b df p MFA and PFA 3.75 ( ) 3.54 ( ) o0.001 Parity Nulliparous 3.94 ( ) 3.71 ( ) o0.001 Multiparous 3.64 ( ) 3.33 ( ) o0.001 Z a ¼ 4.52, po0.001 Z ¼ 4.46, po0.001 Pregnant woman s educational status Primary to secondary school 3.66 ( ) 3.31 ( ) o0.001 High school to university 4.00 ( ) 3.70 ( ) o0.001 Z ¼ 4.94, po0.001 Z ¼ 5.11, po0.001 Pregnant woman s employment status Employed 4.02 ( ) 3.72 ( ) Unemployed 3.75 ( ) 3.50 ( ) o0.001 Z ¼ 1.39, p ¼ 0.16 Z ¼ o2.12, p ¼ 0.03 Partner s educational status Primary to secondary school 3.58 ( ) 3.25 ( ) o0.001 High school to university 3.83 ( ) 3.62 ( ) o0.001 Z ¼ 3.70, po0.001 Z ¼ 3.71, po0.001 Partner s employment status Employed 3.75 ( ) 3.54 ( ) o0.001 Unemployed 3.79 ( ) 3.62 ( ) Z ¼ 0.26, p ¼ 0.79 Z ¼ 0.34, p ¼ 0.73 Pregnancy risk status Low risk 3.79 ( ) 3.58 ( ) o0.001 High risk 3.75 ( ) 3.35 ( ) o0.001 Z ¼ 1.64, p ¼ 0.10 Z ¼ 2.67, p ¼ Planning of pregnancy Planned 3.79 ( ) 3.58 ( ) o0.001 Unplanned 3.41 ( ) 2.87 ( ) o0.001 Z ¼ 3.10, p ¼ 0.02 Z ¼ 3.88, po0.001 a Mann Whitney U test. b Wilcoxon test. feelings of attachment strengthen when fetal movement is felt, and grow stronger with parent infant interaction after birth (Franklin, 2006; Oppenheim et al., 2007). Prenatal nurses should consider this topic because parental fetal attachment has important implications for adaptation to roles of motherhood and fatherhood, and for the child s growth and development. During the prenatal period, nurses can assess parental attachment, perform procedures to develop attachment positively, and direct pregnant women and/or their partners with low attachment scores to receive professional counselling. In addition, this assessment can help to develop disciplinary knowledge and provide nurses with the information they need to advance theory and practice in the area of prenatal care. MFA and PFA were examined in relation to demographic and perinatal variables in this study. Several reports have demonstrated that most pregnant mothers and fathers develop strong affective responses to their unborn child (Cranley, 1981; Weaver and Cranley, 1983; Condon, 1985; Mercer et al., 1988). A positive relationship was found between the MFA and PFA scores in the current study. However, when comparing the pregnant women and their partners, the MFA scores were higher than the PFA scores. This may have

7 e7 Table 4 Regression analyses between maternal fetal attachment (MFA) and paternal fetal attachment (PFA) and selected variables. B t p MFA (Constant) o0.001 Pregnant woman s age Partner s age Woman s education PFA o0.001 PFA (Constant) o0.001 Pregnancy risk status Pregnant woman s age Partner s age Number of children MFA o0.001 been a result of women feeling the physical signs of pregnancy directly in their bodies. In addition, quickening develops when a pregnant woman first feels her baby moving within her uterus. The ability to view the fetus as an independent being at an earlier point in pregnancy likely contributes to development of the maternal fetal relationship (Alhusen, 2008). Stormer (2003) reported that quickening enhances feelings of attachment towards the fetus. Mercer et al. (1988) and Lorensen et al. (2004) reported that mothers had higher fetal attachment than their partners, similar to the present findings. Some studies have reported a negative correlation between MFA score and mother s age, and that younger women have higher MFA scores (Mercer et al., 1988; Zachariah, 1994; Lindgren, 2001). Similarly, MFA and PFA scores decreased with increasing age of the pregnant women and their partners in this study. A negative relationship was found between MFA score and the number of pregnancies and parity, and between PFA score and previous experience of fatherhood. The multigravid mothers and their partners had significantly lower MFA and PFA scores than the primigravid mothers and their partners in this study. Other studies support these findings (Ferketich and Mercer, 1995; Condon and Cortindale, 1997; Haedt and Keel, 2007; Nichols et al., 2007), although others found no such relationship (Zachariah, 1994; Lindgren, 2001). In the current study, this difference with primigravid mothers and their partners may indicate the possibility of less focus on the current pregnancy and on their fetus, perhaps due to giving attention to their other child/children. Furthermore, in traditional Turkish society, women usually take care of responsibilities such as child care, housework, cooking, cleaning and child education (Turmen, 2003). The women therefore have more responsibilities at home than at work, which may have produced the study result. The educational status of the pregnant women and their partners was associated positively with MFA and PFA in this study. Inverse correlations (Mercer et al., 1988; Lindgren, 2001) and no appreciable correlation have been reported between these two variables in different studies (Wilson et al., 2000). This study revealed that the employment status of the woman or her partner did not influence MFA or PFA. Similar to the present study, some studies have reported no correlation between MFA and the pregnant women s employment status and income (Lindgren, 2001; Ustunsoz and Inanc, 2001). If the pregnancy is high risk, it may be difficult for the pregnant woman to cope, and her attachment towards the baby may be adversely affected (Weingarten et al., 1990). However, no significant differences in prenatal attachment were reported between low-risk and high-risk pregnant women in the present study and others (Cranley, 1981; Mercer et al., 1988; Chazotte et al., 1995; Lindgren, 2001; Ustunsoz and Inanc, 2001). The partner of a highrisk pregnant woman may experience a situational crisis due to the high-risk pregnancy in addition to the normal developmental crisis of pregnancy. This stress is additional to the normal emotional reaction in the partner, and may affect prenatal and postpartum attachment (Ferketich and Mercer, 1994; Ustunsoz and Inanc, 2001; Buist et al., 2003). The current study showed that PFA scores of the partners of low-risk pregnant women were

8 e8 higher than those of the partners of high-risk pregnant women. Unlike the present study, Mercer et al. (1988) found no significant differences in the PFA scores of the partners of low-risk and high-risk pregnant women. Studies have reported that the quality of the emotional attachment of pregnant women towards their fetus may be higher if the pregnancy has been planned, social support is available, the woman has a comforting relationship with her partner and prenatal care has been provided (Condon and Cortindale, 1997; Bellieni et al., 2007). The findings of the present study showed that MFA and PFA scores were higher in planned pregnancies than unplanned pregnancies. Contrary to the results of this study, Damato (2004) found that planning of pregnancy did not predict the level of fetal attachment. This study found that MFA and PFA had the most positive effect on each other among variables influencing the fetal attachment of pregnant women and their partners. This result emphasises the importance of evaluating the pregnant woman and her partner together when assessing attachment. It is hoped that these results will be beneficial for future investigations and for midwives and nurses working in the prenatal field. However, the study did have some limitations. This study was conducted in three hospitals in a large urban area, and cannot be said to represent the whole of the Turkish population. In addition, the relationship between the gender of the unborn baby and attachment was not investigated. A male child increases a woman s status in rural areas of Turkey, and further studies in rural areas are recommended. Conclusion This study has three main findings. First, Cranley s MFA and PFA scales were found to be valid instruments for Turkish pregnant women and their partners. Second, some demographic and perinatal characteristics were found to influence prenatal attachment, with MFA and PFA having the most positive effect on each other. Finally, pregnant women had higher levels of fetal attachment than their partners. Promotion of prenatal attachment may serve as the crucial link to improving maternal health practices, perinatal health and neonatal outcomes. It is important to recognise the factors influencing attachment of the mother and father towards their fetus, and to strengthen nursing interventions regarding these factors both for the physical and emotional development of the infant and to provide familycentred prenatal care. Consequently, more studies are required to gain a better understanding of the factors that influence MFA and PFA. References A. Ustunsoz et al. Ahern, N.R., Ruland, J.P., Maternal fetal attachment in African-American and Hispanic-American women. Journal of Perinatal Education 12, Alhusen, J.L., A literature update on maternal fetal attachment. 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9 e9 Lerum, C.W., LoBiondo-Wood, G., The relationship of maternal age, quickening and physical symptoms of pregnancy to the development of maternal fetal attachment. Birth 16, Lindgren, K., Relationships among maternal fetal attachment, prenatal depression, and health practices in pregnancy. Research in Nursing and Health 24, Lorensen, M., Wilson, M.E., White, M.A., Norwegian families: transition to parenthood. Health Care for Women International 25, Mercer, R., Becoming a mother versus maternal role attainment. Journal of Nursing Scholarship 36, Mercer, R.T., Ferketich, S., May, K., DeJoseph, J., Sollid, D., Further exploration of maternal and paternal attachment. Research in Nursing and Health 11, Nichols, M.R., Roux., M., Haris, N.R., Primigravid and multigravid women: prenatal perspectives. Journal of Perinatal Education 16, Oppenheim, D., Koren-Karie, N., Sagi-Schwartz, A., Emotion dialogues between mothers and children at 4, 5 and 7, 5 years: relations with children s attachment at 1 year. Child Development 78, Schodt, C.M., Parental fetal attachment and couvade: a study of patterns of human environment integrality. Nursing Science Quarterly 2, Shieh, C., Kravitz, M., Wang, H.H., What do we know about maternal fetal attachment? Kaohsiung Journal of Medical Sciences 17, Stormer, N., Seeing the fetus: the role of technology and image in the maternal fetal relationship. Journal of the American Medical Association 289, Turmen, T., Toplumsal cinsiyet ve kadın sağlığı [Gender and women s health]. In: Akın, A. (Ed.), Gender, Health and Women. Hacettepe University Press, Ankara, pp Ustunsoz, A., Inanc, N., Sağlıklı ve yüksek riskli gebelerde prenatal bağlılığın kars-ılas-tırılması [Comparing prenatal attachment in healthy pregnant and high-risk pregnant women]. Gulhane Medical Journal 43, (in Turkish). Weaver, R.H., Cranley, M.S., An exploration of paternal - fetal attachment behaviour. Nursing Research 32, Weingarten, C.T., Baker, K., Manning, W., Kutzner, S.K., Married mothers perceptions of their premature or term infants and the quality of their relationships with their husbands. Journal of Obstetric, Gynecologic, and Neonatal Nursing 19, White, M.A., Wilson, M.E., Elander, G., Persson, B., The Swedish family: transition to parenthood. Scandinavian Journal of Caring Sciences 13, Wilson, M.E., White, M.A., Cobb, B., Curry, R., Greene, D., Popovich, D., Family dynamics, parental fetal attachment and infant temperament. Journal of Advanced Nursing 31, Zachariah, R., Maternal fetal attachment: influence of mother daughter and husband wife relationships. Research in Nursing and Health 17,