From research to clinical work in pregnancy

1. From research to clinical work in pregnancy Massimo Ammaniti (Sapienza University of Rome) massimo.ammaniti@uniroma1.it

2. For a woman and for the couple pregnancy is an extremely important transition phase, during which one prepares to become a parent and to take care of a child who will be immature and dependant for all his first year of life. Research and clinical contributions have lent specific attention to the construction of the maternal identity, defined by Stern (1995) maternal constellation, and to the development of maternal capabilities during pregnancy, which are indicative and foretelling of the mother-child relationship after birth, even in at-risk situations.

3. The psychology and the psychopathology of pregnancy have been studied using research tools that have addressed different areas. In this paper we will take into consideration a few of the more relevant research areas for this phase: • 1) The psychological dynamics connected to the attainment of the maternal identity, analysed through the mental representations of pregnant women; • 2) The formation process of the mother’s attachment to the child during pregnancy, which prepares the stabilization of this attachment after birth; • 3) Mental states specific to pregnancy, such as the primary maternal preoccupation (Winnicott, 1956). • The assessment of prenatal parenting has been done through research instruments with different purposes: semi-structured clinical interviews, self-report-questionnaires and scales.

4. 1) Semi-structured clinical interviews that investigate the pregnant woman’s mental representations, focusing attention to the woman’s past experiences, to how she copes with pregnancy and maternity and to how she progressively creates the image of the foetus and of the future child. To study the mental representations the woman has of herself as a mother and of the child in a more systematic way, attention is put on the structure of the narration the woman does during the interview. The interview is very susceptible an instrument for exploring parenting mental representations when they are still not defined and stabilized.

5. Among prenatal interviews, the IRMAG-R (Interview for Maternal Representations during Pregnancy- Revised Version, Ammaniti et al., 1992-2008) must be noted; this is a semi-structured interview made of 41 questions which bring women to tell their experience of pregnancy and of becoming mothers: their stories are not evaluated by their content, but on the basis of their narrative structure. The Interview is performed between the 6th and the 8th month of pregnancy and is audiotaped and transcribed. The average length of the Interview is approximately 45 minutes.

6. The Interview explores the following areas: • I How the mother organizes and communicates her experience through a narrative structure • II The desire of maternity within the personal and marital history • III Partner’s and family’s reactions to the news of the pregnancy • IV Emotions and changes in personal life, in relationship with the husband/partner and between the two families occurred during pregnancy • V Impressions, negative and positive emotions, maternal and paternal representations: space for internal baby • VI Temporal perspective: expectations for the future • VII Historical perspective with respect to the mother’s past

7. The narrative structure of the interview is coded considering the mother's representation of herself as a mother and her representation of the child on the basis of seven parameters :

8. Richness of perception • It refers to the woman’s acknowledgement of herself as a mother and of the child: this parameter evaluates the way the episodes, the feelings and the emotions of the woman herself, of her partner and of the future baby are told. • Openness to change • This parameter evaluates the mother’s flexibility towards those physical and psychological transformations which are specific to the experience she is living, referred to herself and to the future baby. It evaluates the capability of recognising these physical and psychological changes which involve herself, her emotional, sexual and relational life as being part of the process. It evaluates the capability to modify the representation of the baby as the pregnancy goes along.

9. Intensity of the involvement • This scale is used to measure the breadth of the woman’s psychological involvement in confronting experiences connected to the pregnancy, to the child and to her relation with the child; this can be found in the description of the emotional echoes caused by the event as well as in the woman’s participation to the interview. • Coherence • It measures the story’s coherence, by which the woman, through a well organised and logical narrative flux gives a comprehensible picture of herself as a mother, of the child and of her relation with the child. Coherence is found in the plausibility of the story told and in the capability to provide evidence and episodes which sustain her considerations and her evaluations.

10. Differentiation • It evaluates the level of the mother’s acknowledgement of her personal boundaries, of her stable mental and physical characteristics, of her specific needs and wishes, differentiated from those of her partner and of her parent figures. It evaluates the degree to which the mother is conscious that the child has his own mental and physical characteristics, with specific boundaries and specific needs. • Social dependence • It evaluates the degree of influence and dependence, to the limit of subordination, of the woman’s representation of herself as a mother and of the child from the opinions, judgements and messages coming from the partner, the family, friends, the social context, mass media, social and medical institutions.

11. It measures the degree of conformism towards others, which can in extreme cases cause a flatness of representation and a lack of personal elaboration. • Predominance of fantasies • It is used to measure the emerging of fantasies regarding the pregnancy, her future motherhood and the representation of the child, intended as all those images, metaphors, analogies, open-eye and night dreams, expectations, fears and wishes which characterise the way a woman imagines the pregnancy experience and the representation of herself as a mother and of the child. The fantasies can refer to the pregnancy itself, to the woman’s body, to delivery, to rearing, to the integrity and physical health of the baby, its physical and character qualities, to the mother’s role; these can all have a more or less realistic quality. It is not only the number of fantasies which must be considered in assigning the score but their importance and their impact on the representation of the mother and the child.

12. These seven parameters all refer to the woman’s representation of herself as a mother and to her representation of the child and are codified in scales with a five-point range (from 1 to 5). The assignment of the final score individuates three different styles of maternal representation: • Integrated/Balanced • The integrated/balanced maternal representations are coherent narrations, in which the description of the experience the woman is living is rich in episodes, moods, and has an intense emotional involvement in an atmosphere of flexibility and openness towards the physical, psychological and emotional transformations the mother is confronting. The relationship with the child is already present during the pregnancy, and the child is considered as a person with his own motives and moods.

13. Integrated/Balanced Mothers • Martina’s story is a perfect example of an Integrated Mother model . In her answers, we feel the importance she gives to her pregnancy on which she has concentrated all her forces. A great capability of recognising her mental states as well as her husband’s emerges from her words, as if she is used to examining herself and the people who surround her.

14. Q – Would you tell me about your pregnancy? • A – This was a desired pregnancy, completely, even because I’m more than 30 years old. I was once married, then separated and now I live with this new man who gives me great tranquillity. I have always wanted a child, so I thought I had to have it now or decide I’d have a life without children. So I did all the tests, a year before, I got prepared; it definitely was a planned pregnancy. When I became pregnant, I had just switched to a new job, since I was planning to have a child I had switched from a full-time to a part-time job. I have many interests, I do artistic gymnastics and many other things; I don’t believe you have to quit everything when you have a baby. Of course you will be dedicating most of your time to the baby, but you have to keep doing your own things.

15. Q – How did you face this pregnancy? • A – I had some problems, from a physical point of view. Psychologically I faced it very well. Of course you are a bit shocked, I think that happens to everyone because there’s something new, something you don’t quite understand, especially when you have your first ultrasonography, when it’s still tiny, you see this little spider. And then this child is growing inside of you. It kicks you, and you feel something weird and think “Oh God, there’s a baby growing inside of me”. I know it’s not really strange but it just surprises you. • I actually accepted it from the start; I wanted a child so much; of course it’s also important that the man I live with now gives me such tranquillity.

16. Q – Would you tell me how you felt when you first found out you were pregnant? • A – When I first found out, because of the practical problems with my job I wasn’t actually sure if I should be happy or not. Then I thought that everything could be arranged, because even when confronting problems of schedules, of work, when you know you’re going to have a baby it all becomes relative before the baby. • At first you’re a bit surprised, even because they tell you you’re pregnant but you can’t feel it yet. You feel as usual, normal, at least until you start growing a belly.

17. Q – Who else did you tell? • A – My mother, my father, my cousin • Q – All the same day? • A – Yes, the same day. I called my mother that evening. I wasn’t sure if I should tell her immediately, or how to tell her, if in person. Then I just called.

18. Q – When did you notice the first changes in your body? • A – Everybody asks that. In the first few months, only around the fourth month when the belly starts becoming noticeable. At that stage, when it’s still small. You actually feel as if you are only overweight and you feel ugly. Now that I have a big belly, I have no problems: if I pass before a mirror I see it. • Q – Have there been specific moments of great emotion during the pregnancy, until now? • A – Some times I feel very sad; I don’t know if this is normal, or connected to the pregnancy. For example I am more easily upset and seem to feel things more intensely.

19. Q – Do you have specific fears? • A – I’m afraid the baby might have some problems, defects, but it’s not a great fear; I’m actually convinced I will deliver a beautiful girl. I don’t know why, but I’m convinced. • Q – Have you had dreams related to the pregnancy? • A – One dream I remember, because it was only a couple of nights ago, I was losing blood from my mouth, I don’t know why. In general when I dream I see myself pregnant, yes, I’m always pregnant in my dreams now, even if I don’t remember them clearly.

20. Q – When you realised there was a baby girl inside of you what did you feel? • A – As I said before, a lot of amazement. And in this period, I feel very creative. Alessandro said: “Of course, this is the most creative of periods!” And I answered “Actually, if you think about it, you and I have created a girl, created her from scratch, because before there was nothing.” • (Zero) • Q – And the awareness of this new being came with her first movements? • A – With the first movements, yes, but even more in this last month. I really feel her, I feel she’s in here.

21. Q – What do you imagine her like? • A – Beautiful. I imagine her beautiful. And then obviously she sleeps. She has to sleep for months. And then I imagine her calm, friendly and always smiling. • Q – And physically? • A – I imagine her tall, skinny. And blond with blue eyes. Simply beautiful.

22. Q – Would you say that there already is a relationship between you and the baby? • A – I don’t know. I sing lullabies to her, inventing them. I talk to her, simple things like “How are you?”. I talk to her in my head more than with my voice. In the morning I tell her “Now I will sing a lullaby for you, calm down”. • Q – Have you chosen a name? • A – Yes, we will call her Chiara. It’s not a family name, we just chose it from the start. It’s nice, it’s a name we like.

23. Q – What do you think she will need in the first months? • A – Most of all love, lots of love, attention, in the first months especially. She needs to feel in a warm atmosphere, full of care, where she is taken care of, welcomed. • Q – What kind of mother do you think you will be in the first months? • A – In the first months I would like to be tolerant, open. I hope to be very stimulating for the baby, and very caring. • Q – What kind of mother you don’t want to be? • A – I don’t want to be obsessive, anxious, authoritarian in a bad sense.

24. Restricted/Disinvested • The restricted/disinvested representations emerge from narratives in which a strong emotional control prevails, with mechanisms of rationalisation towards the fact of becoming a mother and towards the child: these women talk of their pregnancy, of motherhood and of the child in poor terms, without many references to emotional events and changes. The storytelling has an impersonal quality, is frequently abstract and does not communicate emotions or specific images .

25. Restricted/Disinvested Mothers • Flaminia is a young woman who shows a restricted representation of herself as a mother and of her child. Even though she gives value to her motherhood experience, Flaminia wants to maintain her independence and self control and does not want to be too conditioned by the child that is about to be born.

26. Q – Would you tell me about your pregnancy? • A – I must say I was very lucky, I never had any problems. Even in the first three months, I had no nausea, vomiting etc. I did some things which you’re supposed to avoid, like skiing, going on a motorcycle… but I felt ok, felt I could do it. But my first three months were characterised by a certain nervousness, a state of tension. After the first three months I started getting used to the idea and calmed down. I still had no physical problems. Then slowly, with great difficulty, I started getting used to the idea of my body transforming.

27. Q – Why a baby in this moment of your life? • A – I thought about it a lot because I didn’t feel ready, even if I’m not a kid anymore. I always had this idea I wouldn’t have kids. I’m not crazy about kids, I’ve never been drawn to them much. Then, maybe because you feel the need after a number of years in a marriage, or maybe because my husband who wasn’t convinced either, changed his mind… it was a series of things which pushed me towards this decision. • Q – What did you feel when you found out you were pregnant? • A – I am quite cold, as a person. I don’t get carried away easily, so even in this case I wouldn’t have told anyone, I’d have kept it for myself. I first needed to get used to the idea.

28. Q – Have there been specific moments of great emotion during the pregnancy, until now? • A – Maybe when I did the ultrasonography towards the fourth month. That’s the first time you actually see this little growing being and you see it whole. But mostly my feeling was a reflection of the great emotion I could see on my husband’s face. Seeing his reaction, I let myself be influenced by his state of mind mood and felt it as if it were a feeling of mine. • Q – During the pregnancy, were there times when you felt worried or mad about something? Have you ever felt any particular needs? • A – I can’t think of anything now. The preoccupation everyone has, on the baby’s health.

29. Q – Have you had dreams during the pregnancy? • A – Yes, but I never remember my dreams. I remember I was eating yoghurt in the last one, but I have no idea what it might mean. • Q – How do you imagine the baby? • A – I actually don’t imagine it. • Q – Do you imagine its physical features, its character? • A – No. • Q – And its sex? • A – Not even its sex, I didn’t want to know and I don’t want to think about it. It will be a surprise.

30. Q – Do you and your husband talk to the baby or use nick names? • A – Yes, but it’s mostly my husband who talks to it, not me. Even if I feel there is a bond between the baby and me, I still can’t bring myself to talk to it.

31. Not integrated/Ambivalent • The not integrated/ambivalent maternal representations • are those found in confused narrations, characterised by • digressions and by the woman’s difficulty in answering • questions in a clear and articulate way. The coherence of the • story is poor, and an ambivalent involvement of the mother • towards the experience she is living, towards her partner and • towards her family is present. These women often express • contrasting attitudes towards their motherhood, or towards the • child. The son or daughter is frequently awaited to satisfy the • caregiver’s needs.

32. Not Integrated/Ambivalent Mothers Roberta is an example of Not Integrated Mother. A young woman of twenty-nine years old, the idea of having a child has made its way in her amidst many ambivalences and uncertainties, showing all the difficulties that a not integrated mother manifests in fully accepting a maternal identity.

33. Q – Would you tell me about your pregnancy? • A – In the beginning we had many things, those egoistic projects of settling everything first, because we started out with nothing, and we thought ‘we’ll think about a baby later on. So let’s say it wasn’t a thought, like we both had of the baby in the beginning. Then when things started working out, everything, we looked each other in the eye and said ‘what do you think about it? I am thirty already’. And he didn’t want to, he had decided that he was already old when we married; he had already settled, so he had some difficulties, he said he didn’t want to be a grandfather. (…) He had these problems, fears, which I didn’t have, mine were completely different, like how will I help my child in 20 years time, finding a job, or school for example.

34. Now I’m completely terrified on how to do things, and the kinder garden, the people he will hang out with cause we know what it’s like, and my mentality is not ‘live by the day’, maybe I worry too much about everything around me. That’s why I used to say ‘let’s wait’ then one fine day this decision just arrived. ‘What do you think about it?’ ‘And maybe yes, it’s time’, we made a joke about it, ‘Time to take on responsibilities...’ That’s when I started thinking, I started asking around, how many children, how long did it take etc. Someone told me ‘I thought about having the first one for four years and then the second in twenty day’; others go: ‘Immediately, one after the other’. These kind of things. I said ‘O God, I waited so long, and now I’m thirty’, in fact this was my fear, I said ‘You’ll see that now that I want one, it won’t come’. (…)

35. I looked for a laboratory where they could do my, my urine test and so I did it, and she goes ‘Congratulations’ and I was practically walking trying to avoid holes, absurd, because I had taken two buses to get there, and I was walking as if over boxes of eggs, I was afraid of ruining this thing. I thought ‘Oh my God maybe I did something in the first days. (…) In the beginning, after a month and a half, I started having nausea problems, upset stomach, lots of saliva, so that after two months I was thinking ‘Why on earth did I do it?’. Because I was really sick. (…) I was thinking ‘What a terrible pregnancy I’m going to have’ because some would say ‘It’s all going to end soon’ and others ‘I threw up all the way to the ninth month’. (…)

36. And my doctor said ‘it’s mostly psychological’. On one hand we wanted it, but on the other maybe there was a part of truth, because I was very embarrassed to tell my boss, I didn’t know how to tell him. • Q – How did you feel when you found out you were pregnant? • A – I found out after only a week, and there I was, telling the nurse ‘Are you really sure?’, because maybe it could be like with those pharmacy tests, which are uncertain. They told me in the pharmacy that if it’s sure, when it appears clearly it’s positive, that is, it’s negative; no, no it’s positive, when it appears clearly; when it’s uncertain it could be positive or negative. I was so excited because it’s not… I was saying ‘No, it’s not possible’, in that moment it wasn’t ready. (…)

37. In the laboratory, he said “Look, the stick doesn’t become pink if it’s not positive”; so nothing, this thing was pink, ‘if you say so it must be, you guarantee, when I walk out of here I can tell my husband’. • Q – How did you feel and how did your life change during pregnancy? • A – How did I feel? Happy, really happy personally, and all the people around me where happy, so it was really nice; except for my boss, maybe, because probably for him it wasn’t. But aside from that, even with the people we know, I found people very happy to give me some advice, things like don’t do this, or that. Don’t gain too much wait or eat all you can cause it’s for the baby, everyone. Younger people will say ‘Don’t eat too much, you’ll get fat’ and older people will say ‘Eat a lot so you have a big healthy baby’, clearly not.

38. Q – Have there been specific moments of great emotion during the pregnancy? A – Yes, when I did my ultrasonography in the fourth month, when they said ‘this is the heart beating’ and on the screen monitor there was this confused image, but when we saw the head, I absolutely didn’t imagine that I could see a profile. It really gave me a strange impression, seeing it. (…) Then there’s this thing which doesn’t excite me but amuses me. I have found out that, in the morning, drinking very hot milk, the baby does some strange movements. And I feel them even when I drink cold water, directly out of the fridge; so sometimes I switch from a hot thing to a cold thing to see what reactions it has.

39. Q – Are there dreams you remember of this pregnancy period? • A – Yes, I realise I have been dreaming more, but mostly it’s bad dreams. Sometimes sad dreams, sometimes bad ones, really bad. • Q – What did you feel when you first realised there was a baby inside you, ? • A – Happy, because I thought ‘it’s there, so I have to be careful of what I do, to do things to not… The first period for example I was very anxious and I had terrible pains in the stomach and I was afraid the baby felt pain too.

40. Q – How do you imagine this baby? • A – Wishing is different from imagining. How I imagine it, I don’t know, I imagine the baby ugly and dark, with dark hair; how I wish it to be instead is different, obviously beautiful and with clear eyes, beautiful; well, I’d like one thing, one wish, that it doesn’t look like me. • Q – Do you imagine the baby as a boy or a girl? • A – I imagine it as a boy but I hope it’s a girl.

41. Two independent, trained, certified, and reliable judges code IRMAG interviews according to the above described seven rating scales. Inter-rater reliability for IRMAG scales ranged from .89 (coherence) to .96 (predominance of fantasies), with a mean reliability of .92. Inter-rater reliability with respect to the main category was 94% (k=.83, p<.001). Disagreement was solved by a third rater. • Statistical validity is supported by an exploratory factor analysis using oblimin rotation, performed both for maternal representation of herself as a mother and of her child.

42. Considering the statistical characteristics of the Interview the screen plot suggested that two factors should be extracted, in both cases. The two dimensions formulated to define the construct of mother's mental representations of herself as a mother were confirmed by factor analysis and accounted for 70.50% of the post-rotational variance. Measures of internal consistency (Cronbach’s alpha) were conducted to examine the reliability of the two dimensions (F1, M=2.99, SD .40, α .85;F2, M=2.61, SD .58, α .52 ).

43. In the same manner, the two dimensions formulated to define the construct of the mother's mental representations of her unborn infant were confirmed by factor analysis and accounted for 78.95% of the post-rotational variance. Measures of internal consistency (Cronbach’s alpha) were conducted to examine the reliability of the two dimensions ((F1, M=2.89, SD .40, α .93;F2, M=2.63, SD .73, α .45 ).

44. At the end of the interview the are 5 scales modelled on semantic differentials, each containing 17 pairs of opposite adjectives. The first three scales designate the individual characteristics of the unborn infant, of the woman’s self and of the infant’s father. Comparing the three lists, it is possible to evaluate if the representation of the baby is more influenced by the woman’s self-representation or that of her partner. The other two scales, deal with the maternal characteristics of the pregnant woman and those of her mother. In this case adjectives will refer to affective orientations, personal lay-out, maternal role, maternal sensitivity and competence.

45. The interview is used to assess how information and emotions concerning the woman herself and her child are organized, whereas the five scales give us a picture of the contents of the representations. The two instruments can be used together (Ammaniti et al. 1992; Ilicali, Fisek, 2004) and independently (Ammaniti, Tambelli, Perucchini, 1998; Pajulo et al. 2001; 2006). To explore the configuration of paternal representations and their differences from the mother’s the I.R.PA.G. (Interview for Paternal Representations during Pregnancy-Ammaniti, Tambelli, Odorisio 2006) is used. As indicated in table 1, fathers’ representations have a different distribution confronted with mothers’ ones.

46. Tab. 1 Distribution of Maternal and Paternal Representations during Pregnancy (IRMAG/IRPAG) • hi2(2, N=324)= 10,87 g.di l.=2 p= 0.004.

47. The results reported in tab 1 show that in our sample the integrated/balanced parental representation is equally distributed among women and men, as opposed to the restricted/disinvested one more common among men and the non integrated/ambivalent one more common among women. These data confirm the differences of psychological orientation of mothers and fathers during pregnancy, even though the mothers’ and fathers’ attitudes draw closer after birth. The use of IRMAG-R in at-risk pregnancies allows to study the contents and structure of maternal representations which give significant indication to evaluate parenting capabilities during pregnancy and the postnatal period.

48. Tab. 2 Distribution of Maternal Representations during pregnancy in risk and non-risk mothers • hi2(2, N=371)= 11,93 g.di l.=2 p< 0.003.

49. In at-risk situations, persistent preoccupations and phobic fears have been found; a specific scale is being created for these. This scale allows us to detect the levels of pervasiveness and intrusiveness of fears in relation to the pregnancy, to delivery and to the rearing of the child. The scale for the evaluation of the risk factors is, like the others, an ordinal scale with a five point range. The IRMAG-R can be used for research in the clinical field to study the psychological state of women during pregnancy or for at-risk situations, in medically assisted pregnancies or in projects to support motherhood.

50. 2) Self-Report Questionnaires and Scales have been used to assess attachment processes during pregnancy, when emotional ties start rising between mother and child. The construct of prenatal attachment (Cranley, 1981; Condon, 1993; Muller, 1993) takes account of the mother’s affective investment for the foetus, which is “the most precocious and basic form of human intimacy” (Condon & Corkindale, 1997, 1998). Condon (1993) has suggested a hierarchical model of attachment based on five subjective experiences which derive from maternal love experience and mediate this core experience and overt behaviours. These subjective experiences are expressed in maternal disposition "to know" the loved foetus, "to be with" him or her, "to avoid separation or loss" of the loved object, disposition "to protect" the foetus and finally "to gratify" the foetus's needs.