International Journal of Nursing Studies 46 (2009) 708715

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Review

A meta-analytic study of predictors of maternal-fetal attachment

Adela Yarcheski a,*, Noreen E. Mahon a, Thomas J. Yarcheski b, Michele M. Hanks c,
Barbara L. Cannella a
a

College of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07102, USA
School of Management, Health Services Management, State University of NY Institute of Technology, Utica, NY, USA
c
University of Ilinois, Urbana-Champaign, IL, USA
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 2 April 2008
Received in revised form 21 August 2008
Accepted 19 October 2008

Objectives: To identify predictors of maternal-fetal attachment (MFA) through a

comprehensive review of the literature, and to use quantitative meta-analysis to
determine the magnitude of the relationship between each predictor and MFA.
Design: The literature reviewed included 183 studies of MFA, published and unpublished,
between 1981 and 2006.
Methods: Seventy-two studies met the inclusion criteria and yielded 14 predictors of MFA.
A meta-analysis was performed on each of the 14 predictors in relation to MFA.
Results: The results indicated that gestational age had a moderate to substantial effect
size. Two predictors (social support and prenatal testing) had moderate effect sizes; 10
predictors (anxiety, self-esteem, depression, planned pregnancy, age, parity, ethnicity,
marital status, income, and education) had low effect sizes. High-risk pregnancy had a
trivial effect size.
Conclusions: The most powerful predictors of MFA using meta-analysis were identied to
direct future research and evidence-based practice.
2008 Elsevier Ltd. All rights reserved.

Keywords:
Maternal-fetal attachment
Predictors
Meta-analysis

What is already known about the topic?

 A body of knowledge about maternal-fetal attachment
has been developed over the past 25 years.
 Systematic reviews have been conducted on prenatal
attachment and have identied variables studied in
relation to maternal-fetal attachment; statistical analyses were not performed.
What this paper adds
 This quantitative meta-analysis identies predictors of
maternal-fetal attachment through a comprehensive
review of the literature.

* Corresponding author at: 30 Coolidge Avenue, Carteret, NJ 07008,

USA. Tel.: +1 973 353 3842x520/732 541 7673 (H); fax: +1 973 353 1277.
E-mail address: yarchesk@rutgers.edu (A. Yarcheski).
0020-7489/$ see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2008.10.013

 The predictors are statistically analyzed for their effect

size relative to maternal-fetal attachment.

1. Introduction
Prenatal attachment has been discussed in the literature for decades, and has evolved in recent years into the
construct of maternal-fetal attachment (MFA) primarily
through the work of Cranley (1981). Cranley (1981)
dened maternal-fetal attachment as the extent to which
women engage in behaviors that represent an afliation
and interaction with their unborn child (p. 282), and
developed the Maternal-Fetal Attachment Scale (MFAS) to
measure the construct. The use of the MFAS by researchers
has resulted in an explosion of knowledge about the
construct, and, as stated by Beck (1999), Cranleys MFAS is
a frequently used instrument by nurse researchers in
prenatal studies. Two other instruments that have con-

A. Yarcheski et al. / International Journal of Nursing Studies 46 (2009) 708715

tributed signicantly to the body of knowledge about MFA

are the Prenatal Attachment Inventory (Muller, 1993) and
the Antenatal Emotional Attachment Questionnaire (Condon, 1993). In light of the recent emphasis on evidencebased practice, there was a need to identify the most
salient predictors of MFA using meta-analytic techniques,
which was the focus of this study.
1.1. Background
In addition to the growing body of scientic knowledge
on MFA, much has been written about the construct in the
literature. Theoretical and methodological issues surrounding MFA have been addressed in the literature
through concept analysis and systematic reviews of
scientic studies whereby relevant variables related to
MFA have been identied.
In their concept analysis, Shieh et al. (2001) identied
three critical attributes of MFA, which include cognitive,
affective, and altruistic attachment. Cognitive attachment
describes the desire to know the baby. Affective attachment is the pleasure related to interactions with the
unborn child. Altruistic attachment is the desire to protect
the fetus. A phenomenological study by Sandbrook and
Adamson-Macedo (2004) expanded conceptualizations of
MFA. Data revealed that the overwhelming emotion
experienced by mothers was not love but an innate desire
to protect their unborn child. To stress the importance of
MFA, Sandbrook and Adamson-Macedo (2004) proposed
that the protective instinct promotes behavioural changes
to ensure a favourable intra-uterine environment and
eradicate threats to fetal well-being (p. 180). Support
from partners or parents form the cornerstone of their
paradigm on MFA.
Doan et al. (2003) suggested that a summary of MFA
ndings be published to direct future research. In 2005,
Cannella presented an integrative review of studies using
Cranleys (1981) Maternal-Fetal Attachment Scale, which
identied psychosocial, demographic, and pregnancyrelated and pregnancy-risk variables related to MFA, which
providing future research directions for MFA. Her work
added to earlier systematic reviews of prenatal attachment
by Gaffney (1988), Muller (1992), and Erickson (1996).
These reviews have contributed to our understanding of the
theoretical underpinnings of MFA, but they have not
identied the most powerful variables related to MFA.
1.2. Purpose of the study
The purpose of this study was to identify predictors of
MFA through a review of the literature and to use
quantitative meta-analysis to determine the magnitude
of the relationships between each predictor and MFA.
Three research questions were addressed: (a) what are the
salient predictors of MFA as identied in the review of the
literature? (b) what is the magnitude of the relationship
between MFA and each salient predictor variable, and (c) to
what extent are the effect sizes of the relationships
between the predictor variables and MFA correlated with
the methodological variables of sample size and quality
index?

709

2. Methods
The methods used in the present meta-analytic study
were similar to those used successfully in previous metaanalytic studies (Mahon et al., 2006; Yarcheski et al.,
2004). Thus, the format and reporting of procedures and
results in the present study are comparable to those
presented earlier. In addition, the reporting of content in
the methods below is consistent with those recommended by Stroup et al. (2000) for meta-analysis of
observational studies in epidemiology, known as the
MOOSE criteria.
2.1. Search
To address the rst research question, several methods
recommended by Cooper (1998) were used to identify and
locate all available studies in which MFA was used as a
study variable, including online searches and the ancestry
approach. One researcher who had a published abstract
referring to unpublished MFA data was contacted.
The following online databases were searched for
publications in the years from 1980 to 2006: CINAHL,
PsycINFO, MEDLINE, Social Science Index, and Dissertations and Theses. The terms used were: maternal-fetal
attachment, parental-fetal attachment, maternal-fetal
bonding, and prenatal attachment.
The inclusion criteria for the meta-analyses were
studies: (a) published in English as a scientic article or
unpublished as a doctoral dissertation (chapters in books
and masters theses were not included), (b) using different
instruments to measure MFA, such as the Cranley (1981)
Maternal-Fetal Attachment Scale (n = 50), the Muller
(1993) Prenatal Attachment Scale (n = 9), a combination
of the Cranley and Muller Scales (n = 2), the Condon (1993)
Maternal Antenatal Attachment Scale (n = 9), the Rees
(1980) Prenatal Tool (n = 1), and an investigator developed Antenatal Maternal Attachment Scale (n = 1) (justication for including studies using different MFA
instruments is that all had evidence of reliability and
validity established in methodological studies); (c) using
different instruments to measure the predictor variable.
In addition, (d) the relationship between the predictor and
MFA (treated as a hypothesis in the present metaanalysis) had to be examined at least 10 times across
studies, (e) only maternal data/ndings could be used
from studies that examined parental-fetal attachment,
and (f) adequate statistics had to be reported in the study
to submit to meta-analysis procedures. Excluded were: (a)
ndings in which MFA was a predictor of maternal-infant
outcomes post-partum; (b) ndings from studies that
used only subscale analyses of the MFA instruments
because the construct rather than its individual dimensions were relevant to this study.
A total of 115 potential studies and 68 unpublished
doctoral dissertations and masters theses were located
using the search methods described above. Of the 183
studies, 72 met the inclusion criteria and comprised the
sample for these meta-analyses. Of the 72 studies, 71 had
one sample and 1 had 2 samples, resulting in a total of 73
samples across the 72 studies.

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A. Yarcheski et al. / International Journal of Nursing Studies 46 (2009) 708715

To answer the rst research question, 49 predictors

were studied in relation to MFA two or more times. Of the
49 predictors, 14 met the inclusion criterion of being
studied at least 10 times in relation to MFA. The 14 salient
predictors of MFA were: social support, anxiety, depression, self-esteem, gestational age, prenatal testing, planned
pregnancy, age, parity, ethnicity, marital status, income,
education, and high risk.
2.2. Procedure
Using a codebook developed for meta-analysis (Yarcheski et al., 2004), the 72 studies were coded for substantive,
methodological, and miscellaneous variables. Substantive
(predictor) variables included theoretical variables such as
social support and anxiety, demographic variables such as
age and income, and pregnancy-related variables such as
planned pregnancy and prenatal testing (ultrasound).
Methodological variables included design, instruments,
sampling methods, sample size, type of statistical analysis,
and statistical results. Miscellaneous variables included
information such as publication type (e.g. journal article or
dissertation), and funding.
All authors participated in locating the potential MFA
studies. The rst two authors eliminated studies that did
not meet the inclusion criteria. Independently, the rst and
fourth authors coded 36 of the 72 studies and the second
and third authors coded the remaining 36 studies. Initial
interrater agreement between the pairs ranged from 97%
to 100%. All disagreements were discussed until 100%
consensus was reached between the two raters for all
coding. Then the rst two authors reviewed a random
sample of 36 studies and achieved 100% agreement.
2.3. Quality index
A quality index was constructed for each study to be
used in the analyses according to criteria used in previous
meta-analyses studies (Mahon et al., 2006; Yarcheski et al.,
2004). The highest possible quality index score that a study
could achieve was 25. The quality index consisted of the
following criteria: (a) rst author expertise was scored as 1
(bachelors or masters degrees), 2 (doctoral degree), or 3
(doctoral degree plus multiple publications on MFA); (b)
funding was scored 0 (no funding) or 1 (funding); (c)
sampling method was scored as 1 (convenience), 2
(matched), or 3 (random); (d) sample size was scored as
1 (150 participants), 2 (51100), 3 (101200), or 4 (201 or
more); (e) reported reliability (R) and validity (V) for the
MFA and each predictor instrument was scored as 0 (no R
and V), 1 (only previous R or V), 2 (R or V for current study),
or 3 (R and V for current study); (f) research design was
scored as 1 (correlational), 2 (causal modeling), 3
(comparative), 4 (methodological), 5 (longitudinal), or 6
(quasi-experimental); (g) statistics used were scored as 1
(bivariate) or 2 (multivariate).
2.4. Data analysis
The Advanced BASIC Meta-Analysis software system
developed by Mullen (1989) was used for the meta-

analysis. To answer the second research question, the

general combinations and comparisons of effect sizes and
signicance levels were calculated in three ways:
unweighted, weighted by sample size, and weighted by
quality score. With r as the indicator of effect size, Cohens
(1988) standard denitions, as rened by Zangaro and
Soeken (2007), were used to interpret the effect size
ndings: trivial (.01.09), low to moderate (.10.29),
moderate to substantial (.30.49), substantial to very
strong (.50.69), and very strong (.70.89).
To answer the third research question, the effects of
sample size or quality index were each correlated with the
magnitude of the relationship between each predictor
variable and MFA. Only statistically signicant ndings are
reported with the results.
There were 11 longitudinal studies used in these metaanalyses. To meet the assumption of independent data
(Curlette and Cannella, 1985), only one point in time from
these studies was randomly selected and used in the metaanalysis.
3. Results
3.1. Description of studies in sample
A total of 72 studies were used in the meta-analysis
procedures (references available upon request). They were
published between the years 1981 and 2006. Of these 72
studies, 43 were journal articles, and 27 were doctoral
dissertations conducted in the United States; there were 2
sets of unpublished data (A. R. Brandon, personal communication, July 3 and 25, 2007). Concerning the rst authors
credentials, 29 studies were rst-authored by researchers
who had doctoral degrees and multiple MFA publications. Of
the remaining studies, 32 rst authors were researchers
with doctoral degrees, 5 had masters degrees, and 1 had a
baccalaureate degree; 5 authors did not report their
educational preparation. Of the 72 studies, funding was
reported for 18. Thus, a majority of the studies were
published journal articles authored by professionals with
doctoral degrees; most of the studies were not funded.
Research designs were primarily correlational (n = 36), 3
used causal modeling, 18 were comparative designs, 2 were
methodological studies, 11 were longitudinal designs, and 2
were quasi-experiments. Relative to sampling methods, all
73 samples were samples of convenience. Most sample sizes
(n = 30) consisted of 51-100 participants, 17 samples sizes
ranged from 1 to 50, 14 ranged from 101 to 200, and 12 had
200 or more participants. The smallest sample size was 15
and the largest was 339. Relative to data analysis, 34 studies
used bivariate statistics whereas 38 used multivariate. The
quality index scores ranged from 6 to 20 with a median of 13
and a mode of 11. Thus, approximately 50% of the studies
had a correlational design, and all of the studies used
samples of convenience. A majority of the studies were
characterized by small sample sizes with 100 or less
participants. A majority of the studies used multivariate
statistics.
Relative to the samples in the studies, the youngest
participant was 14 years of age and the oldest was 47. The
gestational ages of the samples were as follows: rst

A. Yarcheski et al. / International Journal of Nursing Studies 46 (2009) 708715

trimester (n = 2), rst and second trimester (n = 2), second

trimester (n = 6), second and third trimester (n = 25), third
trimester (n = 21), all three trimesters (n = 13), and no
information provided (n = 4).
3.2. Statistical parameters
The fail-safe N calculation was used to determine if
publication bias existed. Cooper (1998) suggested that the
fail-safe N is used to calculate the number of studies
needed to change the conclusion that a relation exists.
According to Rosenthal (1991), a reasonable tolerance for
discounting publication bias is attained if the fail-safe N
exceeds 5K + 10 (K = number of hypotheses included in the
analyses). One predictor (high-risk pregnancy) had a failsafe N below the tolerance level.
According to Wolf (1986), the test of homogeneity is
used to determine whether independent studies are
testing the same hypotheses. Using chi-square, ve
statistically signicant homogeneity tests indicated that
outliers were present (social support, gestational age,
prenatal testing, planned pregnancy, and age). Nonsignicant homogeneity tests were achieved for two
predictors (social support and planned pregnancy) when
outliers were removed.
To help interpret the effect size obtained for each
predictor variable in relation to MFA, a 95% condence
interval was constructed around the average effect size to
determine if it encompassed zero. According to Wolf
(1986), it would be desirable for the average effect size not
to encompass zero in order for us to be more certain that
there is a signicant effect across studies (p. 27). The only
condence interval encompassing zero was high-risk
pregnancy (Table 1).
3.3. Predictors of MFA
In the present study, each of the 14 predictor variables
were analyzed separately in relation to MFA, resulting in

711

14 separate meta-analyses. The departure from the MOOSE

criteria (Stroup et al., 2000) is that effect sizes are
presented for each of the 14 predictors of MFA rather
than presented for each study included in each separate
meta-analysis of the 14 predictors. Table 1 presents the
number of hypotheses tested, the total number of
participants, the fail-safe N, homogeneity test, and the
95% condence intervals for each of the 14 predictors.
Table 2 presents the signicance levels and effects sizes for
each of the 14 predictors analyzed by unweighted,
weighed by sample size, and weighted by quality index
scores. The important observations from Tables 1 and 2 are
presented.
3.3.1. Social support
Social support as related to MFA was examined via 20
hypotheses derived from 19 studies. The quality index
scores (QIS) ranged from 9 to 17. The homogeneity test was
not signicant after three outliers were removed. The r
effect sizes indicated that the relationships were moderate
for studies with outliers (all r = .27) and when outliers
were removed (all r = .29; Table 2).
3.3.2. Anxiety
Anxiety as related to MFA was examined via 15
hypotheses derived from 14 studies. The QIS ranged from
8 to 20. The r effect sizes indicated that the relationships
were in the range of low effect sizes (r = .17 to .21; Table 2).
The magnitude of the relationship for the two variables covaried signicantly with sample size (r = .29, p = .05) and
quality index (r = .41, p = .01), indicating that as sample
size or quality of the studies increased, the effect size
between anxiety and MFA increased.
3.3.3. Self-esteem
Self-esteem as related to MFA was examined via 11
hypotheses derived from 10 studies. The QIS ranged from
12 to 18. The r effect sizes indicated that the relationships
were low (all r = .19; Table 2).

Table 1
Prole statistics of the predictors of Maternal-Fetal Attachment (MFA).
Predictors

Social support
No outliers
Anxiety
Depression
Self-esteem
Gestational age
Prenatal testing
Planned pregnancy
No outliers
Age
Parity
Ethnicity
Marital status
Income
Education
High risk

Number of hypotheses

20
17
15
16
11
24
11
10
9
29
21
11
12
10
21
10

Total participants

3007
2636
1471
2103
1325
3251
925
1455
1260
3883
3416
1738
1922
1708
3352
1569

Fail-safe

Homogeneity test (diffuse

comparison of effect sizes)

x2

One-tailed p*

1342.63
1190.08
219.99
345.09
172.83
2323.76
219.42
88.04
87.43
909.60
392.85
81.03
94.23
61.41
215.66
5.06

37.19
22.77
20.46
15.39
13.02
260.10
41.72
17.39
13.99
75.52
29.55
12.09
5.33
9.09
14.87
.30

.007
.120
.116
.424
.233
1.01E 36
9.22E 07
.043
.081
5.68E 07
.077
.279
.913
.428
.784
.999

95% Condence Intervals

for effect sizes

.242.312
.253.327
.162.264
.149.235
.137.247
.312.418
.267.399
.100.202
.117.227
.130.192
.107.175
.094.188
.098.143
.074.168
.066.134
0.099

*
Some of the one-tailed p values were highly statistically signicant. For example, a one-tailed p value of 9.22E 07 represents scientic notation for
p = .000000922.

A. Yarcheski et al. / International Journal of Nursing Studies 46 (2009) 708715

712

Table 2
Signicance levels and effect sizes for each of the predictors of MFA.
Predictor

Social support
Unweighted
Weighted by sample size
Weighted by quality score

Effect sizes mean rc

Signicance levels
b

Z for combination

Associated one-tailed p

13.58 (13.86)
14.59 (14.73)
13.79 (14.20)

1.10E 30 (2.13E 31)

3.34E 33 (1.54E 33)
3.20E 31 (3.07E 32)

.27 (.29)
.27 (.29)
.27 (.29)

Anxiety
Unweighted
Weighted by sample size
Weighted by quality score

6.51
5.74
5.80

5.84E 10
5.45E 09
4.01E 09

.21
.17
.19

Self-esteem
Unweighted
Weighted by sample size
Weighted by quality score

6.72
6.61
6.68

1.56E 11
3.23E 11
2.00E 11

.19
.19
.19

Depression
Unweighted
Weighted by sample size
Weighted by quality score

7.81
7.51
7.67

1.38E 14
1.03E 13
3.65E 14

.19
.17
.18

Gestational age
Unweighted
Weighted by sample size
Weighted by quality score

16.27
12.74
16.70

4.20E 37
1.59E 28
4.75E 38

.35
.27
.36

Prenatal testing
Unweighted
Weighted by sample size
Weighted by quality score

7.53
7.16
7.10

9.04E 14
9.82E 13
1.43E 12

.27
.25
.26

Planned pregnancy
Unweighted
Weighted by sample size
Weighted by quality score

5.15 (5.30)
4.54 (4.87)
5.14 (5.31)

1.38E 07 (3.98E 08)

2.85E 06 (5.67E 07)
1.47E 07 (5.38E 08)

.15 (.17)
.13 (.15)
.15 (.16)

Age
Unweighted
Weighted by sample size
Weighted by quality score

9.36
9.37
9.89

4.59E 19
4.15E 19
1.26E 20

.16
.16
.17

Parity
Unweighted
Weighted by sample size
Weighted by quality score

7.30
7.64
7.54

3.94E 13
4.51E 14
8.17E 14

.14
.13
.13

Ethnicity
Unweighted
Weighted by sample size
Weighted by quality score

4.76
4.11
4.97

1.01E 06
1.95E 05
3.46E 07

.14
.11
.13

Marital status
Unweighted
Weighted by sample size
Weighted by quality score

4.89
4.84
4.84

5.12E 07
6.60E 07
6.61E 07

.12
.11
.12

Income
Unweighted
Weighted by sample size
Weighted by quality score

4.40
4.10
4.22

5.58E 06
2.07E 05
1.23E 05

.12
.11
.11

Education
Unweighted
Weighted by sample size
Weighted by quality score

5.52
5.94
5.56

1.80E 03
1.76E 09
1.50E 08

.10
.10
.10

High risk
Unweighted
Weighted by sample size
Weighted by quality score

2.02
2.13
2.12

.022
1.66E 02
1.71E 02

.05
.06
.05

a
b
c

Z without parentheses includes outliers; Z in parentheses excludes outliers.

Associated one-tailed p without parentheses includes outliers; associated one-tailed p in parentheses excludes outliers.
Effect sizes without parentheses includes outliers; effect sizes in parentheses excludes outliers.

A. Yarcheski et al. / International Journal of Nursing Studies 46 (2009) 708715

713

3.3.4. Depression
Depression as related to MFA was examined via 16
hypotheses derived from 15 studies. The QIS ranged from 7
to 16. The r effect sizes indicated that the relationships
were low (r = .17.19; Table 2).

3.3.12. Income
Income as related to MFA was examined via 10
hypotheses derived from 9 studies. The QIS ranged from
6 to 18. The r effect sizes indicated that the relationships
were low (r = .11.12; Table 2).

3.3.5. Gestational age

Gestational age as related to MFA was examined via
24 hypotheses derived from 24 studies. The QIS ranged
from 8 to 17. The homogeneity test was signicant after
repeated analyses to remove the outliers. The r effect
sizes indicated that the relationships were moderate to
substantial (r = .27.36; Table 2). The magnitude of
the relationship for the two variables co-varied signicantly with sample size (r = .44, p < .002) and
quality index (r = .23, p = .01). These correlations indicate that as sample size or quality of the studies
increased, the effect size between gestational age and
MFA increased.

3.3.13. Education
Education as related to MFA was examined via 21
hypotheses derived from 20 studies. The QIS ranged from 6
to 18. The r effect sizes indicated that the relationships
were low (all r = .10; Table 2).
3.3.14. High-risk pregnancy
High-risk pregnancy as related to MFA was examined
via 10 hypotheses derived from 9 studies. The QIS ranged
from 9 to 15. The r effect sizes indicated that the
relationships were trivial and not signicant (all r = .05;
Table 2).
4. Discussion

3.3.6. Prenatal testing

Prenatal testing (ultrasound) as related to MFA was
examined via 11 hypotheses derived from 10 studies. The
QIS ranged from 6 to 15. The homogeneity test was
signicant after repeated analyses to remove the outliers.
The r effect sizes indicated that the relationships were
moderate (r = .25.27; Table 2).
3.3.7. Planned pregnancy
Planned pregnancy as related to MFA was examined via
10 hypotheses derived from 10 studies. The QIS ranged
from 6 to 16. The homogeneity test was not signicant
after 1 outlier was removed. The r effect sizes indicated
that the relationships were low with outliers (r = .13.15)
and without outliers (r = .15.17; Table 2).
3.3.8. Age
Age as related to MFA was examined via 29 hypotheses
derived from 28 studies. The QIS ranged from 7 to 17. The
homogeneity test was signicant after repeated analyses
to remove the outliers. The r effect sizes indicated that the
relationships were low (r = .16.17; Table 2).
3.3.9. Parity
Parity as related to MFA was examined via 21
hypotheses derived from 20 studies. The QIS ranged from
9 to 18. The r effect sizes indicated that the relationships
were low (r = .13.14; Table 2).
3.3.10. Ethnicity
Ethnicity as related to MFA was examined via 11
hypotheses derived from 10 studies. The QIS ranged from
8 to 17. The r effect sizes indicated that the relationships
between ethnicity and MFA were low (r = .11.14;
Table 2).
3.3.11. Marital status
Marital status as related to MFA was examined via 12
hypotheses derived from 11 studies. The QIS ranged from 6
to 17. The r effect sizes indicated that the relationships
were low (r = .11.12; Table 2).

The ndings of the present MFA meta-analytic study

provide direction for future research and evidence-based
practice. Of the 14 predictors of MFA examined, 4 were
theoretical in nature (social support, anxiety, self-esteem,
and depression), 5 were pregnancy-related (gestational
age, prenatal testing (ultrasound), planned pregnancy,
parity, and high-risk pregnancy), and 5 were demographic
(age, ethnicity, marital status, income, and education).
Social support was the most powerful theoretical
predictor studied in relation to MFA, but, surprisingly,
its effect size was only moderate. One explanation can be
found in the thesis by Condon and Corkindale (1997) who
proposed that the actual level of social support may
increase (or decrease) as a result of pregnancy. The
perceived level may decrease if the womens need for
support increases (p. 361). This dynamic, if operative,
might inuence the magnitude of the relationship between
social support and MFA. The relationship of actual and
perceived social support in relation to MFA is worthy of
further research, using the paradigm by Sandbrook and
Adamson-Macedo (2004) that emphasizes the importance
of emotional support of others in relation to MFA.
The low effect sizes of the theoretical predictors of
anxiety, self-esteem, and depression raise the question as
to whether they warrant future study in relation to MFA.
Visual inspection of the range of individual effect sizes
across studies for anxiety (r = .02.37), depression (r = .01
.38) and self-esteem (r = .01.38) indicates that they varied
substantially from the nal average effect sizes for these
predictors as shown in Table 2. According to Mullen et al.
(2001), this lack of stability in the individual effect sizes
across studies vis-a`-vis the nal average effect sizes
suggests that further investigation of these predictors in
relation to MFA is warranted. The recommendation
emerging from this set of weak predictors is that theory
construction using an inductive approach is needed to
identify other and potentially more powerful concepts
related to MFA.
Gestational age was the most powerful predictor of
MFA. Researchers have suggested that little is known about

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A. Yarcheski et al. / International Journal of Nursing Studies 46 (2009) 708715

the process by which MFA develops (Lindgren, 2001;

Salisbury et al., 2003). A qualitative study suggested that
MFA is progressive in nature (Sandbrook and AdamsonMacedo, 2004). As noted in the substantial effect sizes
between gestational age and MFA, clearly as the pregnancy
progresses MFA intensies. These ndings provide insight
into the development of MFA, and suggest that studies of
MFA be conducted in the later rather than the earlier stages
of pregnancy.
Prenatal testing using fetal ultrasound screening has
progressively become routine practice in prenatal care in
many countries (Righetti et al., 2005). Based on the
moderate effect size found between prenatal testing and
MFA, the use of ultrasound enhances the mothers
attachment to her fetus. As found by Sandbrook and
Adamson-Macedo (2004), attachment is strengthened by
the rst ultrasound scan which provides visual evidence of
fetal viability. Clinical guidelines for prenatal care should
include routine ultrasound screening for both physical and
psychological reasons.
The predictors of planned pregnancy, parity, and
high-risk pregnancy had low to trivial effect sizes in
relation to MFA, and probably do not merit further study.
The pregnancy-related variables of prenatal-education,
fetal movement, and gravida have been studied in
relation to MFA but fell short of meeting the criteria
for inclusion in these meta-analyses; they deserve
continued study.
The demographic predictors of age, ethnicity, marital
status, income, and education had low effect sizes in
relation to MFA. Thus, the ndings are not very useful for
theory building or clinical practice. Since these data are
routinely collected in research, researchers should continue to study demographic variables knowing that they do
not contribute signicantly to MFA.
Three predictors in relation to MFA, gestational age,
prenatal testing, and chronological age, yielded heterogeneous estimates, and homogeneity was not achieved by
excluding potential outliers through repeated analyses.
These three predictors do not pose problems in measurement, leaving open to question the assessments of MFA. If
measurements of MFA were at issue, lack of homogeneity
would have been a problem with all of the relationships
studied, which it was not. Becker and Hedges (1984)
suggested that many studies by many investigators using
different methods and designs might result in heterogeneity. These authors suggested that inferences can be
drawn from heterogeneous estimates with outliers, as was
done in this study with the relationships between MFA and
gestational age, prenatal testing, and age. However,
heterogeneity may be due to either artifactual or true
sources of variance between correlational indices of
studies (Reynolds et al., 1992). Thus, all inferences drawn
from heterogeneous estimates should be viewed with
caution, which is a limitation of the present meta-analyses
of gestational age, prenatal testing, and chronological age.
Evidence-based practice relies on meta-analytic studies
for the best research to apply to patient care (Melnyk and
Fineout-Overholt, 2005). Based on the ndings of this
meta-analytic study, clinical guidelines in prenatal care
should be developed to ensure that women perceive

adequate levels of social support during their pregnancy.

This is especially true for vulnerable populations.
As noted by Lindgren (2001), clinicians should be
cautious in interfering with maternal-fetal attachment, a
process about which little is understood (p. 214). The
present meta-analysis portrays a process of maternal-fetal
attachment that is integral with gestational age. Thus, for
most women, the strength of their attachment to their
fetus evolves over time. Clinicians concerns about low
levels of MFA probably should be limited to the third
trimester of pregnancy when the magnitude of the
relationship is expected to be the strongest.
The present meta-analyses were performed on data
extracted from non-experimental and correlational studies. Meta-analyses of these types of studies help
determine whether the relationship between the predictor
and outcome variable is strong enough to warrant
development of experimental designs (Reynolds et al.,
1992), which is a strength of this approach. However, a
limitation of meta-analysis of non-experimental data is
that it does not provide the highest and thus best level of
evidence for practice, which meta-analyses of randomized
control trials do offer (Melnyk and Fineout-Overholt,
2005).
The ndings of this meta-analytic study have shed light
on the antecedents of MFA, but more research is needed.
Continued research is also needed to determine if there are
cultural differences in MFA. In addition, the postnatal
consequences of MFA need to be examined using metaanalytic techniques.
Funding
None
Ethical approval
None
Conict of interest
There is no conict of interest in the work presented
due to our employment, or other resources such as
consultancies, honoraria, and grants or other funding.
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